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Pedersen AKB, Skinner MS, Sogstad M. Service Allocators' Experiences of Ethical Dilemmas and Strategies in Long-Term Care: A Qualitative Study. Health Serv Insights 2024; 17:11786329241238883. [PMID: 38495895 PMCID: PMC10943711 DOI: 10.1177/11786329241238883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/26/2024] [Indexed: 03/19/2024] Open
Abstract
The provision of long-term care services for older adults is characterised by increasing needs and scarce resources, leading to ethical dilemmas. This qualitative study explored the ethical dilemmas experienced by healthcare professionals when allocating long-term care services to older adults and the strategies used to handle ethical dilemmas. Data from semi-structured individual interviews, focus group interviews, and observations of service allocators assessing needs and assigning long-term care services to older adults were analysed using content analysis. The overarching theme was the struggle for safe and equitable service allocation. The identified dilemmas were: (i) Struggles with A Just Allocation of Services due to Limited Time and Trust, (ii) Pressure on Professional Values Concerning Safety and Dignity, and (iii) Difficulties in Prioritising One Group Over Another. The strategies to deal with ethical dilemmas were: (i) Assessing Needs Across the Entire Municipality, (ii) Ensuring Distance to Service Recipients, (iii) Working as a Team, and (iv) Interprofessional Decision-Making. Scarce resources, organisational limitations, and political expectations drive the ethical dilemmas in long-term care service allocation. An open public discussion regarding the acceptable minimum standard of long-term care is needed to reduce the ethical pressure on service allocators.
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Affiliation(s)
- Ann Katrin Blø Pedersen
- Centre for Care Research, Department of Health Sciences in Gjøvik, Faculty of Medicine and Health Sciences, NTNU – Norwegian University of Science and Technology, Trondheim, Norway
| | - Marianne Sundlisæter Skinner
- Centre for Care Research, Department of Health Sciences in Gjøvik, Faculty of Medicine and Health Sciences, NTNU – Norwegian University of Science and Technology, Trondheim, Norway
| | - Maren Sogstad
- Centre for Care Research, Department of Health Sciences in Gjøvik, Faculty of Medicine and Health Sciences, NTNU – Norwegian University of Science and Technology, Trondheim, Norway
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2
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Różyńska J, Zawiła-Niedźwiecki J, Maćkiewicz B, Czarkowski M. Tough Clinical Decisions: Experiences of Polish Physicians. HEC Forum 2024; 36:111-130. [PMID: 35939219 PMCID: PMC10864525 DOI: 10.1007/s10730-022-09491-x] [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] [Accepted: 07/14/2022] [Indexed: 11/29/2022]
Abstract
The paper reports results of the very first survey-based study on the prevalence, frequency and nature of ethical or other non-medical difficulties faced by Polish physicians in their everyday clinical practice. The study involved 521 physicians of various medical specialties, practicing mainly in inpatient healthcare. The study showed that the majority of Polish physicians encounter ethical and other non-medical difficulties in making clinical decisions. However, they confront such difficulties less frequently than their foreign peers. Moreover, Polish doctors indicate different circumstances as a source of the experienced problems. The difficulties most often reported relate to (i) patients (or their proxies) requests for medically non-indicated interventions; (ii) problems with communication with patients (or their proxies) due to the patients' negative attitude, unwillingness to cooperate, or aggression; and (iii) various difficulties with obtaining informed consent. Polish physicians report difficulties associated with disagreements among care givers or scarcity of resources less frequently than doctors from other countries. The study's findings provide support for the thesis that a significant portion of Polish physicians still follow a traditional, paternalistic, and hierarchical model of healthcare practice. Instead of promoting patient's empowerment, engagement, and rights, they often consider these ideas as a threat to physicians' professional authority and autonomy. The study leads to the conclusion that due to insufficient training in medical ethics, communication skills, and medical law, many Polish physicians lack the knowledge and competence necessary to adequately respond to challenges posed by modern healthcare practice.
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Affiliation(s)
- Joanna Różyńska
- Center for Bioethics and Biolaw, Faculty of Philosophy, University of Warsaw, Krakowskie Przedmieście 3, 00-047, Warsaw, Poland
| | - Jakub Zawiła-Niedźwiecki
- Center for Bioethics and Biolaw, Faculty of Philosophy, University of Warsaw, Krakowskie Przedmieście 3, 00-047, Warsaw, Poland.
| | - Bartosz Maćkiewicz
- Center for Bioethics and Biolaw, Faculty of Philosophy, University of Warsaw, Krakowskie Przedmieście 3, 00-047, Warsaw, Poland
| | - Marek Czarkowski
- Collegium Medicum Cardinal Stefan Wyszyński University in Warsaw, ul. Kazimierza Wóycickiego 1/3, 01-938, Warsaw, Poland
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3
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Bosompim Y, Aultman J, Pope J. Specific Trends in Pediatric Ethical Decision-Making: An 18-Year Review of Ethics Consultation Cases in a Pediatric Hospital. HEC Forum 2024:10.1007/s10730-024-09524-7. [PMID: 38416336 DOI: 10.1007/s10730-024-09524-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 02/29/2024]
Abstract
This is a qualitative examination of ethics consultation requests, outcomes, and ethics committee recommendations at a tertiary/quaternary pediatric hospital in the U.S. The purpose of this review of consults over an 18-year period is to identify specific trends in the types of ethical dilemmas presented in our pediatric setting, the impact of consultation and committee development on the number and type of consults provided, and any clinical features and/or challenges that emerged and contributed to the nature of ethical situations and dilemmas. Furthermore, in reviewing clinical ethics consultation trends for nearly two decades, we can identify topic areas for further ethics education and training for ethics consultants, ethics committee members, and pediatric healthcare teams and professionals based on our experiences. Our study with nearly two decades of data prior to the COVID-19 pandemic can serve as groundwork for future comparisons of consultation requests and ethics support for pediatric hospitals prior to, during, and following a pandemic.
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Affiliation(s)
- Yaa Bosompim
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - Julie Aultman
- Northeast Ohio Medical University, Rootstown, OH, USA.
