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Koivisto T, Paavolainen M, Olin N, Korkiakangas E, Laitinen J. Strategies to mitigate moral distress as reported by eldercare professionals. Int J Qual Stud Health Well-being 2024; 19:2315635. [PMID: 38373153 PMCID: PMC10878340 DOI: 10.1080/17482631.2024.2315635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 02/03/2024] [Indexed: 02/21/2024] Open
Abstract
Eldercare workers experience higher levels of moral distress than other health and social care service workers. Moral distress is a psychological response to a morally challenging event. Very little is known about moral distress in the context of eldercare and about the mechanisms of preventing or mitigating moral distress. This qualitative study was conducted as part of the "Ensuring the availability of staff and the attractiveness of the sector in eldercareservices" project in Finland in 2021. The data were from 39 semi-structured interviews. This qualitative interview data were examined using two-stage content analysis. The key finding of this study, as reported by eldercare professionals, is that strategies to mitigate moral distress can be found at all organizational levels : organizational, workplace and individual. The tools that emerged from the interviews fell into four main categories:) organizational support and education 2) peer support 3) improving self-care and competence and 4) defending patients. The main identified categories confirmed the earlier findings but the qualitative, rich research interview data provided new insights into a little-studied topic: mitigating moral distress in eldercare. The main conclusion is that, in order to mitigate moral distress, ethical competence needs to be strengthened at all organizational levels.
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Affiliation(s)
- Tiina Koivisto
- CONTACT Tiina Koivisto Finnish Institute of Occupational Health, PO Box 40, Helsinki00032, Finland
| | | | - Nina Olin
- Finnish Institute of Occupational Health, Helsinki, Finland
| | | | - Jaana Laitinen
- Finnish Institute of Occupational Health, Helsinki, Finland
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You J, Kim M, Son S, Lee I. Organ Donation and Transplantation Coordinators' Experience and needs for ethics education. Nurs Ethics 2024:9697330241265405. [PMID: 39033308 DOI: 10.1177/09697330241265405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
BACKGROUND Transplant coordinators face ethical conflicts in various situations, such as deciding who should receive organ donations and how to consider patient costs and such conflicts are expected to be more frequent in Korea, as organ transplant coordinators in the country perform both organ acquisition and transplantation. RESEARCH AIM This study aims to develop an ethics education program to enhance organ transplant coordinators' ethical competence and address the ethical conflicts faced by them during clinical practice. RESEARCH DESIGN A descriptive study. PARTICIPANTS AND RESEARCH CONTEXT An online survey was conducted from March 22 to May 28, 2021. The study was conducted among 160 registered members of the Korea Organ Transplant Coordinators Association. Ultimately, 87 participants agreed to participate in the study. ETHICAL CONSIDERATIONS Permission to conduct the study was obtained from the Institutional Review Board. RESULTS The study revealed variations in the degree of ethical conflict based on the participants' general characteristics. Furthermore, organ transplant coordinators exhibited high levels of ethical competence and expressed a need for ethics education. The findings also indicated a positive correlation between higher ethical competence and greater demand for ethics education. CONCLUSIONS Based on the findings, developing standardized ethics education programs tailored to organ transplant coordinators is recommended. These programs should focus on improving ethical decision-making skills and establishing professional ethics. The education provided should be practical, applicable in the clinical setting, and responsive to the participants' awareness and concerns regarding ethics education.
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Affiliation(s)
- Jayoung You
- Yonsei University
- Severance Hospital, Yonsei University Health System
| | | | - Sunyoung Son
- Gangnam Severance Hospital, Yonsei University Health System
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Naamati-Schneider L, Arazi-Fadlon M, Daphna-Tekoah S. Strategic technological processes in hospitals: Conflicts and personal experiences of healthcare teams. Nurs Ethics 2024:9697330241252876. [PMID: 38738983 DOI: 10.1177/09697330241252876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
BACKGROUND Global health systems operate amid dynamic factors, including demographic shifts, economic variations, political changes, technological progress, and societal trends that lead to VUCA reality (Volatility, Uncertainty, Complexity, and Ambiguity). To address these challenges, healthcare organizations are increasingly turning to Strategic Technological Processes and digital transformation. RESEARCH OBJECTIVE Against this background, the current study examined the personal experiences, conflicts, difficulties, and moral dilemmas attendant upon accommodating this digital transformation of healthcare professionals. PARTICIPANTS The study involved 27 healthcare professionals working in Israeli hospitals, whose experiences and perspectives were central to understanding the impact of digital transformation in healthcare settings. RESEARCH DESIGN The study methodology rested on in-depth interviews, which were analyzed through the prism of the Listening Guide analytical technique. ETHICAL CONSIDERATIONS The research obtained pre-approval from the Ethics Committee at the researcher's institution. FINDINGS The study revealed that the healthcare professionals are indeed facing ethical conflicts and personal challenges related to digitalization (such as providing the best quality of care, being the best caregiver, and acting for the betterment of the hospital). It also identified dilemmas resulting from conflicts between the needs and demands of the health system and the healthcare professionals' values and resources. DISCUSSION The study findings highlight the impact of ethical and moral challenges accompanying strategic organizational and digital transformation changes implemented by healthcare organizations worldwide. These challenges arise as healthcare institutions adapt to the demands of the 21st century, potentially leading to burnout and moral distress among healthcare professionals, further exacerbating the already stressful reality they face. CONCLUSION In conclusion, the study emphasizes the critical necessity for comprehensive support strategies to alleviate stress and burnout among healthcare professionals. As healthcare organizations and personnel navigate significant organizational changes to address contemporary challenges, prioritizing the well-being of healthcare workers through effective support mechanisms becomes imperative.
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Wiisak J, Stolt M, Igoumenidis M, Chiappinotto S, Gastmans C, Keogh B, Mertens E, Palese A, Papastavrou E, Mc Cabe C, Suhonen R. Factors contributing to the promotion of moral competence in nursing. Nurs Ethics 2024:9697330241235305. [PMID: 38504620 DOI: 10.1177/09697330241235305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
Ethics is a foundational competency in healthcare inherent in everyday nursing practice. Therefore, the promotion of qualified nurses' and nursing students' moral competence is essential to ensure ethically high-quality and sustainable healthcare. The aim of this integrative literature review is to identify the factors contributing to the promotion of qualified nurses' and nursing students' moral competence. The review has been registered in PROSPERO (CRD42023386947) and reported according to the PRISMA guideline. Focusing on qualified nurses' and nursing students' moral competence, a literature search was undertaken in January 2023 in six scientific databases: CINAHL, Cochrane Library, PsycINFO, PubMed Medline, Scopus and Web of Science. Empirical studies written in English without time limitation were eligible for inclusion. A total of 29 full texts were retrieved and included out of 5233 citations. Quality appraisal was employed using Joanna Briggs Institute checklists and the Mixed Method Appraisal Tool. Data were analysed using inductive content analysis. Research about the factors contributing to the promotion of qualified nurses' and nursing students' moral competence is limited and mainly explored using descriptive research designs. The contributing factors were identified as comprising two main categories: (1) human factors, consisting of four categories: individual, social, managerial and professional factors, and ten sub-categories; and (2) structural factors, consisting of four categories: educational, environmental, organisational and societal factors, and eight sub-categories. This review provides knowledge about the factors contributing to the promotion of qualified nurses' and nursing students' moral competence for the use of researchers, nurse educators, managers, organisations and policymakers. More research about the contributing factors is needed using complex intervention, implementation and multiple methods designs to ensure ethically sustainable healthcare.
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Affiliation(s)
| | - Minna Stolt
- University of Turku; Wellbeing Services County of Satakunta
| | | | | | | | | | | | | | | | | | - Riitta Suhonen
- University of Turku; Turku University Hospital; Wellbeing Services County of Southwest Finland
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van Schaik M, Kröger C, Zuidema L, Stolper M, Widdershoven G, Pasman HR, Metselaar S. Training nurses to facilitate and implement CURA in palliative care institutions: development and evaluation of a blended learning program. BMC Palliat Care 2023; 22:158. [PMID: 37865740 PMCID: PMC10590004 DOI: 10.1186/s12904-023-01284-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 10/13/2023] [Indexed: 10/23/2023] Open
Abstract
BACKGROUND Healthcare professionals in palliative care are found to be confronted with moral challenges on a frequent basis. CURA is a low-threshold instrument for dialogical ethical reflection that was developed to deal with these challenges. A previous study identified the need of healthcare professionals to be trained to introduce CURA in their organization, initiate and facilitate reflections with CURA, and contribute to the implementation of CURA. The aim of this study was to develop and evaluate a training for professionals to become 'CURA-ambassadors'. METHODS The training was developed in a participatory way in two cycles. We trained 72 healthcare professionals. The training was evaluated by means of a questionnaire and six semi-structured interviews. RESULTS The study resulted in a blended learning training combining training sessions with an e-module and with practicing with organizing and facilitating CURA in daily healthcare practice. The main objectives of the training are to enable CURA-ambassadors to introduce CURA within their organization, initiate and facilitate ethical reflections using CURA, and contribute to the implementation of CURA. Participants were generally positive about the training program and the trainers. Technical difficulties related to the e-module were mentioned as main point of improvement. DISCUSSION The training program can generate ownership, responsibility, and competency among CURA-ambassadors, which are essential foundations for implementing complex interventions in healthcare practice. The training program received positive evaluations shortly after completing the program. This study adds to our understanding of what is needed for healthcare professionals to use CURA, in order to support them in dealing with moral challenges and to foster their moral resilience. Further research is needed to assess whether participants experience the training as sufficient and effective when using and implementing CURA structurally in their organizations over a longer period of time.
