The need for a clinical ethics service and its goals in a community healthcare service centre: a survey

Ethical issues in oncology practice: a qualitative study of stakeholders' experiences and expectations

Background

Clinical Ethics Support Services (CESS) have been established to support healthcare professionals in addressing ethically sensitive issues in clinical practice and, in many countries, they are under development. In the context of growing CESS, exploring how healthcare professionals experience and address clinical ethics issues in their daily practice represents a fundamental step to understand their potential needs. This is even more relevant in the context of extremely sensitive diseases, such as cancer. On this basis, we carried out a qualitative study conducting in-depth semi-structured interviews with stakeholders of a major comprehensive cancer centre in Italy, with the twofold aim of investigating what ethical issues arise in the context of clinical oncology and how they are addressed, as well as stakeholders’ expectations about a potential CESS to be implemented within the Institution.

Methods

The study was conducted within the theoretical framework of Grounded Theory. Participants were healthcare professionals and other key stakeholders working within the cancer centre. The semi-structured interview aimed at exploring common ethical aspects of oncology, investigating stakeholders’ professional experience in dealing with clinical ethics issues, their expectations and requests regarding ethics support services. Transcripts of the interviews were coded and analysed according to the principles of Grounded Theory.

Results

Twenty-one stakeholders were interviewed. Our analysis showed a wide consensus on the identification of ethically relevant issues, above all those concerning communication, end-of-life, and resource allocation. The absence of institutional tools or strategies to address and manage ethical issues at the patient bedside emerged, and this is reflected in the widespread request for their development in the future. The ideal support service should be fast and flexible in order to adapt to different needs and clinical cases.

Conclusions

The interviewees showed a limited degree of ‘ethical awareness’: despite having reported many issues in clinical practice, they could hardly identify and describe the ethical aspects, while  complaining about a lack of ethical resources in their management. To build a truly effective support service, it therefore seems appropriate to take such context into consideration and address the emerged needs. Ethical sensitivity seems to be key and it becomes even more relevant in critical clinical areas, such as the therapeutic pathways of terminally ill patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-022-00803-x.

Clinical ethics committees in nursing homes: what good can they do? Analysis of a single case consultation

Background:

Ought nursing homes to establish clinical ethics committees (CECs)? An answer to this question must begin with an understanding of how a clinical ethics committee might be beneficial in a nursing home context – to patients, next of kin, professionals, managers, and the institution. With the present article, we aim to contribute to such an understanding.

Aim:

We ask, in which ways can clinical ethics committees be helpful to stakeholders in a nursing home context? We describe in depth a clinical ethics committee case consultation deemed successful by stakeholders, then reflect on how it was helpful.

Research design:

Case study using the clinical ethics committee’s written case report and self-evaluation form, and two research interviews, as data.

Participants and research context:

The nursing home’s ward manager and the patient’s son participated in research interviews.

Ethical considerations:

Data were collected as part of an implementation study. Clinical ethics committee members and interviewed stakeholders consented to study participation, and also gave specific approval for the publication of the present article.

Findings/results:

Six different roles played by the clinical ethics committee in the case consultation are described: analyst, advisor, support, moderator, builder of consensus and trust, and disseminator.

Discussion:

The case study indicates that clinical ethics committees might sometimes be of help to stakeholders in moral challenges in nursing homes.

Conclusions:

Demanding moral challenges arise in the nursing home setting. More research is needed to examine whether clinical ethics committees might be suitable as ethics support structures in nursing homes and community care.

Making the (Business) Case for Clinical Ethics Support in the UK

This paper provides a series of reflections on making the case to senior leaders for the introduction of clinical ethics support services within a UK hospital Trust at a time when clinical ethics committees are dwindling in the UK. The paper provides key considerations for those building a (business) case for clinical ethics support within hospitals by drawing upon published academic literature, and key reports from governmental and professional bodies. We also include extracts from documents relating to, and annual reports of, existing clinical ethics support within UK hospitals, as well as extracts from our own proposal submitted to the Trust Board. We aim for this paper to support other ethicists and/or health care staff contemplating introducing clinical ethics support into hospitals, to facilitate the process of making the case for clinical ethics support, and to contribute to the key debates in the literature around clinical ethics support. We conclude that there is a real need for investment in clinical ethics in the UK in order to build the evidence base required to support the wider introduction of clinical ethics support into UK hospitals. Furthermore, our perceptions of the purpose of, and perceived needs met through, clinical ethics support needs to shift to one of hospitals investing in their staff. Finally, we raise concerns over the optional nature of clinical ethics support available to practitioners within UK hospitals.

How Community Nurses Manage Ethical Conflicts: A Grounded Theory Study

Research is limited on how nurses in community settings manage ethical conflicts. To address this gap, we conducted a study to uncover the process of behaviors enacted by community nurses when experiencing ethical conflicts. Guided by Glaserian grounded theory, we developed a theoretical model (Moral Compassing) that enables us to explain the process how 24 community nurses managed challenging ethical situations. We discovered that the main concern with which nurses wrestle is moral uncertainty ("Should I be addressing what I think is a moral problem?"). Moral Compassing comprises processes that resolve this main concern by providing community nurses with the means to attain the moral agency necessary to decide to act or to decide not to act. The processes are undergoing a visceral reaction, self-talk, seeking validation, and mobilizing support for action or inaction. We also discovered that community nurses may experience continuing distress that we labeled moral residue.