- Akron Children's Hospital, Akron, OH, USA.
| | - John Pope
- Akron Children's Hospital, Akron, OH, USA
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Jakobsen LM, Molewijk B, de Snoo-Trimp J, Svantesson M, Ursin G. What is a High-Quality Moral Case Deliberation?-Facilitators' Perspectives in the Euro-MCD Project. HEC Forum 2024:10.1007/s10730-023-09519-w. [PMID: 38315250 DOI: 10.1007/s10730-023-09519-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 02/07/2024]
Abstract
The evaluation of the European Moral Case Deliberation Outcomes project (Euro-MCD) has resulted in a revised evaluation instrument, knowledge about the content of MCD (moral case deliberation), and the perspectives of those involved. In this paper, we report on a perspective that has been overlooked, the facilitators'. We aim to describe facilitators' perceptions of high-quality moral case deliberation and their Euro-MCD sessions. The research took place in Norway, Sweden, and the Netherlands using a survey combined with interviews with 41 facilitators. Facilitators' perceived that attaining a high-quality MCD implies fostering a safe and respectful atmosphere, creating a wondering mode, being an attentive authority, developing moral reflective skills, reaching a common understanding, and ensuring organisational prerequisites for the MCD sessions. Our central conclusion is that efforts at three levels are required to attain a high-quality MCD: trained and virtuous facilitator; committed, respectful participants; and organizational space. Furthermore, managers have a responsibility to prepare MCD participants for what it means to take part in MCD.
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Affiliation(s)
- Lena M Jakobsen
- Department of Health and Care Sciences, Faculty of Health Sciences, UiT The Arctic University of Norway, Harstad, Norway.
- Faculty of Nursing and Health Science, Nord University, Bodø, Norway.
| | - Bert Molewijk
- Department of Ethics, Law and Humanities, Amsterdam UMC, VU University, Amsterdam, The Netherlands
- Center of Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Janine de Snoo-Trimp
- Department of Ethics, Law and Humanities, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Mia Svantesson
- Faculty of Medicine and Health, University Health Care Research Centre, Örebro University, Örebro, Sweden
| | - Gøril Ursin
- Faculty of Nursing and Health Science, Nord University, Bodø, Norway
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Weiner C, Pergert P, Castor A, Molewijk B, Bartholdson C. Difficult situations and moral questions raised during moral case deliberations in Swedish childhood cancer care – A qualitative nationwide overview. Eur J Oncol Nurs 2022; 60:102189. [DOI: 10.1016/j.ejon.2022.102189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/18/2022] [Accepted: 08/04/2022] [Indexed: 11/27/2022]
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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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Rykkje L, Holm AL, Hem MH. Norwegian Nurses' Reflections Upon Experiences of Ethical Challenges in Older People Care: A Qualitative Thematic Analysis. SAGE Open Nurs 2021; 7:23779608211057938. [PMID: 34869863 PMCID: PMC8640321 DOI: 10.1177/23779608211057938] [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: 11/19/2022] Open
Abstract
Introduction Internationally, aging populations have increased needs for health care services, and often specialized care is required. However, services for older people tend to be underfunded, resulting in lack of qualified staff and poor quality care. Resource shortages lead to ethical challenges and insufficient nursing care. Therefore, quality in daily care for older people also depends upon the nurses’ ability to make complex, ethical decisions in their practice. Objectives To explore ethical challenges experienced by nurses caring for older people in clinical practice, and to provide examples of management for the challenges. Methods The data collected were written reflection notes by Norwegian continuous education students in advanced gerontology. Forty two of 83 notes were included and a thematic analysis in six steps was utilized. Findings There are three main themes: (1) meeting vulnerability, discomfort, and suffering, (2) collaboration with relatives, and (3) struggling to perform professional care. Conclusion Nurses strive to “do what is in the patients’ best interest”, and this is fostered through collaboration, professionalism, care, and presence. Nurses’ ethical competencies may develop when reflecting upon their own care performance. Building ethical competencies should be a priority in both nursing education and clinical practice. However, to improve care quality, nurses also need professional knowledge about older people care and ethical awareness should be supported by the workplace.
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Affiliation(s)
- Linda Rykkje
- Faculty of Health Studies, VID Specialized University, Bergen, Norway
| | - Anne Lise Holm
- Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Haugesund, Norway
| | - Marit Helene Hem
- Faculty of Health Studies, VID Specialized University, Oslo, Norway
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Expert nurses' coping strategies in ethically challenging situations: a qualitative study. BMC Nurs 2021; 20:183. [PMID: 34587956 PMCID: PMC8479722 DOI: 10.1186/s12912-021-00709-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 09/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nurses frequently encounter ethically challenging situations in everyday practice. In these situations, nurses often know an appropriate course of action to take but are unable to do so. Many studies have examined the ethically challenging situations faced by nurses, but how nurses cope with these situations is not well understood. Therefore, this study aims to explore the coping strategies used or adopted in ethically challenging situations by expert nurses in South Korea. METHODS Participants were recruited via purposive sampling. Small group interviews were conducted with 26 expert registered nurses in a general hospital in South Korea. The data were analyzed using Giorgi's descriptive phenomenological method. RESULTS The essential theme of nurses' experience of coping with ethically challenging situations was "being faithful to the nature of caring." This essential theme comprised three themes: self-monitoring of ethical insensitivity, maintaining honesty, and actively acting as an advocate. CONCLUSIONS The findings of this study suggest that the coping strategies of expert nurses are mostly consistent with the attributes of ethical competence as previously defined in healthcare, and expert nurses can address ethically challenging situations in an effective and ethical manner by faithfully adhering to the spirit of caring. System-wide early counseling and interventions should be considered for nurses who have experienced ethical difficulties.