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Affiliation(s)
- Malene van Schaik
- Department of Ethics, Law and Humanities, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands.
| | - Charlotte Kröger
- Department of Ethics, Law and Humanities, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Lisa Zuidema
- Department of Ethics, Law and Humanities, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Margreet Stolper
- Department of Ethics, Law and Humanities, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Guy Widdershoven
- Department of Ethics, Law and Humanities, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - H Roeline Pasman
- Department of Public and Occupational Health, Expertise Center for Palliative Care, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Suzanne Metselaar
- Department of Ethics, Law and Humanities, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
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Amos V, Phair N, Sullivan K, Wocial LD, Epstein B. A Novel Web-Based and Mobile Application to Measure Real-Time Moral Distress: An Initial Pilot and Feasibility Study. Jt Comm J Qual Patient Saf 2023; 49:494-501. [PMID: 37336696 DOI: 10.1016/j.jcjq.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/19/2023] [Accepted: 05/24/2023] [Indexed: 06/21/2023]
Abstract
PROBLEM DEFINITION Moral distress (MoD) is a vital clinical indicator linked to clinician burnout and provider concerns about declining patient care quality. Yet it is not routinely assessed. Earlier, real-time recognition may better target interventions aimed at alleviating MoD and thereby increase provider well-being and improve patient care quality. INITIAL APPROACH AND TESTING Combining two validated MoD instruments (the Moral Distress Thermometer [MDT] and the Measure of Moral Distress for Healthcare Professionals [MMD-HP]), the authors developed a novel mobile and Web-based application environment to measure and report levels MoD and their associated causes. This app was tested for basic feasibility and acceptability in two groups: graduate nursing students and practicing critical care nurses. RESULTS The MDT app appears feasible and acceptable for future use. All participants (n = 34) indicated the MDT app was satisfying to use, and 91.2% (n = 31) indicated the app was "very appropriate" for measuring MoD. In addition, 84.2% (n =16) of practicing nurses indicated the app fit either "somewhat well" (47.4%, n = 9) or "very well" (36.8%, n = 7) into their typical workday, and 68.4% (n = 13) said they were either "extremely likely" or "somewhat likely" to use the app daily in clinical practice. KEY INSIGHTS AND NEXT STEPS Education about moral distress and its associated causes proved important to the MDT app's success. It is ready for future validity and reliability testing, as well as examining usability beyond nursing, longitudinal data monitoring, and possible leveraging to pre- and postintervention evaluation studies.
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Mashayekhi J, Mafinejad MK. Mapping the core competencies and entrustable professional activities of medical ethics for faculty members. BMC MEDICAL EDUCATION 2023; 23:409. [PMID: 37277754 DOI: 10.1186/s12909-023-04305-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 04/28/2023] [Indexed: 06/07/2023]
Abstract
INTRODUCTION The present study aimed to develop core competencies and Entrustable Professional Activities (EPAs) for faculty members through participating in faculty development programs in medical ethics. METHODS This study included five stages. First, categories and subcategories were extracted based on the literature review and interviews with 14 experts and through inductive content analysis. Second, the content validity of the core competency list was checked by 16 experts using qualitative and quantitative approaches. Third, based on the previous phase, a framework for EPAs was developed by the taskforce in two sessions through consensus. Fourth, the content validity of the list of EPAs was compiled based on a three-point Likert 11 medical ethics experts from necessity and relevance perspectives. Fifth, EPAs were mapped by ten experts to the developed core competencies. RESULTS After conducting the literature review and interviews, 295 codes were extracted, which were further classified into six categories and 18 subcategories. Finally, five core competencies and 23 EPAs were developed. The core competencies include "Teaching medical ethics", "Research and scholarship in the field of medical ethics", "Communication skills", "Moral reasoning", and "Policy-making, decision-making, and ethical leadership". CONCLUSION Medical teachers can be effective in the moralizing healthcare system. Findings showed that faculty members should acquire core competencies and EPAs for proficiently integrating medical ethics into curricula. Faculty development programs can be designed in medical ethics for faculty members to help them to acquire core competencies and EPAs.
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Affiliation(s)
- Jannat Mashayekhi
- Medical Ethics Department, Medical school, Quran and Hadith Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mahboobeh Khabaz Mafinejad
- Health Professions Education Research Center, Education Development Center, Department of Medical Education, Tehran University of Medical Sciences, Tehran, Iran.
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Pennestrì F, Villa G, Giannetta N, Sala R, Manara DF, Mordacci R. Training Ethical Competence in a World Growing Old: A Multimethod Ethical Round in Hospital and Residential Care Settings. JOURNAL OF BIOETHICAL INQUIRY 2023; 20:279-294. [PMID: 36959489 PMCID: PMC10035964 DOI: 10.1007/s11673-023-10236-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/20/2022] [Indexed: 06/18/2023]
Abstract
Ethical challenges are traditionally described in a negative light, even though moral conflict can express the individual ability to perceive when something is not working and promote change. The true question, therefore, is not to how to silence moral conflict but how to educate it. Although the need for ethical support of health- and social-care professionals in elderly care is clearly perceived, there is no universal method for providing effective interventions. The authors hypothesize that adequate training sessions can help care professionals enhance this skill, once clear goals and specific educational techniques are set. This research tests the hypothesis on twenty care professionals working in acute and residential care settings for the elderly, building on the ethics round method. Mixed methods drawn from literature and the experience of educators were adapted to meet different educational goals. Moral issues can hardly be removed from a context characterized by increasing demand and decreasing resources, but they can be recognized and addressed with common efforts, a critical attitude, and a growth mindset. Enhancing these skills in qualified workers can help them accept the reality of work, release pressure, and identify common team goals. Introducing these skills before graduation can help future workers avoid unreal expectations and reduce frustration and early job quit rates.
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Affiliation(s)
- Federico Pennestrì
- Faculty of Philosophy, Vita-Salute San Raffaele University, Via Olgettina 58, 20132 Milan, Italy
| | - Giulia Villa
- Centre for Nursing Research and Innovation, Vita-Salute San Raffaele University, Via Olgettina 58, 20132 Milan, Italy
| | - Noemi Giannetta
- Faculty of Philosophy, Vita-Salute San Raffaele University, Via Olgettina 58, 20132 Milan, Italy
- Centre for Nursing Research and Innovation, Vita-Salute San Raffaele University, Via Olgettina 58, 20132 Milan, Italy
| | - Roberta Sala
- Faculty of Philosophy, Vita-Salute San Raffaele University, Via Olgettina 58, 20132 Milan, Italy
| | - Duilio Fiorenzo Manara
- Centre for Nursing Research and Innovation, Vita-Salute San Raffaele University, Via Olgettina 58, 20132 Milan, Italy
| | - Roberto Mordacci
- Faculty of Philosophy, Vita-Salute San Raffaele University, Via Olgettina 58, 20132 Milan, Italy
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Elderly Care Practitioners' Perceptions of Moral Distress in the Work Development Discussions. Healthcare (Basel) 2023; 11:healthcare11030291. [PMID: 36766866 PMCID: PMC9914093 DOI: 10.3390/healthcare11030291] [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: 12/19/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/19/2023] Open
Abstract
Elderly care practitioners are at specific risk of experiencing prolonged moral distress, which is associated with occupational health-related problems, low job satisfaction, and staff turnover. So far, little attention has been paid to the moral concerns specific to elderly care, a field whose importance is constantly growing as the populations in Western countries age. By drawing on seven workshop conversations as data and interaction-oriented focus group research, conversation analysis and discursive psychology as methods, we aim to study the ways in which elderly care practitioners discuss moral distress in their work. We found that the moral distress experienced was related to three topics that arose when client work and teamwork contexts were discussed: the power to influence, equal treatment of people, and collaboration. The interaction in client work and teamwork contexts differed systematically. The discussion on client work was characterised by negotiations on the rights and wrongs of care work, whereas the teamwork discussion engendered emotional outbursts, a potential manifestation of work-related burnout. Hence, attempts to improve the work-related health of elderly care practitioners require time and space for sharing the emotional load, followed by reflection on what could be improved in the work and what institutional solutions could help in morally distressing situations.
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Davies J, Brockie A, Breeze J. Bioethics in humanitarian disaster relief operations: a military perspective. BMJ Mil Health 2022; 168:449-452. [PMID: 34266976 DOI: 10.1136/bmjmilitary-2021-001927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 06/22/2021] [Indexed: 11/03/2022]
Abstract
The ethical dilemmas faced every day by military personnel working within the NHS will potentially be very different to ones that will be faced in the wake of a humanitarian disaster. Allied to this the potentially differing objectives from military personnel when compared with other healthcare workers in these scenarios and a conflict of ethics could arise.Within this paper, the fundamentals of this conflict will be explored and how working within the military framework can affect clinical decisions. This is a paper commissioned as a part of the humanitarian and disaster relief operations special issue of BMJ Military Health.
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Affiliation(s)
- James Davies
- Department of Maxillofacial Surgery, University Hospitals Birmingham, Birmingham, UK
| | - A Brockie
- Headquarters Joint Hospital Group, Plymouth, UK
| | - J Breeze
- Department of Maxillofacial Surgery, University Hospitals Birmingham, Birmingham, UK
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Arends SAM, Steenbergen M, Thodé M, Francke AL, Jongerden IP. Moral distress among nurses involved in life-prolonging treatments in patients with a short life expectancy: A qualitative interview study. PATIENT EDUCATION AND COUNSELING 2022; 105:2531-2536. [PMID: 35123835 DOI: 10.1016/j.pec.2022.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 12/17/2021] [Accepted: 01/25/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To explore whether nurses in hospital settings experience moral distress when involved in potentially life-prolonging treatments in adults with a short life expectancy. METHODS A qualitative study using semi-structured interviews. RESULTS 23 Registered nurses working in inpatient or outpatient hospital settings participated. The nurses stated they were often not involved in decisions regarding life-prolonging treatments. They reported signs of moral distress such as feeling powerless when they when they were not being listened to in the decision-making process and when confronted with negative treatment outcomes. Nurses felt frustrated when their own values were not reflected in the decision-making or when physicians created unrealistic expectations. CONCLUSIONS Hospital nurses experience moral distress when they are involved in life-prolonging treatment because of the patient's advanced condition and their own lack of involvement in the decision-making process about the treatment. In these situations, moral distress is characterised by feelings of powerlessness and frustration. PRACTICE IMPLICATIONS Nurses need to be empowered by training programmes that focus on an active role in the decision-making process. Further research is needed to evaluate effective tools and training programmes that help nurses in shared decision-making processes.
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Affiliation(s)
- Susanne A M Arends
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Public and Occupational Health and Amsterdam Public Health Research Institute, Amsterdam, Netherlands.
| | | | - Maureen Thodé
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Public and Occupational Health and Amsterdam Public Health Research Institute, Amsterdam, Netherlands.
| | - Anneke L Francke
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Public and Occupational Health and Amsterdam Public Health Research Institute, Amsterdam, Netherlands; Nivel. Netherlands Institute for Health Services Research, P.O. Box 1568, 3500 BN Utrecht, Netherlands.
| | - Irene P Jongerden
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Public and Occupational Health and Amsterdam Public Health Research Institute, Amsterdam, Netherlands.
