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Phua GLG, Owyong JLJ, Leong ITY, Goh S, Somasundaram N, Poon EYL, Chowdhury AR, Ong SYK, Lim C, Murugam V, Ong EK, Mason S, Hill R, Krishna LKR. A systematic scoping review of group reflection in medical education. BMC MEDICAL EDUCATION 2024; 24:398. [PMID: 38600515 PMCID: PMC11007913 DOI: 10.1186/s12909-024-05203-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 02/20/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Reviewing experiences and recognizing the impact of personal and professional views and emotions upon conduct shapes a physician's professional and personal development, molding their professional identity formation (PIF). Poor appreciation on the role of reflection, shortages in trained tutors and inadequate 'protected time' for reflections in packed medical curricula has hindered its integration into medical education. Group reflection could be a viable alternative to individual reflections; however, this nascent practice requires further study. METHODS A Systematic Evidence Based Approach guided Systematic Scoping Review (SSR in SEBA) was adopted to guide and structure a review of group reflections in medical education. Independent searches of articles published between 1st January 2000 and 30th June 2022 in bibliographic and grey literature databases were carried out. Included articles were analysed separately using thematic and content analysis, and combined into categories and themes. The themes/categories created were compared with the tabulated summaries of included articles to create domains that framed the synthesis of the discussion. RESULTS 1141 abstracts were reviewed, 193 full-text articles were appraised and 66 articles were included and the domains identified were theories; indications; types; structure; and benefits and challenges of group reflections. CONCLUSIONS Scaffolded by current approaches to individual reflections and theories and inculcated with nuanced adaptations from other medical practices, this SSR in SEBA suggests that structured group reflections may fill current gaps in training. However, design and assessment of the evidence-based structuring of group reflections proposed here must be the focus of future study.
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Affiliation(s)
- Gillian Li Gek Phua
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, Level 11, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
- Lien Centre for Palliative Care, Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Division of Cancer Education, National Cancer Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Jasmine Lerk Juan Owyong
- Division of Cancer Education, National Cancer Centre Singapore, Singapore, Singapore
- School of Humanities and Behavioural Sciences, Singapore University of Social Sciences, 463 Clementi Road, Singapore, Singapore
| | - Ian Tze Yong Leong
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, Level 11, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Suzanne Goh
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- KK Women's and Children Hospital, 100 Bukit Timah Rd, Singapore, 169854, Singapore
| | - Nagavalli Somasundaram
- Division of Cancer Education, National Cancer Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Eileen Yi Ling Poon
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | | | - Simon Yew Kuang Ong
- Division of Cancer Education, National Cancer Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Crystal Lim
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Medical Social Services, Singapore General Hospital, 16 College Road, Block 3 Level 1, Singapore, 169854, Singapore
| | - Vengadasalam Murugam
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Eng Koon Ong
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
- Division of Cancer Education, National Cancer Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
- Assisi Hospice, 832 Thomson Rd, Singapore, Singapore
- Office of Medical Humanities, SingHealth Medicine Academic Clinical Programme, 31 Third Hospital Ave, Singapore, 168753, Singapore
| | - Stephen Mason
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, Cancer Research Centre, University of Liverpool, 200 London Rd, Liverpool, L3 9TA, UK
| | - Ruaridh Hill
- Health Data Science, University of Liverpool, Whelan Building, The Quadrangle, Brownlow Hill, Liverpool, UK
| | - Lalit Kumar Radha Krishna
- Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, Level 11, Singapore, Singapore.
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore.
- Division of Cancer Education, National Cancer Centre Singapore, Singapore, Singapore.
- Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, Cancer Research Centre, University of Liverpool, 200 London Rd, Liverpool, L3 9TA, UK.
- PalC, The Palliative Care Centre for Excellence in Research and Education, PalC c/o Dover Park Hospice, Singapore, Singapore.
- Centre for Biomedical Ethics, National University of Singapore, Singapore, Singapore.
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Laureano CD, Laranjeira C, Querido A, Dixe MA, Rego F. Ethical Issues in Clinical Decision-Making about Involuntary Psychiatric Treatment: A Scoping Review. Healthcare (Basel) 2024; 12:445. [PMID: 38391820 PMCID: PMC10888148 DOI: 10.3390/healthcare12040445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/31/2024] [Accepted: 02/06/2024] [Indexed: 02/24/2024] Open
Abstract
In mental health and psychiatric care, the use of involuntary psychiatric treatment for people with mental disorders is still a central and contentious issue. The main objective of this scoping review was to map and systematize the literature on ethical issues in clinical decision-making about involuntary psychiatric treatment. Five databases (Embase, PsycINFO, CINAHL, Medline, and Scopus) were searched for articles on this topic. Out of a total of 342 articles found, 35 studies from 14 countries were included based on the selection criteria. The articles were analyzed using the inductive content analysis approach. The following main categories were identified: (1) ethical foundations that guide clinical decision-making; (2) criteria for involuntary psychiatric treatment; (3) gaps, barriers, and risks associated with involuntary psychiatric treatment; (4) strategies used to reduce, replace, and improve the negative impact of involuntary treatment; and (5) evidence-based recommendations. Most of the selected articles discuss the logic underlying involuntary treatment of the mentally ill, exploring ethical principles such as autonomy, beneficence, non-maleficence, or justice, as well as how these should be properly balanced. During the process of involuntary psychiatric admission, there was a notable absence of effective communication and a significant power imbalance that disenfranchised those seeking services. This disparity was further intensified by professionals who often use coercive measures without a clear decision-making rationale and by family members who strongly depend on hospital admission. Due to the pluralistic and polarized nature of opinions regarding legal capacity and the complexity and nuance of involuntary admission, further studies should be context-specific and based on co-production and participatory research.