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Czarkowski M, Różyńska J, Maćkiewicz B, Zawiła-Niedźwiecki J. Clinical Ethics Consultations in the Opinion of Polish Physicians. JOURNAL OF BIOETHICAL INQUIRY 2021; 18:499-509. [PMID: 34398387 PMCID: PMC8566376 DOI: 10.1007/s11673-021-10116-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 04/08/2021] [Indexed: 06/13/2023]
Abstract
Clinical Ethics Consultations (CEC) are an important tool for physicians in solving difficult cases. They are extremely common in North America and to a lesser extent also present in Europe. However, there is little data on this practice in Poland. We present results of a survey of 521 physicians practising in Poland concerning their opinion on CECs and related practices. We analysed the data looking at such issues as CECs' perceived availability, use of CECs, and perceived usefulness of such support. Physicians in our study generally encounter hard ethics cases, even-surprisingly-those who do not work in hospitals. Most physicians have no CEC access, and those that do still do not employ CECs. However, physicians perceive this form of support as useful-even more so among actual users of CECs. We compared these findings with similar studies from other European countries and the North America. We point out peculiarities of our results as compared to those in other countries, with some possible explanations. We hope the results may encourage regulatory debate on the need to formally introduce CECs into the Polish healthcare system.
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Affiliation(s)
- Marek Czarkowski
- Collegium Medicum, Cardinal Stefan Wyszyński University, Kazimierza Wóycickiego 1/3, 01-938 Warszawa, Poland
| | - Joanna Różyńska
- University of Warsaw, Krakowskie Przedmieście 3, 00-927 Warszawa, Poland
| | - Bartosz Maćkiewicz
- University of Warsaw, Krakowskie Przedmieście 3, 00-927 Warszawa, Poland
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Pakkanen P, Häggman-Laitila A, Kangasniemi M. Ethical issues identified in nurses´ interprofessional collaboration in clinical practice: a meta-synthesis. J Interprof Care 2021; 36:725-734. [PMID: 34120556 DOI: 10.1080/13561820.2021.1892612] [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: 10/21/2022]
Abstract
The aim of this study was to synthesize previous knowledge about ethics in nurses' interprofessional collaboration in clinical practice. Although healthcare professionals have common goals and shared values, ethical conflicts still arise during patient care. We carried out a meta-synthesis of peer-reviewed papers published in any language from 2013-2019, using both electronic searches, with the CINAHL, PubMed, Scopus, and SocINDEX databases, and manual searches. We identified 4,763 papers and selected six qualitative papers, and three theoretical papers, based on predetermined inclusion and exclusion criteria and quality appraisal. The studies came from the USA, Canada, Sweden, Australia, Botswana, and the Netherlands. We found that in ethics studies on nurses' interprofessional collaboration in clinical practice the focus has been on factors that affect how patients receive care. These factors were patients' wishes, whether they were told the truth about their condition, and how different professionals recognized and treated their pain. The focus in the papers we reviewed was on the roles of different professionals during the care process, including ethical conflicts with regard to their aims, commitment, and the balance of power among them and other professions. More research is needed to raise the visibility of how nurses and other professionals recognize, and evaluate, their professional and interprofessional ethics.
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Affiliation(s)
- Piiku Pakkanen
- Department of Nursing Science, Faculty of Medicine, University of Turku, Turku, Finland
| | - Arja Häggman-Laitila
- Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Mari Kangasniemi
- Department of Nursing Science, Faculty of Medicine, University of Turku, Turku, Finland
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11
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Fischer-Grönlund C, Brännström M, Zingmark K. The 'one to five' method - A tool for ethical communication in groups among healthcare professionals. Nurse Educ Pract 2021; 51:102998. [PMID: 33639607 DOI: 10.1016/j.nepr.2021.102998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 02/10/2021] [Accepted: 02/14/2021] [Indexed: 11/24/2022]
Abstract
Healthcare professionals have expressed a wish for facilitated inter-professional communications about ethical difficulties experienced in clinical practice. The introduction of an easily accessible method for facilitating ethical communication in groups may promote its implementation in everyday clinical practice. The aim of this paper was to draw on previous studies and available knowledge in order to develop and describe a method that enables systematic implementation of inter-professional ethical communication in groups. The 'one-to-five method' for facilitated ethical communication in groups is theoretically inspired by Habermas's theory of communicative actions and base on previous studies that accords with the Helsinki Declaration (2013). The 'one to five method' supports guidance of ethical communication in five steps: telling the story about the situation; reflections and dialogue concerning the emotions involved; formulation of the problem/dilemma; analysis of the situation and the dilemma; and searching for a choice of action or approach. It offers an easily accessible method for teaching healthcare professionals how to facilitate ethics communication groups. Educating facilitators closely connected to clinical work may lead to ethical dialogue becoming a natural part of clinical practice for healthcare professionals.
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Affiliation(s)
| | | | - Karin Zingmark
- Department of Health Science, Division of Nursing, Luleå University of Technology, Sweden.
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12
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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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Spronk B, Widdershoven G, Alma H. Addressing harm in moral case deliberation: the views and experiences of facilitators. BMC Med Ethics 2020; 21:10. [PMID: 32000784 PMCID: PMC6993317 DOI: 10.1186/s12910-020-0450-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 01/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In healthcare practice, care providers are confronted with decisions they have to make, directly affecting patients and inevitably harmful. These decisions are tragic by nature. This study investigates the role of Moral Case Deliberation (MCD) in dealing with tragic situations. In MCD, caregivers reflect on real-life dilemmas, involving a choice between two ethical claims, both resulting in moral damage and harm. One element of the reflection process is making explicit the harm involved in the choice. How harmful are our decisions? We investigated how facilitators of MCD experience the importance of addressing harm in MCD and what participants learn from reflecting on harm. METHODS The study was qualitative, focusing on the views and experiences of the facilitators of MCD. Semi-structured interviews (N = 12) were conducted with facilitators of MCD. The research focuses on the subjective experiences of facilitators. Grounded Theory was used for analysis. RESULTS The results show two main categories. The first concerns the awareness of tragedy. Within this category, five themes were discerned: making explicit that there is no solution, visualizing consequences, uncovering pain, focusing on emotion, and exploring perspectives on harm. The second category concerns the support for healthcare professionals in dealing with the tragedy of the choices they face. In this category, five themes came forward: acknowledging, offering comfort, managing harm, consideration through dialogue and repairing harm. CONCLUSION Our study shows that addressing harm in MCD in tragic situations provides an important moral learning opportunity for participants. By formulating and becoming aware of harm, MCD aids healthcare professionals in the task they are faced with, namely making difficult and painful choices. MCD helps healthcare professionals to repair moral damage, making clear at the same time that harm cannot be undone.