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Andersson H, Svensson A, Frank C, Rantala A, Holmberg M, Bremer A. Ethics education to support ethical competence learning in healthcare: an integrative systematic review. BMC Med Ethics 2022; 23:29. [PMID: 35305627 PMCID: PMC8933936 DOI: 10.1186/s12910-022-00766-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/07/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Ethical problems in everyday healthcare work emerge for many reasons and constitute threats to ethical values. If these threats are not managed appropriately, there is a risk that the patient may be inflicted with moral harm or injury, while healthcare professionals are at risk of feeling moral distress. Therefore, it is essential to support the learning and development of ethical competencies among healthcare professionals and students. The aim of this study was to explore the available literature regarding ethics education that promotes ethical competence learning for healthcare professionals and students undergoing training in healthcare professions. METHODS In this integrative systematic review, literature was searched within the PubMed, CINAHL, and PsycInfo databases using the search terms 'health personnel', 'students', 'ethics', 'moral', 'simulation', and 'teaching'. In total, 40 articles were selected for review. These articles included professionals from various healthcare professions and students who trained in these professions as subjects. The articles described participation in various forms of ethics education. Data were extracted and synthesised using thematic analysis. RESULTS The review identified the need for support to make ethical competence learning possible, which in the long run was considered to promote the ability to manage ethical problems. Ethical competence learning was found to be helpful to healthcare professionals and students in drawing attention to ethical problems that they were not previously aware of. Dealing with ethical problems is primarily about reasoning about what is right and in the patient's best interests, along with making decisions about what needs to be done in a specific situation. CONCLUSIONS The review identified different designs and course content for ethics education to support ethical competence learning. The findings could be used to develop healthcare professionals' and students' readiness and capabilities to recognise as well as to respond appropriately to ethically problematic work situations.
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Affiliation(s)
- Henrik Andersson
- Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden.
- Centre of Interprofessional Collaboration within Emergency Care (CICE), Linnaeus University, Växjö, Sweden.
- Faculty of Caring Science, Work Life, and Social Welfare, University of Borås, 50190, Borås, Sweden.
| | - Anders Svensson
- Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
- Centre of Interprofessional Collaboration within Emergency Care (CICE), Linnaeus University, Växjö, Sweden
- Department of Ambulance Service, Region Kronoberg, Växjö, Sweden
| | - Catharina Frank
- Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
- Centre of Interprofessional Collaboration within Emergency Care (CICE), Linnaeus University, Växjö, Sweden
| | - Andreas Rantala
- Centre of Interprofessional Collaboration within Emergency Care (CICE), Linnaeus University, Växjö, Sweden
- Department of Health Sciences, Lund University, Lund, Sweden
- Emergency Department, Helsingborg General Hospital, Helsingborg, Sweden
| | - Mats Holmberg
- Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
- Centre of Interprofessional Collaboration within Emergency Care (CICE), Linnaeus University, Växjö, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
- Department of Ambulance Service, Region Sörmland, Katrineholm, Sweden
| | - Anders Bremer
- Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
- Centre of Interprofessional Collaboration within Emergency Care (CICE), Linnaeus University, Växjö, Sweden
- Department of Ambulance Service, Region Kalmar County, Kalmar, Sweden
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Naamanka K, Suhonen R, Tolvanen A, Leino-Kilpi H. Ethical competence - exploring situations in physiotherapy practice. Physiother Theory Pract 2022; 39:1237-1248. [DOI: 10.1080/09593985.2022.2039817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Kati Naamanka
- Department of Nursing Science/Turku University of Applied Sciences, University of Turku, Turku, Finland
| | - Riitta Suhonen
- Department of Nursing Science/Turku University of Applied Sciences, University of Turku, Turku, Finland
| | - Anna Tolvanen
- Department of Nursing Science/Turku University of Applied Sciences, University of Turku, Turku, Finland
| | - Helena Leino-Kilpi
- Department of Nursing Science/Turku University of Applied Sciences, University of Turku, Turku, Finland
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Abstract
Moral distress has been well reviewed in the literature with established deleterious side effects for all healthcare professionals, including nurses, physicians, and others. Yet, little is known about the quality and effectiveness of interventions directed to address moral distress. The aim of this integrative review is to analyze published intervention studies to determine their efficacy and applicability across hospital settings. Of the initial 1373 articles discovered in October 2020, 18 were appraised as relevant, with 1 study added by hand search and 2 after a repeated search was completed in January and then in May of 2021, for a total of 22 reviewed articles. This review revealed data mostly from nurses, with some studies making efforts to include other healthcare professions who have experienced moral distress. Education-based interventions showed the most success, though many reported limited power and few revealed statistically lowered moral distress post intervention. This may point to the difficulty in adequately addressing moral distress in real time without adequate support systems. Ultimately, these studies suggest potential frameworks which, when bolstered by organization-wide support, may aid in moral distress interventions making a measurable impact.
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Kilkku N, Halkoaho A. Informed consent, genomic research and mental health: A integrative review. Nurs Ethics 2022; 29:973-987. [PMID: 35119339 PMCID: PMC9289972 DOI: 10.1177/09697330211066573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Research on genomics has increased while the biobank activities are becoming more common in different countries. In the mental health field, the questions concerning the potential participants' vulnerability as well as capacity to give the informed consent can cause reluctancy in recruiting persons with mental health problems, although the knowledge and understanding of mental health problems has remarkable changed, and practice is guided with inclusive approaches, such as recovery approach. AIM The aim of this study was to describe the current knowledge of informed consent practices in the context of genomic research on mental health from the nurses' viewpoint. METHODS An integrative review was conducted with search from seven international databases. Data consist 14 publications which were analyzed with thematic analysis. ETHICAL CONSIDERATIONS Ethical requirements were respected in every phase of the research process. FINDINGS Most of the papers were published in USA and between 2000-2010. Eight reports were categorized as discussion papers, four qualitative studies and one quantitative study. The thematic analysis provided information on five themes: complexity with the capacity to consent, mixed emotions towards participation, factors influencing the decision to participate, nurses' informed consent process competence and variations between consent procedures. DISCUSSION In the informed consent practices, there are various aspects which may affect both the willingness to participate in the study and the informed consent process itself. Implications for practice, education, research, and policies are discussed. CONCLUSION There is a need for more updated international research on the topic in the context of different international and national guidelines, legislation, and directives. This study provided a viewpoint to the more collaborative research activities with people with lived experiences also in this field of research following the ideas of recovery approach.
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Affiliation(s)
- Nina Kilkku
- School of Social Services and Health Care, 20615Tampere University of Applied Sciences, Tampere, Finland
| | - Arja Halkoaho
- School of Health, 52917Tampere University of Applied Sciences, Tampere, Finland Corresponding author
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Fino LB, Alsayed AR, Basheti IA, Saini B, Moles R, Chaar BB. Implementing and evaluating a course in professional ethics for an undergraduate pharmacy curriculum: A feasibility study. CURRENTS IN PHARMACY TEACHING & LEARNING 2022; 14:88-105. [PMID: 35125200 DOI: 10.1016/j.cptl.2021.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 07/23/2021] [Accepted: 11/28/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Pharmacy practice today mandates "patient-centered care", thereby assigning higher levels of professional responsibility for pharmacists leading to ethical challenges. These challenges often involve ethical principles, institutional, personal, or other constraints that can pull practitioners in incompatible opposite directions, creating "ethical dilemmas" in many circumstances. Pharmacists are expected to handle challenges competently and in the best interest of patients. Literature underlines the positive impact of educational interventions focusing on ethical awareness and competence, and that "gaps" existed in pharmacy training/curricula for Jordanian pharmacists. The objective of this study was to develop, implement, and evaluate the utility of a tailored ethics education component in the pharmacy curriculum for students enrolled at a well-ranked Jordanian university. EDUCATIONAL ACTIVITY AND SETTING Fifth-year pharmacy students attending summer school at a university in Jordan from July to September 2020 were invited to participate in an educational intervention (suite of didactic online lectures and skills-based workshops). This study was delivered in four parts, with a pretest administered immediately before and a posttest survey immediately after the educational intervention, the educational intervention (three phases), and focus-group discussions to elicit students' feedback. FINDINGS Findings indicated enhanced levels of confidence in students' decision-making. The development of students' moral reasoning and decision-making skills were also observed to be improved. SUMMARY This study highlighted the importance of the implementation of an ethics course in pharmacy undergraduate curricula. It emphasized the positive impact this course made on the students' learning experiences and provided a strong environment for discussion and group learning.
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Affiliation(s)
- Leen B Fino
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney NSW, 2006, Australia; President of Applied Science Private University, Amman, Jordan.
| | - Ahmad R Alsayed
- President of Applied Science Private University, Amman, Jordan.
| | - Iman A Basheti
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney NSW, 2006, Australia; President of Applied Science Private University, Amman, Jordan.
| | - Bandana Saini
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney NSW, 2006, Australia.
| | - Rebekah Moles
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney NSW, 2006, Australia.
| | - Betty B Chaar
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney NSW, 2006, Australia.
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van Schaik MV, Pasman HR, Widdershoven G, Molewijk B, Metselaar S. CURA-An Ethics Support Instrument for Nurses in Palliative Care. Feasibility and First Perceived Outcomes. HEC Forum 2021; 35:139-159. [PMID: 34888756 PMCID: PMC10167118 DOI: 10.1007/s10730-021-09456-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 11/28/2022]
Abstract
Evaluating the feasibility and first perceived outcomes of a newly developed clinical ethics support instrument called CURA. This instrument is tailored to the needs of nurses that provide palliative care and is intended to foster both moral competences and moral resilience. This study is a descriptive cross-sectional evaluation study. Respondents consisted of nurses and nurse assistants (n = 97) following a continuing education program (course participants) and colleagues of these course participants (n = 124). Two questionnaires with five-point Likert scales were used. The feasibility questionnaire was given to all respondents, the perceived outcomes questionnaire only to the course participants. Data collection took place over a period of six months. Respondents were predominantly positive on most items of the feasibility questionnaire. The steps of CURA are clearly described (84% of course participants agreed or strongly agreed, 94% of colleagues) and easy to apply (78-87%). The perceived outcomes showed that CURA helped respondents to reflect on moral challenges (71% (strongly) agreed), in perspective taking (67%), with being aware of moral challenges (63%) and in dealing with moral distress (54%). Respondents did experience organizational barriers: only half of the respondents (strongly) agreed that they could easily find time for using CURA. CURA is a feasible instrument for nurses and nurse assistants providing palliative care. However, reported difficulties in organizing and making time for reflections with CURA indicate organizational preconditions ought to be met in order to implement CURA in daily practice. Furthermore, these results indicate that CURA helps to build moral competences and fosters moral resilience.
