A systematic scoping review on patients' perceptions of dignity

A Systematic Scoping Review on Dignity Assessment Tools

CONTEXT

The provision of person-centered dignity-conserving care is central to palliative care. It is important to reevaluate current methods of assessing dignity as the concept of dignity is multifaceted.

OBJECTIVES

The aim of this study is to understand the tools which are used to assess a patient's dignity and the elements of dignity evaluated in these tools.

METHODS

Two independent and concurrent Systematic Evidence-Based Approach guided systematic scoping reviews (SSR in SEBA) on existing dignity assessment tools and on accounts of assessments of dignity were carried out. The SSR in SEBA on dignity assessment tools involving PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Scopus, and CINAHL databases saw 22 full-text articles included from the 645 articles reviewed. The SSR in SEBA on accounts of assessments of dignity featured in the PubMed database identified 102 full-text articles which saw 46 articles included.

RESULTS

The domains identified were factors affecting patients' definition of dignity; elements of dignity-conserving care; and components of effective tools.

CONCLUSION

Current accounts to assess dignity and assessment tools fail to capture shifting self-concepts of dignity holistically. A portfolio-like appraisal of dignity is proposed to achieve assessments that are timely, longitudinal, and patient-specific. Portfolio-based assessments by members of the multidisciplinary team will better direct timely evaluations of relevant aspects of changing concepts of dignity, without losing the patient's holistic perception of dignity.

Reflections of nursing students on the care of the person's dignity at the end of life: A qualitative study

BACKGROUND

The education of nursing students not only implies transmitting knowledge and clinical skills, but also values, attitudes, and behaviours. In healthcare, it is considered essential to respect and preserve the dignity of people. This is even more important in palliative care, where the fragility of people makes them potentially vulnerable. There is limited knowledge regarding the conceptualization and experience of nursing students and human dignity in palliative care.

AIM

To describe how 5th-year nursing students conceptualise and experience human dignity, while caring for people with terminal illness.

DESIGN

Qualitative descriptive design, with thematic content analysis as per Graneheim and Lundman.

SETTING

A palliative care centre for people on low incomes with terminal illnesses which no longer respond to curative treatments.

PARTICIPANTS

A total of 11 fifth-year nursing students who completed their professional practice in a palliative care unit.

METHODS

Data collection was conducted through guided online reflections via reflective journaling between April and November 2020. The study protocol was reviewed and approved by the Scientific Ethical Committee within the educational institution (CEC2021065).

RESULTS

Four thematic categories were identified (1) Concept of dignity; (2) Dignity: an essential element in the relationship with others, (3) Instances when the dignity of the person is not considered; (4) The value of reflection on dignity in clinical practice.

CONCLUSION

Dignity is one of the main values recognized in the person. Dignity should be promoted in the education of future nursing professionals, particularly with people who are in the final stage of life, where fragility and vulnerability it is more palpable.

The role of patients' stories in medicine: a systematic scoping review

BACKGROUND

Patients' stories provide Palliative Care physicians with a glimpse into the former's lives and their psycho-emotional, sociocultural, and contextual considerations. Yet, few physicians are trained to interpret and apply patients' stories in their practice. Inherent variability in how stories are transmitted and interpreted raises questions over their potential effects on care. Amidst a dearth of accounts in Palliative Care, we map current use of patient stories to guide the training, assessment, and oversight of this 'care influencing' practice in medicine.

METHODS

This systematic scoping review was guided by the Systematic Evidence-Based Approach (SEBA) to ensure a reproducible and structured approach. The themes and categories identified through the Split Approach's concurrent and independent thematic and directed content analyses provided a comprehensive sketch of the included articles. The Jigsaw Perspective combined the themes and categories identified. The last stage of SEBA compared these results with two recent reviews of storytelling to ensure consistency of the domains created that guided the discussion.

RESULTS

Ten thousand two hundred seven articles were reviewed, 963 full text articles were evaluated, and 199 articles were included. The four domains identified were study characteristics, benefits, approaches, and positive effects and concerns.

CONCLUSION

Stories support patient-centered, personalized, and holistic clinical care. However, variability in the stories, their interpretations and use in care decisions underscore the need for further study on the structuring, teaching, assessing, and delivery of this 'care influencing' practice.

