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van Schaik M, Pasman HRR, Widdershoven GA, De Snoo-Trimp J, Metselaar S. Effectiveness of CURA: Healthcare professionals' moral resilience and moral competences. Nurs Ethics 2024; 31:1140-1155. [PMID: 38031920 PMCID: PMC11437695 DOI: 10.1177/09697330231218344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Background: Clinical ethics support instruments aim to support healthcare professionals in dealing with moral challenges in clinical practice. CURA is a relatively new instrument tailored to the wishes and needs of healthcare professionals in palliative care, especially nurses. It aims to foster their moral resilience and moral competences.Aim: To investigate the effects of using CURA on healthcare professionals regarding their Moral Resilience and Moral Competences.Design: Single group pre-/post-test design with two questionnaires.Methods: Questionnaires used were the Rushton Moral Resilience Scale measuring Moral Resilience and the Euro-MCD, measuring Moral Competences. Respondents mainly consisted of nurses and nurse assistants who used CURA in daily practice. Forty-seven respondents contributed to both pre- and post-test with 18 months between both tests. Analysis was done using descriptive statistics and Wilcoxon signed rank tests. This study followed the SQUIRE checklist.Ethical considerations: This study was approved by the Institutional Review Board of Amsterdam UMC. Informed consent was obtained from all respondents.Results: The total Moral Resilience score and the scores of two subscales of the RMRS, that is, Responses to Moral Adversity and Relational Integrity, increased significantly. All subscales of the Euro-MCD increased significantly at posttest. Using CURA more often did not lead to significant higher scores on most (sub) scales.Conclusion: This study indicates that CURA can be used to foster moral resilience and moral competences of healthcare professionals. CURA therefore is a promising instrument to support healthcare professionals in dealing with moral challenges in everyday practice.
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Affiliation(s)
- Malene van Schaik
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - H Roeline Rw Pasman
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Guy Am Widdershoven
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Janine De Snoo-Trimp
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Suzanne Metselaar
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Stevenson J, Clinch A, Ftanou M, Delany C. What is known about the role of clinical ethics services in cancer care? A systematic/narrative literature review. BMJ Support Palliat Care 2024:spcare-2023-004300. [PMID: 39038989 DOI: 10.1136/spcare-2023-004300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/01/2024] [Indexed: 07/24/2024]
Abstract
The use of clinical ethics services (CES) has been increasing over time, but little is known about the role of CES in cancer care. Cancer diagnosis and treatment are emotionally charged and life-changing experiences, raising existential and ethical questions about the quality and meaning of, living and dying. This narrative review seeks to consolidate the available information regarding how CES are accessed and used in cancer care. The review attempts to answer the question, 'What is known about the role of CES in cancer care?' Papers included in this review were identified through searching PubMed and MEDLINE Ovid; a variety of keywords were used to ensure the capture of all relevant literature. 387 papers were identified using the search strategy, 13 papers were included in the final synthesis following the application of the inclusion and exclusion criteria. Citation searching was conducted. 11 of 13 papers were conducted in the USA, 1 in Germany and 1 in South Korea. A variety of study designs were incorporated into this review. Five key roles of CES in cancer care were identified; conflict resolution/mediation, delivery of ethics education to clinical staff, advising on specific aspects of care, guideline development/resource allocation and emotional support of clinicians. This narrative review outlines how CES can assist clinicians to reflect on, better understand and address, the complex ethical dimensions of their practice. The identified literature demonstrates that early involvement of CES may reduce conflict. More research is needed gathering information from CES directly.
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Affiliation(s)
- Jacob Stevenson
- The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia
| | - Alexandra Clinch
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Maria Ftanou
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- The University of Melbourne School of Population and Global Health, Melbourne, Victoria, Australia
| | - Clare Delany
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- The University of Melbourne Department of Medical Education, Melbourne, Victoria, Australia
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Schürmann J, Reiter-Theil S. What Factors Contribute to Ethical Problems in Patient Care? A Scoping Review and Case Series of Clinical Ethics Consultations. THE JOURNAL OF CLINICAL ETHICS 2024; 35:119-135. [PMID: 38728695 DOI: 10.1086/729414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
AbstractBackground: Healthcare professionals (HCPs) are frequently exposed to ethical problems in patient care that can affect the quality of care. Understanding risk factors for ethical problems may help practitioners to address these problems at an early stage. This study aims to provide an overview of ethical risk factors in patient care. Risk factors known from the literature and those found in clinical ethics consultation (CEC) cases are reviewed. METHODS A scoping review of ethical risk factors in patient care and a CEC case series were conducted, analyzing the documentation (consultation reports, feedback forms, electronic medical records) of 204 CECs from 2012 to 2020 at a somatic and a psychiatric university hospital in Basel, Switzerland. RESULTS Ninety-nine ethical risk factors were identified in nine articles, related to four risk areas: patient (41), family (12), healthcare team (29), and system (17). Eighty-seven of these risk factors were documented at least once in the CEC case series. The most prevalent risk factors in the consultations studied were patient vulnerability (100%), missing or unclear hospital ethics policy (97.1%), shift work (83.3%), lack of understanding between patient and HCP (73.5%), poor communication (66.2%), disagreement between patient and HCP about care (58.8%), and multiple care teams (53.4%). The prevalence differed significantly by medical specialty. CONCLUSIONS There are highly prevalent ethical risk factors at all levels of clinical care that may be used to prevent ethical problems. Further empirical research is needed to analyze risk ratios and to develop specific risk profiles for different medical specialties.