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Affiliation(s)
- Malene Vera van Schaik
- Amsterdam UMC, Location VU Medical Centre, Amsterdam, The Netherlands. .,Department of Ethics, Law and Humanities, Amsterdam UMC Location VUmc, De Boelelaan 1089a, 1081 HV, Amsterdam, The Netherlands.
| | - H Roeline Pasman
- Amsterdam UMC, Location VU Medical Centre, Amsterdam, The Netherlands
| | - Guy Widdershoven
- Amsterdam UMC, Location VU Medical Centre, Amsterdam, The Netherlands
| | - Bert Molewijk
- Amsterdam UMC, Location VU Medical Centre, Amsterdam, The Netherlands.,Centre for Medical Ethics, University of Oslo, Oslo, Norway
| | - Suzanne Metselaar
- Amsterdam UMC, Location VU Medical Centre, Amsterdam, The Netherlands
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How Attendings Can Help Residents Navigate Moral Distress: A Qualitative Study. Acad Pediatr 2021; 21:1458-1466. [PMID: 34146721 DOI: 10.1016/j.acap.2021.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 05/26/2021] [Accepted: 06/07/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To explore how pediatric hospitalist attendings can recognize, prevent, and mitigate moral distress among pediatric residents. METHODS We conducted a qualitative study, utilizing a deductive approach, from August 2019 to February 2020 at 4 university-affiliated, freestanding children's hospitals in the United States using semistructured, one-on-one interviews with pediatric residents and pediatric hospitalist attendings. All transcripts were coded by pairs of research team members. Using constant comparative analysis, codes were categorized into themes and subsequently grouped into domains. We then conceptualized the relationships between the domains. RESULTS We interviewed 40 physicians (18 residents, 22 attendings) and identified specific strategies for attendings to help residents navigate moral distress, which were categorized into 4 proactive and 4 responsive themes. The proactive themes included strategies employed before morally distressing events to minimize impact: ensuring attendings' awareness of residency factors influencing residents' moral distress; knowing available support resources; creating a learning environment that lays the foundation for mitigating distress; and recognizing moral distress in residents. The responsive themes included strategies that help mitigate the impact of morally distressing situations after they occur: partnering with the senior resident to develop a team-specific plan; consideration of who will participate in, the timing of, and content of the debrief. CONCLUSIONS We present multiple strategies that attendings can implement to learn to recognize, prevent, and mitigate moral distress among residents. Our findings highlight the need for both proactive and reactive strategies and offer a possible roadmap for attending physicians to help their residents navigate moral distress.
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Moral Distress in Community and Hospital Settings for the Care of Elderly People. A Grounded Theory Qualitative Study. Healthcare (Basel) 2021; 9:healthcare9101307. [PMID: 34682986 PMCID: PMC8544437 DOI: 10.3390/healthcare9101307] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/26/2021] [Accepted: 09/27/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Moral distress has frequently been investigated in single healthcare settings and concerning a single type of professional. This study aimed to describe the experience of moral distress in all the types of professionals providing daily care to elderly patients and residents. Methods: The Grounded Theory approach, developed by Corbin and Strauss, was used. This study included participants from hospital and nursing homes of northern Italy. Purposive and theoretical sampling was used. Between December 2020 and April 2021, semi-structured interviews were conducted. Results: Thirteen participants were included in the study. Four categories were derived from the data: talking and listening, care provider wellbeing, decision making, protective factors, and potential solutions. The core category identified was “sharing daily”. Interviewees confirm how hard it may be to communicate to the elderly, but at the same time, how adequate communication with the leader is a protective factor of moral distress. They also confirm how communication is key to managing or downsizing misunderstandings at all levels. Findings highlight the scarcity of operators as a fundamental trigger of moral distress. Conclusions: Many determinants of this phenomenon lie behind the direct control of professionals, but education can help them learn how to prevent, manage, or downsize the consequences.
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Maluwa VM, Maluwa AO, Mwalabu G, Msiska G. Assessment of ethical competence among clinical nurses in health facilities. Nurs Ethics 2021; 29:181-193. [PMID: 34346258 DOI: 10.1177/09697330211010259] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Ethical competence in nursing practice helps clinical nurses to think critically, analyse issues, make ethical decisions, solve ethical problems and behave ethically in their daily work. Thus, ethical competence contributes to the promotion of high-quality care. However, studies on ethical competence in Malawi are scanty. OBJECTIVES The aim of this study was to explore ethical competence among clinical nurses in selected hospitals in Malawi. METHODOLOGY A cross-sectional survey was conducted in four selected hospitals in Malawi with a sample of 271 clinical nurses. Data were collected using self-administered questionnaires, which included a Moral Competence Scale for Home Care Nurses. Descriptive statistics and logistic regression were computed for the dataset using STATA version 12.0. ETHICAL CONSIDERATION The study protocol complied with all ethical requirements and was approved by the College of Medicine Research Ethics Committee under the University of Malawi. RESULTS The clinical nurses in Malawi are ethically competent. However, there is a significantly high number (p < 0.05) of nurses 57% (n = 135) with low ethical competence. There was no significant association between respondents' demographic variables and level of ethical competence (p > 0.05). Three determinants of high ethical competence level (strong will, judgement skills and recognition of discrepancy of intention) were identified through a reduced model after stepwise logistic regression analysis. Furthermore, results show that indicators of ethical competence include caring, confidentiality and observance of nurses dressing code. The study has also confirmed that the Moral Competence Scale for Home Care Nurses is a reliable tool to assess ethical competence in low-resource settings. CONCLUSION The majority of nurses who completed the survey had low ethical competence. However, clinical nurses with high ethical competence level are required to competently manage complex ethical challenges in health facilities. Strategies for enhancing ethical competence such as continuing ethics education, establishment of ethics committees and provision of supportive supervision are recommended to enable nurses in Malawi attain a high level of ethical competence.
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Musto L, Schreiber R, Rodney PP. Risking vulnerability: Enacting moral agency in the is/ought gap in mental health care. J Adv Nurs 2021; 77:2458-2471. [PMID: 33609062 DOI: 10.1111/jan.14776] [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: 08/17/2020] [Revised: 12/23/2020] [Accepted: 01/16/2021] [Indexed: 11/29/2022]
Abstract
AIM To explore how healthcare providers in acute care mental health settings navigate ethically challenging situations, enact moral agency, practice in congruence with ethical standards and mitigate moral distress (MD). DESIGN Grounded theory, a qualitative methodology. METHODS Over 18 months between 2015 and 2017, we reviewed documents, conducted observations and interviewed multidisciplinary participants (N = 27) from inpatient and emergency departments. Participants either provided direct care (N = 14) or were in leadership positions (N = 13). Data were analysed iteratively using constant comparison, coding, memoing and theorizing, which continued until saturation was reached in July 2016. FINDINGS The basic social process of how healthcare professionals enacted moral agency, Risking Vulnerability, occurred in the context of Systemic Inhumanity, a constant source of MD. Participants Risked Vulnerability, balancing professional obligations, clinical expertise and organizational processes with their own vulnerability in the system as they strove to practice ethically. Risking Vulnerability was composed of Pushing Back, Working Through Team Relationships and Struggling with Inhumanity. CONCLUSION Healthcare professionals' moral agency occurred at the nexus of structure (organizational constraints) and agency (persons). Given this, interventions for MD should be directed at all levels of healthcare to support moral agency, promote ethical practice and improve care. IMPACT Sociopolitical elements such as austerity measures undermined ethical practice at the level of direct care. Enactment of moral agency is dynamic, influencing experiences of MD: participants supported by leadership or colleagues to enact moral agency noted that they were not stuck in MD. Interventions supporting moral agency throughout the healthcare system are necessary to mitigate experiences of MD. Findings enhance our understanding of the role of action in the experience of MD.
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Affiliation(s)
- Lynn Musto
- School of Nursing, Trinity Western University, Langley, BC, Canada
| | - Rita Schreiber
- School of Nursing, University of Victoria, Victoria, BC, Canada
| | - Patricia Paddy Rodney
- Faculty Associate, UBC Centre for Applied Ethics, School of Nursing, University of British Columbia (UBC), Vancouver, BC, Canada
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Moral reasoning perspectives of community pharmacists in situations of drug shortages. Res Social Adm Pharm 2020; 18:2424-2431. [PMID: 33349586 DOI: 10.1016/j.sapharm.2020.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 10/21/2020] [Accepted: 11/18/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Drug shortages affect health systems worldwide. Research in community pharmacy has focused on the nature, extent and impact of these shortages on patients and pharmacists. However, pharmacists' moral reasoning in situations of drug shortages has not been addressed. OBJECTIVE To explore the moral reasoning perspectives of Dutch community pharmacists in situations of drug shortages. METHOD An electronic survey was developed around three drug shortage scenarios with a varying impact on patient outcomes: a Contraceptive, a Parkinson's and an Osteoporosis scenario. Pharmacists rated the likelihood of nine handling options and rated and ranked 13 considerations that may have played a role therein. The considerations represented three moral reasoning perspectives (MRPs): a business orientation (BO), a rules and regulations (RR), and a professional ethics (PE) MRP. Principle component analysis (PCA) was used to investigate construct validity of the MRPs. MRP rating and MRP ranking scores measured the relative importance of the different MRPs of pharmacists in the three shortages. RESULTS Results from 267 Pharmacists were obtained. They reported mostly similar handling in the three shortages, except for the likelihood to make agreements with prescribers or other pharmacists and regarding the decision to import a product. The PCA analysis confirmed the three MRPs that accounted for 29% of variance in the data. Both the MRP rating and especially the MRP ranking scores indicated that PE-MRP considerations were most influential on pharmacists' intended handling of the shortages. In the Contraceptive and the Osteoporosis scenarios, the relative importance of a BO-MRP was higher than in the Parkinson's scenario. CONCLUSION Pharmacists predominantly reason with a PE-MRP when handling drug shortages. However, this perspective can be compromised when the drug shortage is perceived to have a lower impact on patient outcomes and when alternative drugs or therapy are expensive.
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Gallagher A, Peacock M, Williams E, Zasada M, Cox A. Findings from a mixed-methods pragmatic cluster trial evaluating the impact of ethics education interventions on residential care-givers. Nurs Inq 2020; 28:e12383. [PMID: 33010185 DOI: 10.1111/nin.12383] [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: 12/06/2019] [Revised: 06/17/2020] [Accepted: 06/17/2020] [Indexed: 11/29/2022]
Abstract
There has been little previous research regarding the effectiveness of ethics education interventions for residential care-givers. The Researching Interventions to Promote Ethics in social care project responded to the question: Which is the most effective ethics education intervention for care-givers in residential social care? A pragmatic cluster trial explored the impact of three ethics education interventions for: (a) interactive face-to-face ethics teaching; (b) reflective ethics discussion groups; and (c) an immersive simulation experience. There was also a control arm (d). 144 trial participants were recruited from 39 residential care homes for older people in southern England. Change scores compared across intervention arms showed a significant reduction in work-related moral stress in the teaching arm compared with control group (p = .03); there were no significant differences between control and intervention arms in change scores for moral sensitivity, interpersonal reactivity (empathy) or ethical leadership. Qualitative data themes were as follows: ethical care; care challenges; and ethical care inhibitors. Overall findings stimulate reflection on the value of three different ethics education interventions and the most appropriate means to evaluate their impact. Findings suggest the complexity and diverse nature of ethical competence in care. We suggest a way forward for research evaluating ethics education.