Experiences of dignity: Age at onset of serious illness matters

BACKGROUND

Preserving persons' dignity is integral to nursing. More research is needed to explore how a diversity of patients, particularly those that experience illness from a young age, experience dignity.

AIM

Describe the characteristics of dignity for persons living with serious illness.

RESEARCH DESIGN

Using a secondary data set of twenty audio-recorded interviews, a thematic content analysis was conducted to identify characteristics of dignity. The research team employed van Gennip et al.'s, 2013 "Model of Dignity in Illness" (1) to create a codebook, which the authors utilized to independently code twenty narrative interview transcripts.

PARTICIPANTS AND RESEARCH CONTEXT

Twenty persons living with serious illness of heart failure and/or dialysis-dependent renal failure who were admitted in an acute care hospital.

ETHICAL CONSIDERATIONS

This study was approved on August 26, 2019, by the Colorado Multiple Institutional Review Board (COMIRB) IRB Protocol #19-1874.

FINDINGS

Early-onset participants expressed markedly different dignity concerns than late-onset participants. In the individual domain, early-onset participants felt that their illness was "normal"; they did not experience the "healthy person to patient" transition described by older onset participants. In the relational domain, early-onset participants expressed that their relationships had already integrated their illness while late-onset participants felt that their illness harmed many of their relationships. In the societal domain, early-onset participants described dignity concerns related to how society impacted their ability to financially support themselves during their illness.

DISCUSSION

Differences in the dignity experience of early-onset and late-onset participants are informed by Erikson's "Model of Development" and by Aranda and Jones feminist critique of dignity in healthcare.

CONCLUSIONS

Persons with early-onset illness experience dignity differently. Awareness of the importance of work and financial independence to the experience of dignity for seriously ill patients may enhance persons' dignity experience.

Dignity as a Central Issue in Treating Patients with Dementia Associated with COVID-19 Infection

COVID-19 was initially considered a primary respiratory disorder associated with various short- and long-term complications, affecting many patients and imposing a significant burden. Patients who have dementia are especially vulnerable to the SARS-CoV2 infection, which is associated with an increased risk for neuropsychiatric complications. These patients need a unique approach to managing ethical issues related to the COVID-19 pandemic, including autonomy, veracity, non-maleficence, justice, compassion, and dignity. The latter is one of the most elusive and misunderstood concepts in medical ethics and is extremely important in debates surrounding the proper management of patients with dementia. However, it is often left out of ethical analysis, as most clinicians, when debating issues associated with clinical practice, often evaluate only the "classical" principles of biomedical ethics. In this article, we aim to assess the unique features of dignity in treating this group of patients during the COVID-19 pandemic. We will briefly analyze dignity as a bioethical concept. We will further explore its principal axes, namely compassion, creating a humane and purposeful environment, employing persuasion to meet the person's essential needs, exerting a certain degree of mild restraint to meet the person's critical needs, minimizing harm in terminal care, and justice, through the lens of people who had dementia during the COVID-19 pandemic. Applying this principle in clinical practice requires significant commitment from all healthcare workers. New approaches to the analysis of dignity, such as through the Ring Theory of Personhood, may facilitate its understanding by practitioners and aid its implementation in populations with multiple vulnerabilities, such as dementia patients, during an infectious outbreak that generates significant social and medical changes.

Role modelling in professional identity formation: a systematic scoping review

BACKGROUND

Role modelling's pivotal part in the nurturing of a physician's professional identity remains poorly understood. To overcome these gaps, this review posits that as part of the mentoring spectrum, role modelling should be considered in tandem with mentoring, supervision, coaching, tutoring and advising. This provides a clinically relevant notion of role modelling whilst its effects upon a physician's thinking, practice and conduct may be visualised using the Ring Theory of Personhood (RToP).

METHODS

A Systematic Evidence Based Approach guided systematic scoping review was conducted on articles published between 1 January 2000 to 31 December 2021 in the PubMed, Scopus, Cochrane, and ERIC databases. This review focused on the experiences of medical students and physicians in training (learners) given their similar exposure to training environments and practices.