The Norwegian national project for ethics support in community health and care services

Background

Internationally, clinical ethics support has yet to be implemented systematically in community health and care services. A large-scale Norwegian project (2007–2015) attempted to increase ethical competence in community services through facilitating the implementation of ethics support activities in 241 Norwegian municipalities. The article describes the ethics project and the ethics activities that ensued.

Methods

The article first gives an account of the Norwegian ethics project. Then the results of two online questionnaires are reported, characterizing the scope, activities and organization of the ethics activities in the Norwegian municipalities and the ethical topics addressed.

Results

One hundred and thirty-seven municipal contact persons answered the first survey (55 % response rate), whereas 217 ethics facilitators from 48 municipalities responded to the second (33 % response rate). The Norwegian ethics project is vast in scope, yet has focused on some institutions and professions (e.g., nursing homes, home-based care; nurses, nurses’ aides, unskilled workers) whilst seldom reaching others (e.g., child and adolescent health care; physicians). Patients and next of kin were very seldom involved. Through the ethics project employees discussed many important ethical challenges, in particular related to patient autonomy, competence to consent, and cooperation with next of kin. The “ethics reflection group” was the most common venue for ethics deliberation.

Conclusions

The Norwegian project is the first of its kind and scope, and other countries may learn from the Norwegian experiences. Professionals have discussed central ethical dilemmas, the handling of which arguably makes a difference for patients/users and service quality. The study indicates that large (national) scale implementation of CES structures for the municipal health and care services is complex, yet feasible.

Electronic supplementary material

The online version of this article (doi:10.1186/s12910-016-0158-5) contains supplementary material, which is available to authorized users.

Ethics support in community care makes a difference for practice

BACKGROUND

Through the Norwegian ethics project, ethics activities have been implemented in the health and care sector in more than 200 municipalities.

OBJECTIVES

To study outcomes of the ethics activities and examine which factors promote and inhibit significance and sustainability of the activities.

RESEARCH DESIGN

Two online questionnaires about the municipal ethics activities. Participants and research context: A total of 137 municipal contact persons for the ethics project answered the first survey (55% response rate), whereas 217 ethics facilitators responded to the second survey (33% response rate). Ethical considerations: Based on informed consent, the study was approved by the Data Protection Official of the Norwegian Social Science Data Services.

FINDINGS

Around half of the respondents found the ethics project to have been highly significant for daily professional practice. Outcomes include better handling of ethical challenges, better employee cooperation, better service quality, and better relations to patients and next of kin. Factors associated with sustainability and/or significance of the activities were sufficient support from stakeholders, sufficient available time, and ethics facilitators having sufficient knowledge and skills in ethics and access to supervision.

DISCUSSION

This study shows that ethics initiatives can be both sustainable and significant for practice. There is a need to create regional or national structures for follow-up and develop more comprehensive ethics training for ethics facilitators.

CONCLUSION

It is both possible and potentially important to implement clinical ethics support activities in community health and care services systematically on a large scale. Future ethics initiatives in the community sector should be designed in light of documented promoting and inhibiting factors.

Ethics reflection groups in community health services: an evaluation study

BACKGROUND

Systematic ethics support in community health services in Norway is in the initial phase. There are few evaluation studies about the significance of ethics reflection on care. The aim of this study was to evaluate systematic ethics reflection in groups in community health (including nursing homes and residency), - from the perspectives of employees participating in the groups, the group facilitators and the service managers. The reflection groups were implemented as part of a research and development project.

METHODS

A mixed-methods design with qualitative focus group interviews, observations and written reports were used to evaluate. The study was conducted at two nursing homes, two home care districts and a residence for people with learning disabilities. Participants were employees, facilitators and service managers. The study was guided by ethical standard principles and was approved by the Norwegian Social Science Data Services.

RESULTS

We found support for ethics reflection as a valuable measure to strengthen clinical practice. New and improved solutions, more cooperation between employees, and improved collaboration with patients and their families are some of the results. No negative experiences were found. Instead, the ethics reflection based on experiences and challenges in the workplace, was described as a win-win situation. The evaluation also revealed what is needed to succeed and useful tips for further development of ethics support in community health services.

CONCLUSIONS

Ethics reflection groups focusing on ethical challenges from the participants' daily work were found to be significant for improved practice, collegial support and cooperation, personal and professional development among staff, facilitators and managers. Resources needed to succeed were managerial support, and anchoring ethics sessions in the routine of daily work.