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Affiliation(s)
- Ann Gallagher
- Faculty of Health and Medical Science, School of Health Sciences, University of Surrey, Surrey, UK
| | - Matthew Peacock
- Faculty of Health and Medical Science, School of Health Sciences, University of Surrey, Surrey, UK
| | - Emily Williams
- Faculty of Health and Medical Science, School of Health Sciences, University of Surrey, Surrey, UK
| | - Magdalena Zasada
- Faculty of Health and Medical Science, School of Health Sciences, University of Surrey, Surrey, UK
| | - Anna Cox
- Faculty of Health and Medical Science, School of Health Sciences, University of Surrey, Surrey, UK
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Counteracting Abuse in Health Care: Evaluating a One-Year Drama Intervention with Staff in Sweden. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17165931. [PMID: 32824182 PMCID: PMC7459683 DOI: 10.3390/ijerph17165931] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/10/2020] [Accepted: 08/12/2020] [Indexed: 11/18/2022]
Abstract
In Northern European countries 13–28% of female patients seeking gynecological health care have reported abuse by health care staff (AHC). We conducted workshops with health care staff using the improvised role-play method Forum Play (FP), based on techniques developed by Boal. The study explores to what extent the intervention increased the staff’s awareness of AHC and their ability to take action against it. A total of 16 half-day FP workshops were conducted with staff from a Swedish women’s clinic over one year. Self-reported questionnaires were distributed to all staff before, during, and after the intervention. Primary outcome measures were the number of reported occasions of AHC and FP participants’ ability to act in AHC-situations. We found an increase in the participants’ self-reported ability to act in AHC-related situations. However, no change could be observed in the number of reported occasions of AHC between baseline and one year after the intervention. Health care staff’s participation in workshops using improvised role-play can increase staff’s perceived ability to take action in AHC situations. The voluntary nature of the intervention may have attracted those who were already aware of the topic, and likely explains the unchanged awareness of AHC.
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Falkenström E, Höglund AT. "There is total silence here" Ethical competence and inter-organizational learning in healthcare governance. J Health Organ Manag 2020; 34:53-70. [PMID: 32141269 DOI: 10.1108/jhom-05-2019-0130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper is to analyse ethical competence related to healthcare governance and management tasks at the county/regional level in Sweden. The paper also discusses conditions that support or constrain the development and application of such competence. DESIGN/METHODOLOGY/APPROACH The study is based on original qualitative data from 13 interviews and 6 meeting observations. Three key groups of actors were included: politicians, civil servants and CEOs in publicly financed health-provider organizations. An abductive analysis was carried out by a stepwise method guided by thematic research questions. FINDINGS The informants viewed themselves as having a high degree of ethical responsibility for healthcare practice. However, they did not integrate ethical reflection and dialogue into their work decisions (e.g. regarding budgets, reforms and care agreements). The current organization, control systems and underlying business principles, along with the individuals' understanding of their own and others' roles, tended to constrain the development and use of ethical competence. PRACTICAL IMPLICATIONS Qualities of an appropriate ethical competence related to healthcare governance and management, and conditions to develop and use such competence, are suggested. ORIGINALITY/VALUE Hardly any empirical research has examined ethical competence related to healthcare governance and management tasks. The paper integrates ethics and theories on learning in organizations and contributes knowledge about ethical competence and the conditions necessary to develop and practise ethical competence in an organizational and inter-organizational context.
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Affiliation(s)
| | - Anna T Höglund
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
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de Snoo-Trimp JC, de Vet HCW, Widdershoven GAM, Molewijk AC, Svantesson M. Moral competence, moral teamwork and moral action - the European Moral Case Deliberation Outcomes (Euro-MCD) Instrument 2.0 and its revision process. BMC Med Ethics 2020; 21:53. [PMID: 32616048 PMCID: PMC7331166 DOI: 10.1186/s12910-020-00493-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 06/22/2020] [Indexed: 12/03/2022] Open
Abstract
Background Clinical Ethics Support (CES) services are offered to support healthcare professionals in dealing with ethically difficult situations. Evaluation of CES is important to understand if it is indeed a supportive service in order to inform and improve future implementation of CES. Yet, methods to measure outcomes of CES are scarce. In 2014, the European Moral Case Deliberation Outcomes Instrument (Euro-MCD) was developed to measure outcomes of Moral Case Deliberation (MCD). To further validate the instrument, we tested it in field studies and revised it. This paper presents the Euro-MCD 2.0 and describes the revision process. Methods The revision process comprised an iterative dialogue among the authors as Euro-MCD-project team, including empirical findings from six Euro-MCD field-studies and input from European experts in CES and theory. Empirical findings contained perceptions and experiences of MCD outcomes among healthcare professionals who participated in MCDs in various settings in Norway, Sweden and the Netherlands. Theoretical viewpoints on CES, literature on goals of CES and MCD and ethics theory guided the interpretation of the empirical findings and final selection of MCD outcomes. Results The Euro-MCD 2.0 Instrument includes three domains: Moral Competence, Moral Teamwork and Moral Action. Moral Competence consists of items about moral sensitivity, analytical skills and virtuous attitude. Moral Teamwork includes open dialogue and supportive relationships and Moral Action refers to moral decision-making and responsible care. During the revision process, we made decisions about adding and reformulating items as well as decreasing the number from 26 to 15 items. We also altered the sentence structure of items to assess the current status of outcomes (e.g. ‘now’) instead of an assumed improvement over time (e.g. ‘better’) and we omitted the question about perceived importance. Conclusions The Euro-MCD 2.0 is shorter, less complex and more strongly substantiated by an integration of empirical findings, theoretical reflections and dialogues with participants and experts. Use of the Euro-MCD 2.0 will facilitate evaluation of MCD and can thereby monitor and foster implementation and quality of MCD. The Euro-MCD 2.0 will strengthen future research on evaluation of outcomes of MCD.
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Affiliation(s)
- J C de Snoo-Trimp
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Medical Humanities, Amsterdam Public Health research institute, De Boelelaan, 1117, Amsterdam, the Netherlands.
| | - H C W de Vet
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics, Amsterdam Public Health research institute, De Boelelaan, 1117, Amsterdam, the Netherlands
| | - G A M Widdershoven
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Medical Humanities, Amsterdam Public Health research institute, De Boelelaan, 1117, Amsterdam, the Netherlands
| | - A C Molewijk
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Medical Humanities, Amsterdam Public Health research institute, De Boelelaan, 1117, Amsterdam, the Netherlands.,Center for Medical Ethics, University of Oslo, Oslo, Norway
| | - M Svantesson
- Faculty of Medicine and Health, University Health Care Research Center, Örebro University, Örebro, Sweden
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Hemberg J, Hemberg H. Ethical competence in a profession: Healthcare professionals' views. Nurs Open 2020; 7:1249-1259. [PMID: 32587745 PMCID: PMC7308671 DOI: 10.1002/nop2.501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/02/2020] [Accepted: 03/27/2020] [Indexed: 11/24/2022] Open
Abstract
Aim Ethical competence is a crucial component for enabling good quality care but there is insufficient qualitative research on healthcare professionals' views on ethical competence. The aim of this study was to investigate healthcare professionals' views on ethical competence in a student healthcare context. Design A qualitative design and a hermeneutical approach were used. Methods The material consists of texts from interviews with healthcare professionals (N = 10) in a student healthcare context. The method was inspired by content analysis. Results One main theme and four subthemes emerged. The main theme was as follows: safeguarding the vulnerability of the other. The subthemes were as follows: using sensitivity to establish a trustful relationship, acting in an objective and flexible manner, using a reflective process in decision-making, and maintaining confidentiality and honesty. Future research should focus on investigating ethical competence from various perspectives in student health care, for example the student perspective or observational studies.
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Affiliation(s)
- Jessica Hemberg
- Department of Caring SciencesFaculty of Education and Welfare StudiesÅbo Akademi UniversityVaasaFinland
| | - Håkan Hemberg
- Department of Public AdministrationFaculty of Social Sciences, Business and EconomicsÅbo Akademi UniversityTurkuFinland
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Kulju K, Suhonen R, Puukka P, Tolvanen A, Leino-Kilpi H. Self-evaluated ethical competence of a practicing physiotherapist: a national study in Finland. BMC Med Ethics 2020; 21:43. [PMID: 32471504 PMCID: PMC7257238 DOI: 10.1186/s12910-020-00469-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 04/01/2020] [Indexed: 11/22/2022] Open
Abstract
Background Patients have the right to equal, respectful treatment. Nowadays, one third of patient complaints concern health care staff’s behavior towards patients. Ethically safe care requires ethical competence, which has been addressed as a core competence in physiotherapy. It has been defined in terms of character strength, ethical awareness, moral judgment skills in decision-making, and willingness to do good. The purpose of this study was to analyze the ethical competence of practicing physiotherapists. Method A self-evaluation instrument (Physiotherapist’s Ethical Competence Evaluation Tool) based on an analysis of a concept “ethical competence” was constructed in 2016 and physiotherapists (n = 839), working in public health services or private practice responded to the questionnaire. Results Based on the results, most of the physiotherapists evaluated themselves highly ethically competent in all areas of ethical competence, subscales being Strength, Awareness, Skills and Will. Willingness to do good was evaluated as highest, while character strength, including the strength to support ethical processes and speak on behalf of the patient, was evaluated the lowest. Physiotherapists most commonly consult a colleague when encountering an ethical problem. Other methods for problem solving are not very familiar, neither are the international or national ethical codes of conduct. Conclusions This was the first attempt to assess all aspects of ethical competence empirically in a clinical environment in physiotherapy, using a novel self-evaluation instrument. Even if physiotherapists evaluate themselves as competent in ethics, further exploration is needed for ethical awareness. Also the patients’ viewpoints about ethically competent care should be considered, to better ensure ethical safety of the patient.