RESULTS

12,201 articles were identified, 271 articles were evaluated, and 145 articles were included. Concurrent independent thematic and content analysis revealed five domains: existing theories, definitions, indications, characteristics, and the impact of role modelling upon the four rings of the RToP. This highlights dissonance between the introduced and regnant beliefs and spotlights the influence of the learner's narratives, cognitive base, clinical insight, contextual considerations and belief system on their ability to detect, address and adapt to role modelling experiences.

CONCLUSION

Role modelling's ability to introduce and integrate beliefs, values and principles into a physician's belief system underscores its effects upon professional identity formation. Yet, these effects depend on contextual, structural, cultural and organisational influences as well as tutor and learner characteristics and the nature of their learner-tutor relationship. The RToP allows appreciation of these variations on the efficacy of role modelling and may help direct personalised and longitudinal support for learners.

Evidence-guided approach to portfolio-guided teaching and assessing communications, ethics and professionalism for medical students and physicians: a systematic scoping review

OBJECTIVES

Guiding the development of longitudinal competencies in communication, ethics and professionalism underlines the role of portfolios to capture and evaluate the multiple multisource appraisals and direct personalised support to clinicians. However, a common approach to these combined portfolios continues to elude medical practice. A systematic scoping review is proposed to map portfolio use in training and assessments of ethics, communication and professionalism competencies particularly in its inculcation of new values, beliefs and principles changes attitudes, thinking and practice while nurturing professional identity formation. It is posited that effective structuring of portfolios can promote self-directed learning, personalised assessment and appropriate support of professional identity formation.

DESIGN

Krishna's Systematic Evidence-Based Approach (SEBA) is employed to guide this systematic scoping review of portfolio use in communication, ethics and professionalism training and assessment.

DATA SOURCES

PubMed, Embase, PsycINFO, ERIC, Scopus and Google Scholar databases.

ELIGIBILITY CRITERIA

Articles published between 1 January 2000 and 31 December 2020 were included.

DATA EXTRACTION AND SYNTHESIS

The included articles are concurrently content and thematically analysed using the split approach. Overlapping categories and themes identified are combined using the jigsaw perspective. The themes/categories are compared with the summaries of the included articles in the funnelling process to ensure their accuracy. The domains identified form the framework for the discussion.

RESULTS

12 300 abstracts were reviewed, 946 full-text articles were evaluated and 82 articles were analysed, and the four domains identified were indications, content, design, and strengths and limitations.

CONCLUSIONS

This review reveals that when using a consistent framework, accepted endpoints and outcome measures, longitudinal multisource, multimodal assessment data fashions professional and personal development and enhances identity construction. Future studies into effective assessment tools and support mechanisms are required if portfolio use is to be maximised.

Ethical Implications of Nutrition Therapy at the End of Life

PURPOSE OF REVIEW

Provide an evidence-based resource to inform ethically sound recommendations regarding end of life nutrition therapy.

RECENT FINDINGS

• Some patients with a reasonable performance status can temporarily benefit from medically administered nutrition and hydration(MANH) at the end of life. • MANH is contraindicated in advanced dementia. • MANH eventually becomes nonbeneficial or harmful in terms of survival, function, and comfort for all patients at end of life. • Shared decision-making is a practice based on relational autonomy, and the ethical gold standard in end of life decisions. A treatment should be offered if there is expectation of benefit, but clinicians are not obligated to offer non-beneficial treatments. A decision to proceed or not should be based on the patient's values and preferences, a discussion of all potential outcomes, prognosis for given outcomes taking into consideration disease trajectory and functional status, and physician guidance provided in the form of a recommendation.

A Systematic Review of Stakeholder Perspectives of Dignity and Assisted Dying

INTRODUCTION

The debate on assisted dying and its components, euthanasia and physician-assisted suicide has evolved with the emergence of the right to dignity and the wish to hasten death (WTHD). Whilst shaped by local legal and sociocultural considerations, appreciation of how patients, healthcare professionals and lawmakers relate notions of dignity to self-concepts of personhood and the desire for assisted dying will better inform and direct support of patients.