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Affiliation(s)
- Benita Spronk
- Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Postbus 7057, 1007 MB, Amsterdam, Netherlands.
| | - Guy Widdershoven
- Department of Medical Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1089 a, 1081 HV, Amsterdam, Netherlands
| | - Hans Alma
- Department of Philosophy and Ethics, VUB (Vrije Universiteit Brussel), Pleinlaan 2, 1050, Brussel, Belgium
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14
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Hill DL, Walter JK, Szymczak JE, DiDomenico C, Parikh S, Feudtner C. Seven Types of Uncertainty When Clinicians Care for Pediatric Patients With Advanced Cancer. J Pain Symptom Manage 2020; 59:86-94. [PMID: 31425822 PMCID: PMC6942218 DOI: 10.1016/j.jpainsymman.2019.08.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/05/2019] [Accepted: 08/08/2019] [Indexed: 11/18/2022]
Abstract
CONTEXT Clinicians deciding whether to refer a patient or family to specialty palliative care report facing high levels of uncertainty. Most research on medical uncertainty has focused on prognostic uncertainty. As part of a pediatric palliative referral intervention for oncology teams we explored how uncertainty might influence palliative care referrals. OBJECTIVES To describe distinct meanings of the term "uncertainty" that emerged during the qualitative evaluation of the development and implementation of an intervention to help oncologists overcome barriers to palliative care referrals. METHODS We conducted a phenomenological qualitative analysis of "uncertainty" as experienced and described by interdisciplinary pediatric oncology team members in discussions, group activities and semistructured interviews regarding the introduction of palliative care. RESULTS We found that clinicians caring for patients with advanced cancer confront seven broad categories of uncertainty: prognostic, informational, individual, communication, relational, collegial, and inter-institutional. Each of these kinds of uncertainty can contribute to delays in referring patients to palliative care. CONCLUSION Various types of uncertainty arise in the care of pediatric patients with advanced cancer. To manage these forms of uncertainty, providers need to develop strategies and techniques to handle professionally challenging situations, communicate bad news, manage difficult interactions with families and colleagues, and collaborate with other organizations.
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Affiliation(s)
- Douglas L Hill
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jennifer K Walter
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julia E Szymczak
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Concetta DiDomenico
- Division of Pediatric Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Shefali Parikh
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
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Bruun H, Huniche L, Stenager E, Mogensen CB, Pedersen R. Hospital ethics reflection groups: a learning and development resource for clinical practice. BMC Med Ethics 2019; 20:75. [PMID: 31651308 PMCID: PMC6813973 DOI: 10.1186/s12910-019-0415-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 10/09/2019] [Indexed: 11/13/2022] Open
Abstract
Background An ethics reflection group (ERG) is one of a number of ethics support services developed to better handle ethical challenges in healthcare. The aim of this article is to evaluate the significance of ERGs in psychiatric and general hospital departments in Denmark. Methods This is a qualitative action research study, including systematic text condensation of 28 individual interviews and 4 focus groups with clinicians, ethics facilitators and ward managers. Short written descriptions of the ethical challenges presented in the ERGs also informed the analysis of significance. Results A recurring ethical challenge for clinicians, in a total of 63 cases described and assessed in 3 ethical reflection groups, is to strike a balance between respect for patient autonomy, paternalistic responsibility, professional responsibilities and institutional values. Both in psychiatric and general hospital departments, the study participants report a positive impact of ERG, which can be divided into three categories: 1) Significance for patients, 2) Significance for clinicians, and 3) Significance for ward managers. In wards characterized by short-time patient admissions, the cases assessed were retrospective and the beneficiaries of improved dialogue mainly future patients rather than the patients discussed in the specific ethical challenge presented. In wards with longer admissions, the patients concerned also benefitted from the dialogue in the ERG. Conclusion This study indicates a positive significance and impact of ERGs; constituting an interdisciplinary learning resource for clinicians, creating significance for themselves, the ward managers and the organization. By introducing specific examples, this study indicates that ERGs have significance for the patients discussed in the specific ethical challenge, but mostly indirectly through learning among clinicians and development of clinical practice. More research is needed to further investigate the impact of ERGs seen from the perspectives of patients and relatives.
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Affiliation(s)
- H Bruun
- Focused Research Unit in Psychiatry, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | - L Huniche
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - E Stenager
- Focused Research Unit in Psychiatry, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - C B Mogensen
- Focused Research Unit in Emergency Medicine, Institute for Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - R Pedersen
- Center for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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Hemberg J, Bergdahl E. Dealing with ethical and existential issues at end of life through co-creation. Nurs Ethics 2019; 27:1012-1031. [PMID: 31522601 DOI: 10.1177/0969733019874496] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND In research on co-creation in nursing, a caring manner can be used to create opportunities for the patient to reach vital goals and thereby increase the patient's quality of life in palliative home care. This can be described as an ethical cornerstone and the goal of palliative care. Nurses must be extra sensitive to patients' and their relatives' needs with regard to ethical and existential issues and situations in home care encounters, especially at the end of life. AIM The aim of this study was to explore nurses' experiences of dealing with ethical and existential issues through co-creation at the end of life in palliative home care. RESEARCH DESIGN, PARTICIPANTS, AND RESEARCH CONTEXT The material consisted of texts from interviews with 12 nurses in a home care context. A hermeneutical approach was used, and the method was inspired by a thematic analysis. ETHICAL CONSIDERATIONS Informed consent was sought from the participants regarding study participation and the storage and handling of data for research purposes. Ethical permission to conduct the study was given from organizations that participated in this study. FINDINGS A main theme and four subthemes emerged. The main theme was "Deep co-creative relationships are needed to manage ethical and existential issues at the end of life." A model was created to display the findings and relations between ethical issues and situations and the need for a deep trustful caring relationship to solve problems in palliative home care. DISCUSSION Together, the themes can be considered as a tool for learning and dealing with ethical and existential issues at the end of life in home care. The themes can also be seen as a part of nurses' ethical competence within this context. CONCLUSION The quality of life at the end of life can be improved through co-creation, despite difficult ethical and existential issues. Future research should focus on co-creation from the patients' perspective.