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Affiliation(s)
- Kati Kulju
- Department of Nursing Science, University of Turku, FI-20014, Turku, Finland.
| | - Riitta Suhonen
- Department of Nursing Science/ Turku University Hospital and City of Turku, Welfare Division, University of Turku, Turku, Finland
| | - Pauli Puukka
- National Institute for Health and Welfare, Turku, Finland
| | - Anna Tolvanen
- Department of Nursing Science, University of Turku, FI-20014, Turku, Finland
| | - Helena Leino-Kilpi
- Department of Nursing Science, Turku University Hospital, University of Turku, Turku, Finland
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Exploring pharmacy ethics in developing countries: a scoping review. Int J Clin Pharm 2020; 42:418-435. [PMID: 32277402 DOI: 10.1007/s11096-020-01021-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 03/24/2020] [Indexed: 10/24/2022]
Abstract
Background Healthcare ethics have been profoundly influenced by principles of bioethics that emerged post-World War II in the Declaration of Geneva 1948. 'Beneficence' (to do good), 'Non-Maleficence' (to do no harm), 'Justice' (fairness and justice in access) and 'Respect for Autonomy' (respect for patient individuality, including decision making, privacy, and right to refuse), have become foundational principles of contemporary medical codes of ethics. These principles are well reflected in most professional pharmacy code of ethics globally. This domain remains relatively unexplored in most developing countries and the majority of what has been published in this area relates to western cultures. There have been no attempts to pool findings from a similar scope of research emanating in developing countries. Aim of the review This study aims to explore the scope of pharmacy ethics in the literature pertaining to developing countries. Methods An extensive search of three relevant (Scopus, CINAHL, IPA) databases was conducted from Jan 2000 to Feb 2020, in order to identify relevant studies conducted in or focussed on ethics in pharmacy in developing countries. A separate Google Scholar search was carried out in an effort to locate supplementary articles, hand-searched articles were also included to achieve an exhaustive investigation of all current relevant studies. Results The full text of 20 relevant articles that met inclusion criteria were critically analysed and qualitatively categorised into three emerging themes; Ethical challenges in pharmacy practice, Approaches used in teaching pharmacy ethics, and Code of ethics analysis and implementation. Conclusions: Findings of this literature review illuminated a gap in pharmacy ethics literacy in developing countries and variances in pharmacists' ethical attitudes in handling ethical dilemmas, as well as a lack of familiarity with ethical principles and codes of ethics. Pharmacists' lack of respect for patients' autonomy and pharmacists being prone to financial pressure were found to have a significant impact on pharmacy practice in most of developing countries. However, attempts are being made to rectify this gap by efforts to incorporate ethical and professional education in undergraduate curricula, and by studies in which new codes of ethics are being implemented.
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30
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Kruijtbosch M, Göttgens-Jansen W, Floor-Schreudering A, van Leeuwen E, Bouvy ML. Moral reasoning among Dutch community pharmacists: testing the applicability of the Australian Professional Ethics in Pharmacy test. Int J Clin Pharm 2019; 41:1323-1331. [PMID: 31254151 PMCID: PMC6800840 DOI: 10.1007/s11096-019-00869-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 06/20/2019] [Indexed: 10/26/2022]
Abstract
Background Moral reasoning competency is essential in healthcare practice, especially in situations of moral dilemmas when a professional has to choose a morally justifiable action among several suboptimal action options. The Australian Professional Ethics in Pharmacy test (PEP test) measures moral reasoning among pharmacists. In Australia three levels of moral reasoning (schemas) were measured (1) business orientation (2) rules and regulations, and (3) patient rights (i.e. most advanced schema). Objective To test the applicability of the PEP test to pharmacists working in the Netherlands. Setting Dutch community pharmacy. Methods The PEP test consists of 36 statements (items) accompanying 3 moral dilemma scenarios. It was translated into Dutch and completed by 390 pharmacists. Principle component analysis (PCA) was used to investigate construct validity and Cronbach's Alpha was used to indicate internal consistency of the Dutch version of the PEP test. The eligible grouped statements and perceived possible moral reasoning schemas were compared to the Australian findings. Main outcome measure Moral reasoning schemas. Results The PCA analysis resulted in 3 components (i.e. possible moral reasoning schemas) that together accounted 27% variance in the data. The statements that represented the moral reasoning schemas 'business orientation' and 'rules and regulations' were somewhat similar when comparing these with the statements that represented these schemas in the PEP test study. The most advanced moral reasoning schema identified in Dutch pharmacists contained different statements compared to the statements that represented that schema among Australian pharmacists. This schema was labelled 'professional ethics'. Conclusion The PEP test needs further adaptation to the Dutch pharmacy practice context: especially the statements that should reflect the most advanced moral reasoning schema, need more accurate representations of professional pharmacy ethics that guide pharmacists in the Netherlands. Moral reasoning tests for a specific professional setting or country should be developed and adapted by experts who share the same professional values and practice as the respondents.
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Affiliation(s)
- M Kruijtbosch
- SIR Institute for Pharmacy Practice and Policy, Theda Mansholtstraat 5b, 2331 JE, Leiden, The Netherlands. .,Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, P.O. Box 80082, 3508 TB, Utrecht, The Netherlands.
| | - W Göttgens-Jansen
- Department of Primary and Community Care, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Center, P.O. Box 9101, 120, ELG, 6500 HB, Nijmegen, The Netherlands
| | - A Floor-Schreudering
- SIR Institute for Pharmacy Practice and Policy, Theda Mansholtstraat 5b, 2331 JE, Leiden, The Netherlands.,Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, P.O. Box 80082, 3508 TB, Utrecht, The Netherlands
| | - E van Leeuwen
- Department of Primary and Community Care, Radboud Institute for Health Sciences (RIHS), Radboud University Medical Center, P.O. Box 9101, 120, ELG, 6500 HB, Nijmegen, The Netherlands
| | - M L Bouvy
- Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, P.O. Box 80082, 3508 TB, Utrecht, The Netherlands
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Silén M, Svantesson M. Impact of clinical ethics support on daily practice-First-line managers' experiences in the Euro-MCD project. J Nurs Manag 2019; 27:1374-1383. [PMID: 31220384 DOI: 10.1111/jonm.12818] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 05/21/2019] [Accepted: 06/14/2019] [Indexed: 11/29/2022]
Abstract
AIM To explore first-line managers' experiences of what Moral Case Deliberation has meant for daily practice, to describe perceptions of context influence and responsibility to manage ethically difficult situations. BACKGROUND In order to find measures to evaluate Moral Case Deliberation, the European Moral Case Deliberation Outcome instrument was developed and is now in the stage of revision. For this, there is a need of several perspectives, one of them being the managerial bird-eye perspective. METHOD Eleven first-line managers at workplaces, participating in the European Moral Case Deliberation Outcome instrument project, were interviewed and thematic analysis was applied. RESULTS Managers' experiences were interpreted as enhanced ethical climate: a closer-knit and more emotionally mature team, morally strengthened individuals, as well as ethics leaving its marks on everyday work and morally grounded actions. Despite organizational barriers, they felt inspired to continue ethics work. CONCLUSION AND IMPLICATIONS This study confirmed, but also added ethical climate aspects, such as morally grounded actions. Furthermore, adding ethical climate as a construct in the European Moral Case Deliberation Outcome instrument should be considered. First-line managers need clear directives from their managers that ethics work needs to be prioritized for the good of both the staff and the patients.
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Affiliation(s)
- Marit Silén
- Faculty of Health and Occupational Studies, University of Gävle, Gävle, Sweden.,Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Mia Svantesson
- Faculty of Medicine and Health, University Health Care Research Center, Örebro University, Örebro, Sweden
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Jonasson LL, Sandman L, Bremer A. Managers' experiences of ethical problems in municipal elderly care: a qualitative study of written reflections as part of leadership training. J Healthc Leadersh 2019; 11:63-74. [PMID: 31213938 PMCID: PMC6549386 DOI: 10.2147/jhl.s199167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 04/19/2019] [Indexed: 11/23/2022] Open
Abstract
Background: Managers in elderly care have a complex ethical responsibility to address the needs and preferences of older persons while balancing the conflicting interests and requirements of relatives' demands and nursing staff's work environment. In addition, managers must consider laws, guidelines, and organizational conditions that can cause ethical problems and dilemmas that need to be resolved. However, few studies have focused on the role of health care managers in the context of how they relate to and deal with ethical conflicts. Therefore, the aim of this study was to describe ethical problems experienced by managers in elderly care. Methods: We used a descriptive, interpretative design to analyze textual data from two examinations in leadership courses for managers in elderly care. A simple random selection of 100 out of 345 written exams was made to obtain a manageable amount of data. The data consisted of approximately 300 pages of single-spaced written text. Thematic analysis was used to evaluate the data. Results: The results show that managers perceive the central ethical conflicts relate to the older persons' autonomy and values versus their needs and the values of the staff. Additionally, ethical dilemmas arise in relation to the relatives' perspective of their loved one's needs and preferences. Legislations, guidelines, and a lack of resources create difficulties when managers perceive these factors as conflicting with the care needs of older persons. Conclusion: Managers in elderly care experience ethical conflicts that arise as unavoidable and perennial values conflicts, poorly substantiated values, and problematic organizational conditions. Structured approaches for identifying, reflecting on, and assessing ethical problems in the organization should therefore be implemented.
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Affiliation(s)
- Lise-Lotte Jonasson
- Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Lars Sandman
- Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden.,Department of Medical and Health Sciences, Division of Health Care Analysis, Linköping University, Linköping, Sweden
| | - Anders Bremer
- Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden.,Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
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'You can give them wings to fly': a qualitative study on values-based leadership in health care. BMC Med Ethics 2019; 20:35. [PMID: 31133017 PMCID: PMC6537214 DOI: 10.1186/s12910-019-0374-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 05/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Within contemporary health care, many of the decisions affecting the health and well-being of patients are not being made by the clinicians or health professionals, but by those involved in health care management. Existing literature on organizational ethics provides insight into the various structures, processes and strategies - such as mission statement, ethics committees, ethical rounds … - that exist to create an organizational climate, which fosters ethical practices and decision-making It does not, however, show how health care managers experience their job as being intrinsically ethical in itself. In the present article, we investigate the way in which ethical values are present in the lived experiences and daily practice of health care management. What does it imply to take up a managing position within a health care institution and to try to do this in an ethically inspired way? METHOD We carried out a qualitative study (Grounded Theory Approach) to explore the essence of values-based leadership in health care. We interviewed 15 people with extensive experience in health care management in the fields of elderly care, hospital care and mental health care in the various regions of Flanders, Belgium. RESULTS Six predominant themes, presented as metaphors, illustrate the essence of values-based leadership in health care management. These are: (1) values-based health care management as managing a large garden, (2) as learning and using a foreign language, (3) going on a trekking with an ethical compass, (4) embodying integrity and authenticity in a credible encounter with everyone, (5) being a present and trustworthy leader during sun and storm, and (6) contributing to human flourishing by giving people wings to fly. CONCLUSIONS Notwithstanding the importance of organizing a good ethics infrastructure, values-based leadership in health care entails much more than that. It is about the co-creation of an integrated and comprehensive ethical climate of which community-model thinking and authentic leadership are essential components. As a never-ending process, the six metaphors can help leaders to take substantive proactive steps to shape a fruitful ethical climate within their organization.