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Kok N, Zegers M, van der Hoeven H, Hoedemaekers C, van Gurp J. Morisprudence: a theoretical framework for studying the relationship linking moral case deliberation, organisational learning and quality improvement. JOURNAL OF MEDICAL ETHICS 2022; 48:medethics-2021-107943. [PMID: 35584897 DOI: 10.1136/medethics-2021-107943] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 05/07/2022] [Indexed: 06/15/2023]
Abstract
There is a claim that clinical ethics support services (CESS) improve healthcare quality within healthcare organisations. However, there is lack of strong evidence supporting this claim. Rather, the current focus is on the quality of CESS themselves or on individual learning outcomes. In response, this article proposes a theoretical framework leading to empirical hypotheses that describe the relationship between a specific type of CESS, moral case deliberation and the quality of care at the organisational level. We combine insights from the literature on CESS, organisational learning and quality improvement and argue that moral case deliberation causes healthcare professionals to acquire practical wisdom. At the organisational level, where improving quality is a continuous and collective endeavour, this practical wisdom can be aggregated into morisprudence, which is an ongoing formulation of moral judgements across cases encountered within the organisation. Focusing on the development of morisprudence enables refined scrutinisation of CESS-related quality claims.
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Affiliation(s)
- Niek Kok
- IQ healthcare, Radboudumc, Nijmegen, The Netherlands
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Kana L, Shuman A, De Vries R, Firn J. Taking the burden off: a study of the quality of ethics consultation in the time of COVID-19. JOURNAL OF MEDICAL ETHICS 2022; 48:244-249. [PMID: 33811113 PMCID: PMC8029040 DOI: 10.1136/medethics-2020-107037] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 03/03/2021] [Accepted: 03/20/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND The quality of ethics consults is notoriously difficult to measure. Survey-based assessments cannot capture nuances of consultations. To address this gap, we conducted interviews with health professionals who requested ethics consults during the initial phase of the COVID-19 pandemic. METHOD Healthcare professionals requesting ethics consultation between March 2020 and May 2020 at a tertiary academic medical centre were eligible to participate. We asked participants to comment on the consults they called and thematically analysed responses to identify features associated with optimal quality consultations. RESULTS Of 14 healthcare providers, 8 (57%) were women and professions were as follows: 11 (79%) medical doctors, 1 (7%) social worker, 1 (7%) physician assistant and 1 (7%) nurse practitioner. Two aspects of quality emerged: satisfaction and value. Themes within the domain of satisfaction included: responsiveness of the ethics consultant, willingness to consult, institutional role of the ethics service and identifying areas for improvement. When describing value, respondents spoke of the intrapersonal and interpersonal worth of consultation. CONCLUSION Participants were generally satisfied with ethics consultation services, similar to opinions of those found in pre-COVID-19 survey studies. Our qualitative approach allowed for a richer exploration of the value of ethics consultation during the pandemic and has implications for ethics consultation services more broadly. Ethics consultation-emphasising both the process and outcome-created valuable moral spaces, promoting thoughtful and ethical responses to dilemmas in patient care. Future assessments should incorporate patient and family/surrogate perspectives and explore the domain of education as an additional quality measure.
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Affiliation(s)
- Lulia Kana
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Andrew Shuman
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Raymond De Vries
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Janice Firn
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Quain A, Mullan S, Ward MP. Risk Factors Associated With Increased Ethically Challenging Situations Encountered by Veterinary Team Members During the COVID-19 Pandemic. Front Vet Sci 2021; 8:752388. [PMID: 34760959 PMCID: PMC8573112 DOI: 10.3389/fvets.2021.752388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/15/2021] [Indexed: 12/24/2022] Open
Abstract
Ethically challenging situations (ECS) are commonly encountered in veterinary settings. The number of ECS encountered by some veterinary team members may increase during a crisis, such as the COVID-19 pandemic. This study aimed to determine the risk factors for experiencing an increase in the frequency of ECS in the months following the beginning of the COVID-19 pandemic, utilizing data from a global survey of veterinarians, veterinary nurses and animal health technicians collected from May to July 2020. In this study, descriptive analyses were performed to characterize veterinary team members who responded to the survey (n = 540). Binomial logistic regression analyses were performed to determine factors associated with an increase in ECS encountered since the beginning of the COVID-19 pandemic. Being a veterinary nurse or animal health technician, working with companion animals, working in the USA or Canada, and being not confident or underconfident in dealing with ECS in the workplace were factors associated with an increase in ECS encountered since the beginning of the COVID-19 pandemic. Results suggest a need to explore the ECS encountered by veterinary team members, particularly veterinary nurses and animal health technicians working in companion animal practice, in depth. Identification of risk factors may facilitate better preparation of veterinary team members for managing ECS, and minimizing the negative impact of ECS on the well-being of those who care for animals.