METHODS

Guided by the Systematic Evidence Based Approach, a systematic scoping review (SSR in SEBA) on perspectives of dignity, WTHD and personhood featured in PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, CINAHL, Scopus databases and four key Palliative Care journals was conducted. The review hinged on the following questions: "what is the relationship between dignity and the wish to hasten death (WTHD) in the assisted dying debate?", "how is dignity conceptualised by patients with WTHD?" and "what are prevailing perspectives on the role of assisted dying in maintaining a dying patient's dignity?"

RESULTS

6947 abstracts were identified, 663 full text articles reviewed, and 88 articles included. The four domains identified include 1) concepts of dignity through the lens of the Ring Theory of Personhood (RToP) including their various definitions and descriptions; 2) the relationship between dignity, WTHD and assisted dying with loss of dignity and autonomy foregrounded; 3) stakeholder perspectives for and against assisted dying including those of patient, healthcare provider and lawmaker; and 4) other dignity-conserving measures as alternatives to assisted dying.

CONCLUSION

Concepts of dignity constantly evolve throughout the patient's end of life journey. Understanding when and how these concepts of personhood change and trigger the fear of a loss of dignity or intractable suffering could direct timely, individualised and appropriate person-centred dignity conserving measures. We believe an RToP-based tool could fulfil this role and further study into the design of this tool is planned.

Understanding mentoring relationships between mentees, peer and senior mentors

BACKGROUND

Mentoring relationships play a critical but poorly understood role in mentoring's overall success. To overcome these knowledge gaps, a study of mentee experiences in the Palliative Medicine Initiative, a structured research-based mentoring program, is proposed. The program's clearly described mentoring approach, competency-based mentoring stages and curated mentoring environment ensure a consistent mentoring experience. It provides a unique platform to study mentoring relationships longitudinally and its implications on professional identity formation.

METHODOLOGY

The Tool Design Systematic Evidence-Based Approach methodology is used to map and employ current understanding. A review of recent reviews on mentoring processes, mentoring's effects, professional identity formation and professional identity formation assessment tools lay the foundation for the design of semi-structured interviews and mentoring diaries to evaluate the characteristics of successful mentoring relationships and mentoring's impact on professional identity formation. The data accrued from these tools were evaluated using this methodology whilst changes in professional identity formation were assessed using the Ring Theory of Personhood.

RESULTS

The semi-structured interviews revealed four themes: stakeholders, mentoring stages, mentoring relationships and professional identity formation whilst the mentoring diaries revealed two: mentoring processes and mentoring relationships. Two final domains emerged - mentoring relationships and professional identity formation.

CONCLUSIONS

The Palliative Medicine Initiative's structured stage-based mentoring approach, trained stakeholders, curated environment, assessment-directed and personalized mentoring support reveal seven developmental stages of mentoring relationships. These culminate in changes to the values, beliefs and principles that shape how mentees see, feel and act as professionals. These findings suggest that mentoring programs may help to further develop and fine-tune their professional identity formation.

A systematic scoping review of reflective writing in medical education

BACKGROUND

Reflective writing (RW) allows physicians to step back, review their thoughts, goals and actions and recognise how their perspectives, motives and emotions impact their conduct. RW also helps physicians consolidate their learning and boosts their professional and personal development. In the absence of a consistent approach and amidst growing threats to RW's place in medical training, a review of theories of RW in medical education and a review to map regnant practices, programs and assessment methods are proposed.

METHODS

A Systematic Evidence-Based Approach guided Systematic Scoping Review (SSR in SEBA) was adopted to guide and structure the two concurrent reviews. Independent searches were carried out on publications featured between 1st January 2000 and 30th June 2022 in PubMed, Embase, PsychINFO, CINAHL, ERIC, ASSIA, Scopus, Google Scholar, OpenGrey, GreyLit and ProQuest. The Split Approach saw the included articles analysed separately using thematic and content analysis. Like pieces of a jigsaw puzzle, the Jigsaw Perspective combined the themes and categories identified from both reviews. The Funnelling Process saw the themes/categories created compared with the tabulated summaries. The final domains which emerged structured the discussion that followed.