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Brännström M, Fischer Grönlund C, Zingmark K, Söderberg A. Meeting in a ‘free-zone’: Clinical ethical support in integrated heart-failure and palliative care. Eur J Cardiovasc Nurs 2019; 18:577-583. [DOI: 10.1177/1474515119851621] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Integrating heart-failure and palliative care combines expertise from two cultures, life-saving cardiology and palliative care, and involves ethically difficult situations that have to be considered from various perspectives. We found no studies describing experiences of clinical ethical support (CES) in integrated cardiology and palliative care teams. Objective: Our aim is to describe experiences of CES among professionals after a period of three years working in a multidisciplinary team in integrated heart-failure and palliative homecare. Method: The study design was descriptive qualitative, comprising interviews with seven professionals from one integrated heart-failure and palliative care team who received CES over a three-year period. The interview data were subjected to qualitative content analysis. Results: The CES was found to offer possibilities for meeting in an ethical ‘free-zone’ where the participants could relate to each other beyond their various professional roles and specialties. The trust within the team seemed to increase and the participants were confident enough to express their points of view. Together they developed an integrated understanding, and acquired more knowledge and a comprehensive view of the ethically difficult situation of concern. The CES sessions were considered a means of becoming better prepared to deal with ethical care issues and developing action strategies to apply in practice, from shared standpoints. Conclusion: Participating in CES was experienced as meeting in an ethical ‘free-zone’ and seemed to be a means of facilitating integration of palliative and heart-failure care.
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Affiliation(s)
- Margareta Brännström
- Department of Nursing, Umeå University, Sweden
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | | | - Karin Zingmark
- Department of Health Science, Division of Nursing, Luleå University of Technology & Norrbotten County Council, Sweden
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Interprofessional teamwork, quality of care and turnover intention in geriatric care: A cross-sectional study in 55 acute geriatric units. Int J Nurs Stud 2019; 91:94-100. [DOI: 10.1016/j.ijnurstu.2018.11.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 10/01/2018] [Accepted: 11/24/2018] [Indexed: 11/20/2022]
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36
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Meziane D, Ramirez-Garcia MP, Fortin ML. A reflective practice intervention to act on the moral distress of nurses providing end-of-life care on acute care units. Int J Palliat Nurs 2018; 24:444-451. [DOI: 10.12968/ijpn.2018.24.9.444] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Dounia Meziane
- Pivot nurse in oncology Montreal-West Intergrated University Health and Social Services Center, Montréal, Canada
| | | | - Marie-Laurence Fortin
- Palliative care clinical nurse specialist Montreal-West-Central Integrated University Health and Social Services Centre, Montréal, Canada
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37
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Antonsen Y, Normann AK, Nilsen HR, Magelssen M. Systematisk etikkarbeid krever lederforankring. TIDSSKRIFT FOR OMSORGSFORSKNING 2018. [DOI: 10.18261/issn.2387-5984-2018-01-06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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38
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Rasoal D, Skovdahl K, Gifford M, Kihlgren A. Clinical Ethics Support for Healthcare Personnel: An Integrative Literature Review. HEC Forum 2017; 29:313-346. [PMID: 28600658 PMCID: PMC5688194 DOI: 10.1007/s10730-017-9325-4] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
This study describes which clinical ethics approaches are available to support healthcare personnel in clinical practice in terms of their construction, functions and goals. Healthcare personnel frequently face ethically difficult situations in the course of their work and these issues cover a wide range of areas from prenatal care to end-of-life care. Although various forms of clinical ethics support have been developed, to our knowledge there is a lack of review studies describing which ethics support approaches are available, how they are constructed and their goals in supporting healthcare personnel in clinical practice. This study engages in an integrative literature review. We searched for peer-reviewed academic articles written in English between 2000 and 2016 using specific Mesh terms and manual keywords in CINAHL, MEDLINE and Psych INFO databases. In total, 54 articles worldwide described clinical ethics support approaches that include clinical ethics consultation, clinical ethics committees, moral case deliberation, ethics rounds, ethics discussion groups, and ethics reflection groups. Clinical ethics consultation and clinical ethics committees have various roles and functions in different countries. They can provide healthcare personnel with advice and recommendations regarding the best course of action. Moral case deliberation, ethics rounds, ethics discussion groups and ethics reflection groups support the idea that group reflection increases insight into ethical issues. Clinical ethics support in the form of a "bottom-up" perspective might give healthcare personnel opportunities to think and reflect more than a "top-down" perspective. A "bottom-up" approach leaves the healthcare personnel with the moral responsibility for their choice of action in clinical practice, while a "top-down" approach risks removing such moral responsibility.
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Affiliation(s)
- Dara Rasoal
- School of Health and Medical Sciences, Örebro University, Fakultetsgatan 1, SE - 701 82, Örebro, Sweden.
| | - Kirsti Skovdahl
- Department of Nursing and Health Sciences, University College in Southeast Norway, Drammen, Norway
| | - Mervyn Gifford
- School of Health and Medical Sciences, Örebro University, Fakultetsgatan 1, SE - 701 82, Örebro, Sweden
| | - Annica Kihlgren
- School of Health and Medical Sciences, Örebro University, Fakultetsgatan 1, SE - 701 82, Örebro, Sweden
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Andersson H, Lindholm M, Pettersson M, Jonasson LL. Nurses' competencies in home healthcare: an interview study. BMC Nurs 2017; 16:65. [PMID: 29176934 PMCID: PMC5693583 DOI: 10.1186/s12912-017-0264-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 11/10/2017] [Indexed: 12/02/2022] Open
Abstract
Background Nurses working in Home healthcare (HHC) are facing major challenges since more advanced care and treatment are increasingly being carried out in patients’ homes. The aim of this study has been to explore how nurses experience their competencies in HHC situations. Methods This study has a qualitative and explorative design. Ten nurses were interviewed and data was analyzed using content analysis. Results The themes “Being a capable nurse”, “Being a useful nurse” and “Being a subordinate and dependent nurse” were identified. Nurses want to be capable of taking care of patients, to develop their competencies and to perform their duties in the way required. They also want their work to be useful and to provide good and safe HHC. Finally, nurses want to improve HHC care by applying their competencies. Simultaneously, they are subordinate and dependent in relation to their manager and also dependent upon their manager’s interest in encouraging nurses’ competence development. Conclusions Nurses in HHC are responsible for many seriously ill patients and they want to contribute to good and safe patient care. To maintain patient safety, reduce the risk for burnout and staff turnover as well as to contribute to a sustainable development of the work, strategies for transferring competencies between nurses and efforts for competence development are needed.
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Affiliation(s)
- Henrik Andersson
- University of Borås, Faculty of Caring Science, Work Life and Social Welfare, Borås, Sweden
| | - Maria Lindholm
- Centre for Adult Education, Härryda municipality, SE-435 80 Mölnlycke, Sweden
| | | | - Lise-Lotte Jonasson
- University of Borås, Faculty of Caring Science, Work Life and Social Welfare, Borås, Sweden
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Abstract
Moral distress is a pervasive problem in nursing resulting in a detriment to patient care, providers, and organizations. Over a decade ago, the moral distress theory (MDT) was proposed and utilized in multiple research studies. This middle range theory explains and predicts the distress that occurs in a nurse because of moral conflict. The research findings born from this theory have been substantial. Since inception of this theory, moral distress has been extensively examined which has further elaborated its understanding. This paper provides an analysis and evaluation of the MDT according to applicable guidelines. Current understanding of the phenomenon indicates that a new theory may be warranted to better predict, treat, and manage moral distress.
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Affiliation(s)
- Melissa A Wilson
- Department, of Aeromedical Research, United States Air Force School of Aerospace Medicine, Fairborn, OH
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Stolt M, Leino-Kilpi H, Ruokonen M, Repo H, Suhonen R. Ethics interventions for healthcare professionals and students: A systematic review. Nurs Ethics 2017; 25:133-152. [DOI: 10.1177/0969733017700237] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The ethics and value bases in healthcare are widely acknowledged. There is a need to improve and raise awareness of ethics in complex systems and in line with competing needs, different stakeholders and patients’ rights. Evidence-based strategies and interventions for the development of procedures and practice have been used to improve care and services. However, it is not known whether and to what extent ethics can be developed using interventions. Objectives: To examine ethics interventions conducted on healthcare professionals and healthcare students to achieve ethics-related outcomes. Research design: A systematic review. Methods: Five electronic databases were searched: CINAHL, the Cochrane Library, Philosopher’s Index, PubMed and PsycINFO. We searched for published articles written in English without a time limit using the keywords: ethic* OR moral* AND intervention OR program OR pre-post OR quasi-experimental OR rct OR experimental AND nurse OR nursing OR health care. In the four-phased retrieval process, 23 full texts out of 4675 citations were included in the review. Data were analysed using conventional content analysis. Ethical consideration: This systematic review was conducted following good scientific practice in every phase. Findings: It is possible to affect the ethics of healthcare practices through professionals and students. All the interventions were educational in type. Many of the interventions were related to the ethical or moral sensitivity of the professionals, such as moral courage and empowerment. A few of the interventions focused on identifying ethical problems or research ethics. Conclusion: Patient-related outcomes followed by organisational outcomes can be improved by ethics interventions targeting professionals. Such outcomes are promising in developing ethical safety for healthcare patients and professionals.
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Affiliation(s)
| | | | | | | | - Riitta Suhonen
- University of Turku, Finland; Turku University Hospital, Finland; City of Turku/Welfare Division, Finland
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Perceptions of Pediatric Nurses on Ethical Decision Making Processes. SYSTEMIC PRACTICE AND ACTION RESEARCH 2017. [DOI: 10.1007/s11213-016-9386-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fronek P, Kendall MB. The impact of Professional Boundaries for Health Professionals (PBHP) training on knowledge, comfort, experience, and ethical decision-making: a longitudinal randomized controlled trial. Disabil Rehabil 2016; 39:2522-2529. [PMID: 27737566 DOI: 10.1080/09638288.2016.1236152] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE A randomized controlled trial was conducted to evaluate the impact of Professional Boundaries for Health Professionals (PBHP) training program on the knowledge, comfort, experience, and ethical decision-making of multidisciplinary practitioners facing client-practitioner boundary dilemmas. METHODS In all, 36 rehabilitation practitioners from an Australian state-wide spinal cord injuries service were assigned to experimental and control groups. The Boundaries in Practice (BIP) Scale measured outcomes at four points: pre, post, 3 months, and 1 year. The control group received the training after 3 months. Nonparametric Friedman's two-way analysis of variance was used to examine the trajectories over time. RESULTS Analysis was conducted using the data of 10 experimental and 13 control group participants who responded at four data collection points. The experimental group showed significant improvement in knowledge (χ2 = 10.673, p = 0.014) and comfort (χ2 = 9.727, p = 0.021) managing professional boundaries post-training. The control group showed no significant change in knowledge or comfort. No significant change was seen in experience across either experimental (χ2 = 3.609, p = 0.307) or control group (χ2 = 7.800, p = 0.050). Ethical decision-making improved in the control group (χ2 = 13.188, p = 0.004) following training, however remained unchanged in the experimental group. CONCLUSIONS The findings do not definitively support this training approach. Ethical decision-making may improve more substantially within the practice context and organizational culture change. Multifaceted approaches are indicated. Implications for Rehabilitation Ethical dilemmas related to boundaries between clients and practitioners are a frequent occurrence in the rehabilitation setting. In a relatively small sample, the current randomized trial provided inconclusive evidence on the benefit of a 1-day needs-oriented training program to improve knowledge, comfort, and ethical decision-making. Randomized trials of education and training for rehabilitation practitioners are fraught with challenges in the clinical environment of the rehabilitation setting. Multifaceted training approaches, management support and training as well as changes to policy and organizational context in the rehabilitation setting may be needed to more holistically address the issues surrounding professional boundaries in the rehabilitation setting.