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Svantesson M, de Snoo-Trimp JC, Ursin G, de Vet HCW, Brinchmann BS, Molewijk B. Important outcomes of moral case deliberation: a Euro-MCD field survey of healthcare professionals' priorities. JOURNAL OF MEDICAL ETHICS 2019; 45:608-616. [PMID: 31320403 PMCID: PMC6817990 DOI: 10.1136/medethics-2018-104745] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 06/04/2019] [Accepted: 06/05/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND There is a lack of empirical research regarding the outcomes of such clinical ethics support methods as moral case deliberation (MCD). Empirical research in how healthcare professionals perceive potential outcomes is needed in order to evaluate the value and effectiveness of ethics support; and help to design future outcomes research. The aim was to use the European Moral Case Deliberation Outcome Instrument (Euro-MCD) instrument to examine the importance of various MCD outcomes, according to healthcare professionals, prior to participation. METHODS A North European field survey among healthcare professionals drawn from 73 workplaces in a variety of healthcare settings in the Netherlands, Norway and Sweden. The Euro-MCD instrument was used. RESULTS All outcomes regarding the domains of moral reflexivity, moral attitude, emotional support, collaboration, impact at organisational level and concrete results, were perceived as very or quite important by 76%-97% of the 703 respondents. Outcomes regarding collaboration and concrete results were perceived as most important. Outcomes assessed as least important were mostly about moral attitude. 'Better interactions with patient/family' emerged as a new domain from the qualitative analysis. Dutch respondents perceived most of the outcomes as significantly less important than the Scandinavians, especially regarding emotional support. Furthermore, men, those who were younger, and physician-respondents scored most of the outcomes as statistically significantly less important compared with the other respondents. CONCLUSIONS The findings indicate a need for a broad instrument such as the Euro-MCD. Outcomes related to better interactions between professionals and patients must also be included in the future. The empirical findings raise the normative question of whether outcomes that were perceived as less important, such as moral reflexivity and moral attitude outcomes, should still be included. In the future, a combination of empirical findings (practice) and normative reflection (theories) will contribute to the revision of the instrument.
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Affiliation(s)
- Mia Svantesson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Janine C de Snoo-Trimp
- Department of Medical Humanities, VU Medical Centre, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Göril Ursin
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
| | - Henrica CW de Vet
- Department of Epidemiology and Biostatistics, VU Medical Centre, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | | | - Bert Molewijk
- Department of Medical Humanities, VU Medical Centre, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Center of Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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Bruun H, Pedersen R, Stenager E, Mogensen CB, Huniche L. Implementing ethics reflection groups in hospitals: an action research study evaluating barriers and promotors. BMC Med Ethics 2019; 20:49. [PMID: 31311525 PMCID: PMC6636139 DOI: 10.1186/s12910-019-0387-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 07/01/2019] [Indexed: 11/30/2022] Open
Abstract
Background An ethics reflection group (ERG) is one of a range of ethics support services developed to better handle ethical challenges in healthcare. The aim of this article is to evaluate the implementation process of interdisciplinary ERGs in psychiatric and general hospital departments in Denmark. To our knowledge, this is the first study of ERG implementation to include both psychiatric and general hospital departments. Methods The implementation and evaluation strategies are inspired by action research, using a qualitative approach and systematic text condensation of 28 individual interviews and 4 focus groups with clinicians, ethics facilitators and ward managers. Results The implementation process was influenced by both structural factors and factors related to clinicians having different values, interests and experiences. Structural barriers and promotors in the process to implement ERG included the following sub-categories: Organizational factors, recruitment and training of ethics facilitators, the deliberation model, planning and recruitment of participants to the ERGs, the support of the ward managers and the project group. Barriers and promotors found among clinicians included the following sub-categories: Expectations and pre-understandings of ERGs, understandings of a physician’s job, challenges experienced by ethics facilitators. At the end of the study, when it was decided that the ERGs should be continued, the implementation strategies were remodeled by the participants to meet new challenges. Conclusion The study of ERG implementation identified important structural and professional barriers and promotors that are likely to be relevant to anyone wanting to implement ethics support services across various types of healthcare services.
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Affiliation(s)
- Henriette Bruun
- Focused Research Unit in Psychiatry, Institute of Regional Health Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, 5000, Odense C, Denmark.
| | - Reidar Pedersen
- Center for medical Ethics, Institute of Health and Society, University of Oslo, Kirkevejen 166, 0450, Oslo, Norway
| | - Elsebeth Stenager
- Focused Research Unit in Psychiatry, Institute of Regional Health Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, 5000, Odense C, Denmark
| | - Christian Backer Mogensen
- Focused Research Unit in Emergency Medicine Institute for Regional Health Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, 5000, Odense C, Denmark
| | - Lotte Huniche
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark
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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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de Snoo-Trimp JC, Molewijk B, Ursin G, Brinchmann BS, Widdershoven GA, de Vet HC, Svantesson M. Field-testing the Euro-MCD Instrument: Experienced outcomes of moral case deliberation. Nurs Ethics 2019; 27:390-406. [PMID: 31177947 DOI: 10.1177/0969733019849454] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Moral case deliberation is a form of clinical ethics support to help healthcare professionals in dealing with ethically difficult situations. There is a lack of evidence about what outcomes healthcare professionals experience in daily practice after moral case deliberations. The Euro-MCD Instrument was developed to measure outcomes, based on the literature, a Delphi panel, and content validity testing. To examine relevance of items and adequateness of domains, a field study is needed. AIM To describe experienced outcomes after participating in a series of moral case deliberations, both during sessions and in daily practice, and to explore correlations between items to further validate the Euro-MCD Instrument. METHODS In Sweden, the Netherlands, and Norway, healthcare institutions that planned a series of moral case deliberations were invited. Closed responses were quantitatively analyzed. The factor structure of the instrument was tested using exploratory factor analyses. ETHICAL CONSIDERATIONS The study was approved in Sweden by a review board. In Norway and the Netherlands, data services and review boards were informed about the study. RESULTS The Euro-MCD Instrument was completed by 443 and 247 healthcare professionals after four and eight moral case deliberations, respectively. They experienced especially outcomes related to a better collaboration with co-workers and outcomes about individual moral reflexivity and attitude, both during sessions and in daily practice. Outcomes were experienced to a higher extent during sessions than in daily practice. The factor structure revealed four domains of outcomes, which did not confirm the six Euro-MCD domains. CONCLUSION Field-testing the Euro-MCD Instrument showed the most frequently experienced outcomes and which outcomes correlated with each other. When revising the instrument, domains should be reconsidered, combined with theory about underlying concepts. In the future, a feasible and valid instrument will be presented to get insight into how moral case deliberation supports and improves healthcare.