Goals of clinical ethics support: perceptions of Dutch healthcare institutions

In previous literature, ethicists mention several goals of Clinical Ethics Support (CES). It is unknown what key persons in healthcare institutions see as main–—and sub-goals of CES. This article presents the goals of CES as perceived by board members and members of ethics support staff. This is part of a Dutch national research using a mixed methods design with questionnaires, focus groups and interviews. Quantitative and qualitative data were analyzed and combined in an iterative process. Four main clusters of goals were found: 1) encouraging an ethical climate, 2) fostering an accountable and transparent organization, 3) developing professionalism and a final goal, overarching the previous three, 4) good care. Most important sub-goals of CES were: attention for ethical issues, raising awareness of ethical issues, fostering ethical reflection and supporting employees. The article ends with a discussion on the desirability to further operationalize the general goal of good care, the context-boundedness of our findings and the need to relate goals of CES to the features of organizational cultures to further improve the integration of CES in healthcare institutions.

Bioethics consultation practices and procedures: a survey of a large Canadian community of practice

The literature fails to reflect general agreement over the nature of the services and procedures provided by bioethicists, and the training and core competencies this work requires. If bioethicists are to define their activities in a consistent way, it makes sense to look for common ground in shared communities of practice. We report results of a survey of the services and procedures among bioethicists affiliated with the University of Toronto Joint Centre for Bioethics (JCB). This is the largest group of bioethicists working in healthcare organizations in Canada. The results suggest there are many common services and procedures of JCB bioethicists. This survey can serve as a baseline for further exploration of the work of JCB bioethicists. Common practices exist with respect to the domains of practice, individual reporting relationships, service availability within business hours and the education and training of the bioethicist.

Ethical difficulties in nursing, educational needs and attitudes about using ethics resources

Ethical difficulties arise in healthcare practices. However, despite extensive research findings that demonstrate that most nurses are involved in recurrent ethical problems, institutions are not always able to effectively support nursing care professionals. The limited availability of ethics consultation services and traditional nursing training fails to meet the frequent and strong requests by health workers to support their ethical dilemmas. A questionnaire was administered to 374 nurses attending a specialist training and a lifetime learning programme in Italy. The respondents reported a high frequency of ethically sensitive situations, and they described the poor development of ethics support and a scarcity of ethics training programmes. The results suggest the importance of promoting ethics services that include consultation and ethics training. A need for systematic ethics educational activities was identified for improving the capacity of nurses to manage ethical issues in patient care.

Ethical challenges and how to develop ethics support in primary health care

Ethics support in primary health care has been sparser than in hospitals, the need for ethics support is probably no less. We have, however, limited knowledge about how to develop ethics support that responds to primary health-care workers’ needs. In this article, we present a survey with a mixture of closed- and open-ended questions concerning: How frequent and how distressed various types of ethical challenges make the primary health-care workers feel, how important they think it is to deal with these challenges better and what kind of ethics support they want. Five primary health-care institutions participated. Ethical challenges seem to be prominent and common. Most frequently, the participants experienced ethical challenges related to scarce resources and lack of knowledge and skills. Furthermore, ethical challenges related to communication and decision making were common. The participants welcomed ethics support responding to their challenges and being integrated in their daily practices.

Ethics consultation at a large urban public teaching hospital

OBJECTIVES

To describe the population served and issues encountered by Hospital Ethics Committee consultation, to describe the incidence of consultation per hospital admission, and to describe the resource utilization per consult.

PATIENTS AND METHODS

This is a retrospective review of all ethics consults at a large urban teaching hospital and level one trauma center in a metropolitan area from January 1, 2004, through December 31, 2006. The data points analyzed were patient demographics, time spent by consultants (resource utilization), and the choice to pursue a full consult, which differs from a brief consult by the number of ethics consultants involved and the formality of the deliberative process.

RESULTS

A total of 285 consults were conducted or 0.16% (95% confidence interval, 0.14%-0.18%) of all hospital admissions. The highest incidence was 0.88% (95% confidence interval, 0.59%-1.3%) for the trauma intensive care unit. The average age of patients consulted on was 51 years, and 54% were in the intensive care unit. Of the consults, 90% were brief, and 52% were requested by house staff. Consultants logged 60,368 minutes, 38% of which were devoted to full consults (10% of total). Consults in obstetrics, general medicine, and surgery were the most time-consuming. Pregnancy and human immunodeficiency virus were more prevalent in full consults. The "classic" ethics cases of confidentiality (5%), patients requesting futile treatment (5%), brain death (4%), error disclosure (1%), and organ-donor rights (0.3%) were marginal in our series.

CONCLUSION

Little data exist on the practice of ethics consultation services. To our knowledge, this series represents the largest to date. Specific issues, patient characteristics, and hospital services were more prevalent in the most time-consuming consults. These data can be used to target the education of residents and inform hospital quality initiatives.

Clinical Ethics Committees: a due process wasteland?

The development of clinical ethic support in the UK arguably brings with it a series of legal questions, which need to be addressed. Most particularly, these concern questions of due process and formal justice, which I argue are central to the provision of appropriate ethical advice. In this article, I will compare the UK position with the more developed system in the USA, which often provides a template for development in the UK. While it is not argued that the provision of clinical ethics support in the UK will necessarily follow the path mapped in the USA, there are lessons that can be learned from the US experience – particularly in terms of attention to process – from which UK clinical ethics support service might well benefit.