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Affiliation(s)
- Patricia Fronek
- a School of Human Services and Social Work, Griffith University, Gold Coast Campus , Southport , QLD , Australia.,b Menzies Health Institute Queensland, Griffith University , Gold Coast , QLD , Australia
| | - Melissa B Kendall
- c Transitional Rehabilitation Program, Queensland Spinal Cord Injuries Service , Princess Alexandra Hospital, Metro South Health , Brisbane , QLD , Australia.,d School of Human Services and Social Work, Griffith University , Logan Campus , Meadowbrook , QLD , Australia
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Kim S, Seo M, Kim DR. Unmet Needs for Clinical Ethics Support Services in Nurse: Based on focus group interviews. Nurs Ethics 2016; 25:505-519. [PMID: 27400868 DOI: 10.1177/0969733016654312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND As nurses' ethical competence in their own fields is essential, clinical ethics support services help nurses improve ethical competence. OBJECTIVES The purpose of this study was to identify the unmet needs of ethical support for nurses in clinical settings and explore the differences by nursing units. RESEARCH DESIGN Focus group interview design was applied. Participants and research context: Data were collected via four rounds of focus group interviews with 37 nurses at intensive care units, medical-surgical units, emergency departments and oncology units. Major questions were as follows: 'What is nurses' experience of ethical difficulties while working as a clinical nurse?' and 'What kinds of clinical ethics support services do nurses require in different clinical settings?' Inductive content analysis was performed to analyse the data. Ethical considerations: Ethical approval was obtained from the institutional review of board at the College of Nursing. FINDINGS Five categories (with 14 subcategories) were identified: difficulty providing evidence-based care, lack of support in maintaining patients' and family members' dignity, insufficient education regarding clinical ethics, loss of professional self-esteem and expectations concerning organizational support. Nurses' desire for ethical support varied according to department. CONCLUSION Nurses face both practical and existential ethical issues that require rapid solution each day. There is a need for ethical counselling to prevent compassion fatigue and identify means via which nurses reflect on their daily lives in their own fields. In-house training should be provided for each unit, to improve ethical competence and facilitate the development of pragmatic, sensible solutions.
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Affiliation(s)
- Sanghee Kim
- Yonsei University, Mo-Im Kim Nursing Research Institute, Seoul, Korea
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Ebadi A, Tabanejad Z, Pazokian M, Yasser S. Designing and Psychometric Evaluation of the Competency Inventory for Postgraduate Students of Intensive Care Nursing. Nurs Midwifery Stud 2016. [DOI: 10.17795/nmsjournal32677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Musto LC, Rodney PA. Moving from conceptual ambiguity to knowledgeable action: using a critical realist approach to studying moral distress. Nurs Philos 2015; 17:75-87. [PMID: 26466559 DOI: 10.1111/nup.12104] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Moral distress is a phenomenon that has been receiving increasing attention in nursing and other health care disciplines. Moral distress is a concept that entered the nursing literature - and subsequently the health care ethics lexicon - in 1984 as a result of the work done by American philosopher and bioethicist Andrew Jameton. Over the past decade, research into moral distress has extended beyond the profession of nursing as other health care disciplines have come to question the impact of moral constraint on individual practitioners, professional practice, and patient outcomes. Along with increased interest in the phenomenon of moral distress have come increasing critiques - critiques that in their essence point to a serious lack of conceptual clarity in the definition, study, and application of the concept. Foundational to gaining conceptual clarity in moral distress in order to develop strategies to prevent and ameliorate the experience is a careful revisiting of the epistemological assumptions underpinning our knowledge and use of the concept of moral distress. It is our contention that the conceptual challenges reveal flaws in the original understanding of moral distress that are based on an epistemological stance that holds a linear conception of cause and effect coupled with a simplistic perspective of 'constraint' and 'agency'. We need a more nuanced approach to our study of moral distress such that our ontological and epistemological stances help us to better appreciate the complexity of moral agents acting in organizational contexts. We believe that critical realism offers such a nuanced approach.
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Affiliation(s)
- Lynn C Musto
- Trinity Western University, Vancouver, BC, Canada
| | - Patricia A Rodney
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
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Silén M, Haglund K, Hansson MG, Ramklint M. Ethics rounds do not improve the handling of ethical issues by psychiatric staff. Nord J Psychiatry 2015; 69:418-25. [PMID: 25592287 DOI: 10.3109/08039488.2014.994032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND One way to support healthcare staff in handling ethically difficult situations is through ethics rounds that consist of discussions based on clinical cases and are moderated by an ethicist. Previous research indicates that the handling of ethically difficult situations in the workplace might have changed after ethics rounds. This, in turn, would mean that the "ethical climate", i.e. perceptions of how ethical issues are handled, would have changed. AIM To investigate whether ethics rounds could improve the ethical climate perceived by staff working in psychiatry outpatient clinics. METHODS In this quasi-experimental study, six inter-professional ethics rounds led by a philosopher/ethicist were conducted at two psychiatry outpatient clinics. Changes in ethical climate were measured at these clinics as well as at two control clinics at baseline and after the intervention period using the instrument Hospital Ethical Climate Survey. RESULTS Within-groups comparisons of median sum scores of ethical climate showed that no statistically significant differences were found in the intervention group before or after the intervention period. The median sum scores for ethical climate were significantly higher, both at baseline and after the intervention period (P ≤ 0.001; P = 0.046), in the intervention group. CONCLUSIONS Ethics rounds in psychiatric outpatient clinics did not result in significant changes in ethical climate. Outcomes of ethics rounds might, to a higher degree, be directed towards patient-related outcomes rather than towards the staff's working environment, as the questions brought up for discussion during the ethics rounds concerned patient-related issues.
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Affiliation(s)
- Marit Silén
- Marit Silén, Ph.D., R.N., Post doc., Centre for Research Ethics & Bioethics, Uppsala University , Box 564, SE-751 22 Uppsala , Sweden
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Schaefer R, Vieira M. Ethical competence as a coping resource for moral distress in nursing. TEXTO & CONTEXTO ENFERMAGEM 2015. [DOI: 10.1590/0104-07072015001032014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The study's objectives were: to seek evidence on ethical situations experienced by nurses in the health services; to identify the coping resources which they use; and to ascertain the role of ethical competence in coping with moral distress. The integrative literature review was used as the method. The search was made in the LILACS, IBECS, MEDLINE, SciELO, CINAHL, PubMed, RCAAP and BDTD databases. A total of 23 studies was selected, based on previously established inclusion and exclusion criteria. The results indicate ethical questions experienced by the nurses in their relations with patients and family members, the team and the health system. Coping resources used by the professionals and implemented by the researchers are described. It may be concluded that the ethical challenges and moral distress are present in the nurses' work context, and the strategies aimed at promoting ethical competence, have positive consequences in coping with, and in reducing, levels of moral distress.
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Abstract
Background: Exploring the concept of ethical competence in the context of healthcare is essential as it pertains to better quality of care. The concept still lacks a comprehensive definition covering the aspects of ethical expertise, ethical knowledge and action of a health professional. Objective: This article aims to report an analysis of the concept of ethical competence. Method: A modified strategy suggested by Walker and Avant was used to analyse the concept. Results: As a result, the concept of ethical competence can be defined in terms of character strength, ethical awareness, moral judgement skills and willingness to do good. Virtuous professional, experience of a professional, human communication, ethical knowledge and supporting surroundings in the organisation can be seen as prerequisites for ethical competence. Ethical competence results in the best possible solutions for the patient, reduced moral distress at work and development and democratisation of society. Conclusion: The results of the analysis establish a basis for an instrument to evaluate health professionals’ ethical competence. It will guide educators, as well as managers in healthcare, to support the development of ethical conduct in healthcare.
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Silén M, Ramklint M, Hansson MG, Haglund K. Ethics rounds: An appreciated form of ethics support. Nurs Ethics 2014; 23:203-13. [PMID: 25527354 DOI: 10.1177/0969733014560930] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Ethics rounds are one way to support healthcare personnel in handling ethically difficult situations. A previous study in the present project showed that ethics rounds did not result in significant changes in perceptions of how ethical issues were handled, that is, in the ethical climate. However, there was anecdotal evidence that the ethics rounds were viewed as a positive experience and that they stimulated ethical reflection. AIM The aim of this study was to gain a deeper understanding of how the ethics rounds were experienced and why the intervention in the form of ethics rounds did not succeed in improving the ethical climate for the staff. RESEARCH DESIGN An exploratory and descriptive design with a qualitative approach was adopted, using individual interviews. PARTICIPANTS AND RESEARCH CONTEXT A total of 11 healthcare personnel, working in two different psychiatry outpatient clinics and with experience of participating in ethics rounds, were interviewed. ETHICAL CONSIDERATIONS The study was based on informed consent and was approved by one of the Swedish Regional Ethical Review Boards. FINDINGS The participants were generally positive about the ethics rounds. They had experienced changes by participating in the ethics rounds in the form of being able to see things from different perspectives as well as by gaining insight into ethical issues. However, these changes had not affected daily work. DISCUSSION A crucial question is whether or not increased reflection ability among the participants is a good enough outcome of ethics rounds and whether this result could have been measured in patient-related outcomes. Ethics rounds might foster cooperation among the staff and this, in turn, could influence patient care. CONCLUSION By listening to others during ethics rounds, a person can learn to see things from a new angle. Participation in ethics rounds can also lead to better insight concerning ethical issues.
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