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Affiliation(s)
| | - Bert Molewijk
- Amsterdam UMC, location VU Medical Center, The Netherlands; University of Oslo, Norway
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Grönlund CF, Söderberg A, Dahlqvist V, Andersson L, Isaksson U. Development, validity and reliability testing the Swedish Ethical Climate Questionnaire. Nurs Ethics 2019; 26:2482-2493. [PMID: 30665340 DOI: 10.1177/0969733018819122] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND An ethical climate has been described as a working climate embracing shared perceptions about morally correct behaviour concerning ethical issues. Various ethical climate questionnaires have been developed and validated for different contexts, but no questionnaire has been found concerning the ethical climate from an inter-professional perspective in a healthcare context. The Swedish Ethical Climate Questionnaire, based on Habermas' four requirements for a democratic dialogue, attempts to assess and measure the ethical climate at various inter-professional workplaces. This study aimed to present the construction of and to test the psychometric properties of the Swedish Ethical Climate Questionnaire. METHOD An expert group of six researchers, skilled in ethics, evaluated the content validity. The questionnaire was tested among 355 healthcare workers at three hospitals in Sweden. A parallel analysis (PA), an exploratory factor analysis and confirmatory factor analysis were performed. ETHICAL CONSIDERATIONS The participants included in the psychometric analysis were informed about the study, asked to participate in person and informed that they could withdraw at any time without giving any reason. They were also assured of confidentiality in the reporting of the results. FINDINGS The parallel analysis (PA) recommended one factor as a solution. The initial exploratory factor analysis with a four-factor solution showed low concordance with a four-factor model. Cronbach's alpha varied from 0.75 to 0.82; however, since two factors only consisted of one item, alpha could not be reported. Cronbach's alpha for the entire scale showed good homogeneity (α = 0.86). A confirmatory factory analysis was carried out based on the four requirements and showed a goodness-of-fit after deleting two items. After deletion of these items, Cronbach's alpha was 0.82. DISCUSSION Based on the exploratory factor analysis, we suggest that the scale should be treated as a one-factor model. The result indicates that the instrument is unidimensional and assesses ethical climate as a whole. CONCLUSION After testing the Swedish Ethical Climate Questionnaire, we found support for the validity and reliability of the instrument. We found the 10-item version of Swedish Ethical Climate Questionnaire satisfactory. However, we found no support for measuring different dimensions and, therefore, this instrument should be seen as assessing ethical climate as of whole.
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Hartman LA, Metselaar S, Molewijk AC, Edelbroek HM, Widdershoven GAM. Developing an ethics support tool for dealing with dilemmas around client autonomy based on moral case deliberations. BMC Med Ethics 2018; 19:97. [PMID: 30577790 PMCID: PMC6303905 DOI: 10.1186/s12910-018-0335-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 12/03/2018] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Moral Case Deliberations (MCDs) are reflective dialogues with a group of participants on their own moral dilemmas. Although MCD is successful as clinical ethics support (CES), it also has limitations. 1. Lessons learned from individual MCDs are not shared in order to be used in other contexts 2. Moral learning stays limited to the participants of the MCD; 3. MCD requires quite some organisational effort, 4. MCD deals with one individual concrete case. It does not address other, similar cases (it is case based). These limitations warrant research into complementary ways of providing CES to healthcare professionals. Our research objective was therefore to develop a low threshold CES tool based on a series of MCDs on autonomy in long-term care. METHODS We used a qualitative research design in which we analyzed the process and content of a series of MCDs, combined with reflections on the theoretical background of MCD. In total 28 MCDs (10 transcripts and 18 summary reports) were analyzed by means of a thematic content analysis. In various rounds of development, the results of the analysis were combined with theoretical reflections on CES. Consequently, the tool was evaluated in three focus groups and adjusted. RESULTS The CES tool, called 'moral compass', guides the users through a series of six subsequent questions in order to methodically reflect on their concrete moral dilemma, in the form of a booklet of 23 pages. It combines a methodical element that encourages and structures a reflection process with a substantive element, including norms, values, options, strategies, and insights regarding dealing with client autonomy. CONCLUSION By using data from a series of MCDs, combined with theoretical reflections on MCD, ethics support and moral learning, we developed a thematic, low-threshold CES tool that supports healthcare professionals in daily practice in dealing with moral questions regarding client autonomy. It integrates examples and insights from earlier MCDs on the same topic. The moral compass is not a replacement of, but can be used complementary to MCD. The feasibility and impact of the moral compass need to be investigated in an evaluative follow-up study. The methodology presented in this paper may be used to develop moral compasses on different topics in various healthcare organizations.