RESULTS

A total of 33,076 abstracts were reviewed, 1826 full-text articles were appraised and 199 articles were included and analysed. The domains identified were theories and models, current methods, benefits and shortcomings, and recommendations.

CONCLUSIONS

This SSR in SEBA suggests that a structured approach to RW shapes the physician's belief system, guides their practice and nurtures their professional identity formation. In advancing a theoretical concept of RW, this SSR in SEBA proffers new insight into the process of RW, and the need for longitudinal, personalised feedback and support.

Assessing professional identity formation (PIF) amongst medical students in Oncology and Palliative Medicine postings: a SEBA guided scoping review

BACKGROUND

Introduction to a multi-professional team who are working and caring for the dying, and facing complex moral and ethical dilemmas during Oncology and Palliative Medicine postings influence a medical student's professional identity formation (PIF). However, limited appreciation of PIF, inadequate assessments and insufficient support jeopardise this opportunity to shape how medical students think, feel and act as future physicians. To address this gap, a systematic scoping review (SSR) of PIF assessment methods is proposed.

METHODS

A Systematic Evidence-based Approach (SEBA) guided SSR of assessments of PIF in medical schools published between 1^st January 2000 and 31^st December 2021 in PubMed, Embase, ERIC and Scopus databases was carried out. Included articles were concurrently content and thematically analysed using SEBA's Split Approach and the themes and categories identified were combined using SEBA's Jigsaw Perspective. The review hinged on the following questions: "what is known about the assessment of professional identity formation amongst medical students?", "what are the theories and principles guiding the assessment of professional identity formation amongst medical students?", "what factors influence PIF in medical students?", "what are the tools used to assess PIF in medical students?", and "what considerations impact the implementation of PIF assessment tools amongst medical students?".

RESULTS

Two thousand four hundred thirty six abstracts were reviewed, 602 full-text articles were evaluated, and 88 articles were included. The 3 domains identified were 1) theories, 2) assessment, and 3) implementation in assessing PIF. Differing attention to the different aspects of the PIF process impairs evaluations, jeopardise timely and appropriate support of medical students and hinder effective implementation of PIF assessments.

CONCLUSION

The Krishna-Pisupati model combines current theories and concepts of PIF to provide a more holistic perspective of the PIF process. Under the aegis of this model, Palliative Care and Oncology postings are envisaged as Communities of Practice influencing self-concepts of personhood and identity and shaping how medical students see their roles and responsibilities as future physicians. These insights allow the forwarding of nine recommendations to improve assessments of PIF and shape the design of a PIF-specific tool that can direct timely and personalized support of medical students.

Systematic scoping review on moral distress among physicians

BACKGROUND

Concepts of moral distress (MD) among physicians have evolved and extend beyond the notion of psychological distress caused by being in a situation in which one is constrained from acting on what one knows to be right. With many accounts involving complex personal, professional, legal, ethical and moral issues, we propose a review of current understanding of MD among physicians.

METHODS

A systematic evidence-based approach guided systematic scoping review is proposed to map the current concepts of MD among physicians published in PubMed, Embase, PsycINFO, Web of Science, SCOPUS, ERIC and Google Scholar databases. Concurrent and independent thematic and direct content analysis (split approach) was conducted on included articles to enhance the reliability and transparency of the process. The themes and categories identified were combined using the jigsaw perspective to create domains that form the framework of the discussion that follows.

RESULTS

A total of 30 156 abstracts were identified, 2473 full-text articles were reviewed and 128 articles were included. The five domains identified were as follows: (1) current concepts, (2) risk factors, (3) impact, (4) tools and (5) interventions.

CONCLUSIONS

Initial reviews suggest that MD involves conflicts within a physician's personal beliefs, values and principles (personal constructs) caused by personal, ethical, moral, contextual, professional and sociocultural factors. How these experiences are processed and reflected on and then integrated into the physician's personal constructs impacts their self-concepts of personhood and identity and can result in MD. The ring theory of personhood facilitates an appreciation of how new experiences create dissonance and resonance within personal constructs. These insights allow the forwarding of a new broader concept of MD and a personalised approach to assessing and treating MD. While further studies are required to test these findings, they offer a personalised means of supporting a physician's MD and preventing burn-out.