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Affiliation(s)
- Anne Quain
- Sydney School of Veterinary Science, Faculty of Science, University of Sydney, Camperdown, NSW, Australia
| | - Siobhan Mullan
- UCD School of Veterinary Medicine, University College Dublin, Dublin, Ireland
| | - Michael P Ward
- Sydney School of Veterinary Science, Faculty of Science, University of Sydney, Camperdown, NSW, Australia
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Ethical Challenges Posed by Advanced Veterinary Care in Companion Animal Veterinary Practice. Animals (Basel) 2021; 11:ani11113010. [PMID: 34827742 PMCID: PMC8614270 DOI: 10.3390/ani11113010] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 12/19/2022] Open
Abstract
Simple Summary Veterinary care of companion animals, particularly dogs and cats, continues to advance, with some companion animals receiving a standard of care equal to or exceeding that of human patients. While this has the potential to improve animal welfare and benefit other stakeholders, including animal owners and veterinary team members, it also poses ethical challenges. We discuss key ethical challenges associated with AVC, including its relationship to standards of veterinary care, its potential to perpetuate poor quality of life and suffering, cost and accessibility of veterinary care, conflicts of interest, and concerns about experimentation without appropriate ethical review. We conclude by suggesting some strategies for veterinary teams and other stakeholders, such as professional bodies and regulators, to address these concerns. Abstract Advanced veterinary care (AVC) of companion animals may yield improved clinical outcomes, improved animal welfare, improved satisfaction of veterinary clients, improved satisfaction of veterinary team members, and increased practice profitability. However, it also raises ethical challenges. Yet, what counts as AVC is difficult to pinpoint due to continuing advancements. We discuss some of the challenges in defining advanced veterinary care (AVC), particularly in relation to a standard of care (SOC). We then review key ethical challenges associated with AVC that have been identified in the veterinary ethics literature, including poor quality of life, dysthanasia and caregiver burden, financial cost and accessibility of veterinary care, conflicts of interest, and the absence of ethical review for some patients undergoing AVC. We suggest some strategies to address these concerns, including prospective ethical review utilising ethical frameworks and decision-making tools, the setting of humane end points, the role of regulatory bodies in limiting acceptable procedures, and the normalisation of quality-of-life scoring. We also suggest a role for retrospective ethical review in the form of ethics rounds and clinical auditing. Our discussion reenforces the need for a spectrum of veterinary care for companion animals.
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Bernuzzi C, Setti I, Maffoni M, Sommovigo V. From moral distress to burnout through work-family conflict: the protective role of resilience and positive refocusing. ETHICS & BEHAVIOR 2021. [DOI: 10.1080/10508422.2021.1955682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Chiara Bernuzzi
- Department of Brain and Behavioural Sciences, Unit of Applied Psychology, University of Pavia
| | - Ilaria Setti
- Department of Brain and Behavioural Sciences, Unit of Applied Psychology, University of Pavia
| | - Marina Maffoni
- Psychology Unit of Montescano Institute, Istituti Clinici Scientifici Maugeri IRCCS
| | - Valentina Sommovigo
- Department of Brain and Behavioural Sciences, Unit of Applied Psychology, University of Pavia
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Quain A, Mullan S, McGreevy PD, Ward MP. Frequency, Stressfulness and Type of Ethically Challenging Situations Encountered by Veterinary Team Members During the COVID-19 Pandemic. Front Vet Sci 2021; 8:647108. [PMID: 33912607 PMCID: PMC8071942 DOI: 10.3389/fvets.2021.647108] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/11/2021] [Indexed: 12/22/2022] Open
Abstract
Ethically challenging situations (ECS) are common in veterinary settings and can lead to moral stress. However, there is no published information about how a global pandemic affects the frequency and types of ECS encountered by veterinary team members. An online mixed methods survey was developed to determine the frequency, stressfulness and types of ECS experienced by veterinarians, animal health technicians and veterinary nurses since the advent of the global COVID-19 pandemic in March 2020. Responses from 540 veterinary team members from 22 countries were analyzed. With the advent of the COVID-19 pandemic, the median frequency of ECS encountered by respondents increased from several times per month to several times per week (Spearman Rank Correlation 0.619, P < 0.0001). The most common ECS (encountered at least several times per week) were: challenging decisions about how to proceed when clients have limited finances (64.4%), conflict between personal well-being and professional role (64.3%), conflict between the interests of clients and the interests of their animals (59.6%). These were followed by challenging decisions about what counts as an essential veterinary service (48.1%); conflict between well-being of family/household members