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Affiliation(s)
- L. A. Hartman
- Department of Medical Humanities, VU University Medical Centre, APH, Amsterdam, The Netherlands
| | - S. Metselaar
- Department of Medical Humanities, VU University Medical Centre, APH, Amsterdam, The Netherlands
| | - A. C. Molewijk
- Department of Medical Humanities, VU University Medical Centre, APH, Amsterdam, The Netherlands
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - H. M. Edelbroek
- Institute for Interdisciplinary Studies, University of Amsterdam, Amsterdam, The Netherlands
| | - G. A. M. Widdershoven
- Department of Medical Humanities, VU University Medical Centre, APH, Amsterdam, The Netherlands
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Rasoal D, Kihlgren A, Skovdahl K. Balancing different expectations in ethically difficult situations while providing community home health care services: a focused ethnographic approach. BMC Geriatr 2018; 18:312. [PMID: 30547755 PMCID: PMC6293571 DOI: 10.1186/s12877-018-0996-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 11/27/2018] [Indexed: 11/10/2022] Open
Abstract
Background The general opinion in society is that everyone has the right to live in their own home as long as possible. Provision of community home health care services is therefore increasingly common. Healthcare personnel encounter ethically difficult situations when providing care, but few studies describe such situations in the context of community home health care services. Method This study has a qualitative descriptive design, using focused ethnography. Data from 21 days of fieldwork (in total 123 h) consisting of non-participant observations (n = 122), memos and informal interviews with registered nurses (n = 8), and nurse assistants (n = 4). The transcribed texts were analyzed with interpretive content analysis. Results The inductive analyses revealed two categories: 1) difficulties in balancing different requirements, expectations and needs, and 2) use of coping strategies. The results demonstrate that there are different values and expectations that influence each other in a complex manner. The personnel dealt with these situations by generating strategies of coaxing the patients and finding a space to deliberate and share difficult emotions with their colleagues. Conclusions This study reveals that complex ethically difficult situations emerged in the context of community home health care services, and healthcare personnel were forced to find a balance regarding the different demands, expectations, values and needs that influence the care provided.
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Affiliation(s)
- Dara Rasoal
- School of Health, Care and Social Welfare, Mälardalen University, Högskoleplan 1, 721 23, Västerås, Sweden.
| | - Annica Kihlgren
- Institution of Health and Medical Sciences, Örebro University, Faultetsgatan 1, 701 82, Örebro, Sweden
| | - Kirsti Skovdahl
- Faculty for Health and Social Sciences, University in South-Eastern Norway, Post box 235, 3603, Kongsberg, Norway
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Grönlund CF, Söderberg A, Dahlqvist V, Sandlund M, Zingmark K. Communicative and organizational aspects of clinical ethics support. J Interprof Care 2018; 33:724-733. [PMID: 30497309 DOI: 10.1080/13561820.2018.1551862] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Studies show that healthcare professionals need inter-professional clinical ethics support (CES) in order to communicate and reflect on ethically difficult care situations that they experience in their clinical practice. Internationally, various CES interventions have been performed, but the communication processes and organisation of these interventions are rarely described in detail. The aim of this study was to explore communicative and organisational conditions of a CES intervention with the intention of promoting inter-professional communication about ethically difficult care situations. Eight audio- and video-recorded inter-professional CES sessions, inspired by Habermas' theory of communicative actions, were conducted. The observations were transcribed, sorted, and analysed using concept- and data-driven content analysis methods. The findings show three approaches to promoting communicative agreement, which include the CES facilitators' and participants' approaches to promoting a permissive communication, extended views, and mutual understanding. The CES sessions had organizational aspects for facilitating communicative agreement with both a given structure and openness for variation. The dynamic structure of the organization, promoted both safety and stability as well as a creativity and responsiveness, which in turn opened up for a free and dynamic inter-professional dialogue concerning ethically difficult care situations. The findings constitute a step towards a theory-based CES method inspired by Habermas' theory of communicative action. Further research is needed in order to fully develop the method and obtain increased knowledge about how to promote an inter-professional dialogue about ethically difficulties.
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Affiliation(s)
| | | | - Vera Dahlqvist
- Department of Nursing, Ersta Sköndal University College, Stockholm, Sweden
| | - Mikael Sandlund
- Department of Clinical Science/Psychiatry, Umeå University, Umeå, Sweden
| | - Karin Zingmark
- Department of Health Science, Division of Nursing, Luleå University of Technology & Norrbotten County Council, Luleå, Sweden
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Heidenreich K, Bremer A, Materstvedt LJ, Tidefelt U, Svantesson M. Relational autonomy in the care of the vulnerable: health care professionals' reasoning in Moral Case Deliberation (MCD). MEDICINE, HEALTH CARE, AND PHILOSOPHY 2018; 21:467-477. [PMID: 29243015 PMCID: PMC6267250 DOI: 10.1007/s11019-017-9818-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
In Moral Case Deliberation (MCD), healthcare professionals discuss ethically difficult patient situations in their daily practice. There is a lack of knowledge regarding the content of MCD and there is a need to shed light on this ethical reflection in the midst of clinical practice. Thus, the aim of the study was to describe the content of healthcare professionals' moral reasoning during MCD. The design was qualitative and descriptive, and data consisted of 22 audio-recorded inter-professional MCDs, analysed with content analysis. The moral reasoning centred on how to strike the balance between personal convictions about what constitutes good care, and the perceived dissonant care preferences held by the patient. The healthcare professionals deliberated about good care in relation to demands considered to be unrealistic, justifications for influencing the patient, the incapacitated patient's nebulous interests, and coping with the conflict between using coercion to achieve good while protecting human dignity. Furthermore, as a basis for the reasoning, the healthcare professionals reflected on how to establish a responsible relationship with the vulnerable person. This comprised acknowledging the patient as a susceptible human being, protecting dignity and integrity, defining their own moral responsibility, and having patience to give the patient and family time to come to terms with illness and declining health. The profound struggle to respect the patient's autonomy in clinical practice can be understood through the concept of relational autonomy, to try to secure both patients' influence and at the same time take responsibility for their needs as vulnerable humans.
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Affiliation(s)
- Kaja Heidenreich
- Faculty of Health and Medicine, University Health Care Research Center, Örebro University, Box 1613, 701 16, Örebro, Sweden.
| | - Anders Bremer
- Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
- PreHospen - Centre for Prehospital Research, University of Borås, Borås, Sweden
| | - Lars Johan Materstvedt
- Department of Philosophy and Religious Studies, Faculty of Humanities, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Glasgow End of Life Studies Group, School of Interdisciplinary Studies, University of Glasgow, Dumfries Campus, Scotland, UK
| | - Ulf Tidefelt
- Faculty of Health and Medicine, University Health Care Research Center, Örebro University, Box 1613, 701 16, Örebro, Sweden
| | - Mia Svantesson
- Faculty of Health and Medicine, University Health Care Research Center, Örebro University, Box 1613, 701 16, Örebro, Sweden
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Abstract
BACKGROUND Over the last decade, new healthcare policies are transforming healthcare practices towards independent living and self-care of older people and people with a chronic disease or disability within the community. For professional caregivers in home care, such as nurses, this requires a shift from a caring attitude towards the promotion of patient autonomy. AIM To explore how nurses in home care deal with the transformation towards fostering patient autonomy and self-care. RESEARCH DESIGN AND CONTEXT A case study was conducted in a professional development course ('learning circle') for home care nurses, including participant observations and focus groups. The theoretical notion of 'relational agency' and the moral concept of 'practices of responsibility' were used to conduct a narrative analysis on the nurses' stories about autonomy. PARTICIPANTS Eight nurses, two coaches and two university lecturers who participated in the learning circle. ETHICAL CONSIDERATIONS Informed consent was sought at the start of the course and again, at specific moments during the course of the learning circle. FINDINGS Three main themes were found that expressed the moral demands experienced and negotiated by the nurses: adapting to the person, activating patients' strengths and collaboration with patients and informal caregivers. DISCUSSION On a policy and organisational level, the moral discourse on patient autonomy gets intertwined with the instrumental discourse on healthcare budget savings. This is manifested in the ambiguities the nurses face in fostering patient autonomy in their daily home care practice. To support nurses, critical thinking, moral sensitivity and trans-professional working should be part of their professional development. CONCLUSION The turn towards autonomy in healthcare raises moral questions about responsibilities for care. Promoting patient autonomy should be a collaborative endeavour and deliberation of patients, professional and informal caregivers together.
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Affiliation(s)
- Gaby Jacobs
- Fontys University of Applied Sciences, The Netherlands
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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: 62] [Impact Index Per Article: 8.9] [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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Grönlund CF, Dahlqvist V, Zingmark K, Sandlund M, Söderberg A. Managing Ethical Difficulties in Healthcare: Communicating in Inter-professional Clinical Ethics Support Sessions. HEC Forum 2017; 28:321-338. [PMID: 27147521 DOI: 10.1007/s10730-016-9303-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Several studies show that healthcare professionals need to communicate inter-professionally in order to manage ethical difficulties. A model of clinical ethics support (CES) inspired by Habermas' theory of discourse ethics has been developed by our research group. In this version of CES sessions healthcare professionals meet inter-professionally to communicate and reflect on ethical difficulties in a cooperative manner with the aim of reaching communicative agreement or reflective consensus. In order to understand the course of action during CES, the aim of this study was to describe the communication of value conflicts during a series of inter-professional CES sessions. Ten audio- and video-recorded CES sessions were conducted over eight months and were analyzed by using the video analysis tool Transana and qualitative content analysis. The results showed that during the CES sessions the professionals as a group moved through the following five phases: a value conflict expressed as feelings of frustration, sharing disempowerment and helplessness, the revelation of the value conflict, enhancing realistic expectations, seeing opportunities to change the situation instead of obstacles. In the course of CES, the professionals moved from an individual interpretation of the situation to a common, new understanding and then to a change in approach. An open and permissive communication climate meant that the professionals dared to expose themselves, share their feelings, face their own emotions, and eventually arrive at a mutual shared reality. The value conflict was not only revealed but also resolved.
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Affiliation(s)
| | - Vera Dahlqvist
- Department of Nursing, Ersta Sköndal University College, P.O. Box 111 89, 100 61, Stockholm, Sweden
| | - Karin Zingmark
- Division of Nursing, Department of Health Science, Luleå University of Technology, 971 87, Luleå, Sweden.,Norrbotten County Council, Landstingshuset, 971 89, Luleå, Sweden
| | - Mikael Sandlund
- Department of Clinical Science/Psychiatry, Umeå University, 901 87, Umeå, Sweden
| | - Anna Söderberg
- Department of Nursing, Umeå University, 901 87, Umeå, Sweden
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Svantesson M, Silén M, James I. It’s not all about moral reasoning: Understanding the content of Moral Case Deliberation. Nurs Ethics 2017; 25:212-229. [DOI: 10.1177/0969733017700235] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Moral Case Deliberation is one form of clinical ethics support described as a facilitator-led collective moral reasoning by healthcare professionals on a concrete moral question connected to their practice. Evaluation research is needed, but, as human interaction is difficult to standardise, there is a need to capture the content beyond moral reasoning. This allows for a better understanding of Moral Case Deliberation, which may contribute to further development of valid outcome criteria and stimulate the normative discussion of what Moral Case Deliberation should contain. Objective: To explore and compare the content beyond moral reasoning in the dialogue in Moral Case Deliberation at Swedish workplaces. Methods: A mixed-methods approach was applied for analysing audio-recordings of 70 periodic Moral Case Deliberation meetings at 10 Swedish workplaces. Moral Case Deliberation facilitators and various healthcare professions participated, with registered nurses comprising the majority. Ethical considerations: No objection to the study was made by an Ethical Review Board. After oral and written information was provided, consent to be recorded was assumed by virtue of participation. Findings: Other than ‘moral reasoning’ (median (md): 45% of the spoken time), the Moral Case Deliberations consisted of ‘reflections on the psychosocial work environment’ to a varying extent (md: 29%). Additional content comprised ‘assumptions about the patient’s psychosocial situation’ (md: 6%), ‘facts about the patient’s situation’ (md: 5%), ‘concrete problem-solving’ (md: 6%) and ‘process’ (md: 3%). Conclusion: The findings suggest that a restorative function of staff’s wellbeing in Moral Case Deliberation is needed, as this might contribute to good patient care. This supports outcome criteria of improved emotional support, which may include relief of moral distress. However, facilitators need a strategy for how to proceed from the participants’ own emotional needs and to develop the use of their emotional knowing to focus on the ethically difficult patient situation.
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Affiliation(s)
| | - Marit Silén
- University of Gävle, Sweden; Uppsala University, Sweden
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