and professional role (46.3%); and challenging decisions about whether to perform non-contact veterinary visits (46.3%). The most stressful ECS (reported to be very or maximally stressful) were: conflicts between the interests of clients and the interests of their animals (50.2%), other (42.9%), conflicts between the interests of my employer and my own interests (42.5%), challenging decisions about how to proceed when clients have limited finances (39.4%), conflict between personal well-being and professional role (38.0%), and conflict between well-being of family/household members and professional role (33.6%). Thematic analysis of free-text responses revealed biosecurity, client financial limitations, animal welfare, working conditions, and client relations as prominent themes. This is, to the best of our knowledge, the first study to describe the impacts of the pandemic on ECS experienced by veterinary teams globally. It identifies an increase in the frequency of ECS associated with the COVID-19 pandemic, and a number of stressors unique to the pandemic. We identified a number of resources and strategies that may help veterinary team members navigate ethical challenges that may emerge in their daily work, as well as in the context of global crises.
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Affiliation(s)
- Anne Quain
- Faculty of Science, Sydney School of Veterinary Science, University of Sydney, Camperdown, NSW, Australia
| | - Siobhan Mullan
- Bristol Veterinary School, University of Bristol, Langford, United Kingdom
- University of College Dublin School of Veterinary Medicine, Dublin, Ireland
| | - Paul D. McGreevy
- Faculty of Science, Sydney School of Veterinary Science, University of Sydney, Camperdown, NSW, Australia
| | - Michael P. Ward
- Faculty of Science, Sydney School of Veterinary Science, University of Sydney, Camperdown, NSW, Australia
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Schmitz D, Groß D, Pauli R. Is there a need for a clear advice? A retrospective comparative analysis of ethics consultations with and without recommendations in a maximum-care university hospital. BMC Med Ethics 2021; 22:20. [PMID: 33653322 PMCID: PMC7927398 DOI: 10.1186/s12910-021-00590-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/22/2021] [Indexed: 11/24/2022] Open
Abstract
Background The theory and practice of ethics consultations (ECs) in health care are still characterized by many controversies, including, for example, the practice of giving recommendations. These controversies are complicated by an astonishing lack of evidence in the whole field. It is not clear how often a recommendation is issued in ethics consultations and when and why this step is taken. Especially in a facilitation model in which giving recommendations is optional, more data would be helpful to evaluate daily practice, ensure that this practice is in line with the overarching goals of this approach and support the development of standards. Methods We analyzed all consultations requested from an EC service working under a facilitation approach at a maximum-care university hospital in Germany over a period of more than 10 years. Our aim was to better understand why—and under what circumstances—some consultation requests result in a recommendation, whereas others can be sufficiently addressed solely by facilitated meetings. We especially wanted to know when and why clients felt the need for clear advice from the EC service while in other cases they did not. We compared ethics consultations in terms of the differences between cases with and without recommendations issued by the ethics consultants using χ2 difference tests and Welch’s t-test. Results A total of 243 ECs were carried out between September 2008 and December 2019. In approximately half of the cases, a recommendation was given. All recommendations were issued upon the request of clients. When physicians asked for an EC, the consultation was significantly more likely to result in a recommendation than when the EC was requested by any other party. ECs in cases on wards with ethics rounds resulted in comparably fewer recommendations than those in wards without ethics rounds. When interpersonal conflicts were part of the problem or relatives were present in the meeting, clients less frequently asked for a recommendation. Conclusion From the client’s point of view, there does not seem to be only one “right” way to provide ethics consultations, but rather several. While facilitated meetings are obviously appreciated by clients, there also seem to be situations in which a recommendation is desired (especially by physicians). Further empirical and theoretical research is needed to validate our single-center results and re-evaluate the role of recommendations in ethics consultations. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00590-x.
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Affiliation(s)
- Dagmar Schmitz
- Institute for History, Theory and Ethics in Medicine, RWTH Aachen University, Wendlingweg 2, 52074, Aachen, Germany.
| | - Dominik Groß
- Institute for History, Theory and Ethics in Medicine, RWTH Aachen University, Wendlingweg 2, 52074, Aachen, Germany
| | - Roman Pauli
- Institute for History, Theory and Ethics in Medicine, RWTH Aachen University, Wendlingweg 2, 52074, Aachen, Germany
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