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Affiliation(s)
- Cláudio Domingos Laureano
- Psychiatric and Mental Health Service, Local Health Unit of the Leiria Region-Hospital of Santo André, Rua das Olhalvas, 2410-197 Leiria, Portugal
- Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
- Centre for Innovative Care and Health Technology (ciTechCare), Rua de Santo André-66-68, Campus 5, 13 Polytechnic University of Leiria, 2410-541 Leiria, Portugal
| | - Carlos Laranjeira
- Centre for Innovative Care and Health Technology (ciTechCare), Rua de Santo André-66-68, Campus 5, 13 Polytechnic University of Leiria, 2410-541 Leiria, Portugal
- School of Health Sciences, Polytechnic University of Leiria, Campus 2-Morro do Lena, Alto do Vieiro-Apart. 4137, 2411-901 Leiria, Portugal
- Comprehensive Health Research Centre (CHRC), University of Évora, 7000-801 Évora, Portugal
| | - Ana Querido
- Centre for Innovative Care and Health Technology (ciTechCare), Rua de Santo André-66-68, Campus 5, 13 Polytechnic University of Leiria, 2410-541 Leiria, Portugal
- School of Health Sciences, Polytechnic University of Leiria, Campus 2-Morro do Lena, Alto do Vieiro-Apart. 4137, 2411-901 Leiria, Portugal
- Center for Health Technology and Services Research (CINTESIS), NursID, University of Porto, 4200-450 Porto, Portugal
| | - Maria Anjos Dixe
- Centre for Innovative Care and Health Technology (ciTechCare), Rua de Santo André-66-68, Campus 5, 13 Polytechnic University of Leiria, 2410-541 Leiria, Portugal
- School of Health Sciences, Polytechnic University of Leiria, Campus 2-Morro do Lena, Alto do Vieiro-Apart. 4137, 2411-901 Leiria, Portugal
| | - Francisca Rego
- Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
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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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Mosca CG, Kruger JP. Financial medicine as a source of moral distress: An unrecognised pathway to moral injury in the South African EMS systems. Afr J Emerg Med 2023; 13:235-240. [PMID: 37753241 PMCID: PMC10518332 DOI: 10.1016/j.afjem.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 09/28/2023] Open
Abstract
Introduction The phenomenon of Financial Medicine is a wide spread practice within the South African prehospital domain, which remains poorly researched. Similarly the impact of this phenomenon is not well understood, with many healthcare providers grappling with the moral dilemmas introduced into the work systems through the effects of the practice of Financial Medicine. Persisting, repetitive moral dilemmas can lead to instances of Moral Distress and Moral Injury. The practice of Financial Medicine in the South African prehospital domain proves to introduce many moral dilemmas and subsequently can serve as a source of Moral Distress and Moral Injury. Methods This study used a qualitative research methodology in the form of a constructivist grounded theory design. Participants voluntarily consented to be enrolled into one-on-one in-depth interviews, and were selected using purposive and theoretical sampling techniques. Data was subjected to validated coding procedures and analysed using the constant comparative analysis approach, analytical diagramming, and supported by researcher theoretical sensitivity. Results The sub-category presented in this study stems from the development of 6 final analytical labels that were abstracted in the process of a theory construction, not presented in this article. This sub-category is nested under 1 of the final analytical labels, and comprised of 3 preliminary analytical labels and an associated code and proposition list. Conclusion Understanding the sources of Moral Distress and Moral Injury within the South African prehospital domain are key steps in promoting and supporting the adoption and sustainability of ethical practices. This article presents a key finding that demonstrates a link between the experience of the phenomenon of Financial Medicine and the suffering of a Moral Injury by South African prehospital personnel.
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Affiliation(s)
- Colin Giovanni Mosca
- Department of Emergency Medical Care, University of Johannesburg, Doornfontein, Johannesburg, South Africa
| | - Jaco P Kruger
- St Augustine College of South Africa, Woodmead, Johannesburg, South Africa
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Sørensen OB, Milling L, Laerkner E, Mikkelsen S, Bruun H. Professional prehospital clinicians' experiences of ethical challenges associated with the collaboration with organised voluntary first responders: a qualitative study. Scand J Trauma Resusc Emerg Med 2023; 31:79. [PMID: 37964364 PMCID: PMC10644536 DOI: 10.1186/s13049-023-01147-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 11/07/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Volunteer First Responders are used worldwide. In the Region of Southern Denmark, two types of programs have been established. One of these programs consists of voluntary responders without any requirements of education or training who are summoned to prehospital cardiac arrests. The other type of program is established primarily in the rural areas of the region and consists of volunteers with some mandatory education in first aid. These volunteers are summoned to all urgent cases along with the ambulances. Cooperation between professional healthcare workers and nonprofessionals summoned through official channels may be challenging. This study aimed to explore prehospital clinicians' experiences of ethical challenges in cooperation with volunteer first responders. METHODS We conducted 16 semi-structured interviews at four different ambulance stations in the Region of Southern Denmark. Five emergency physicians and 11 emergency medical technicians/paramedics were interviewed. The interviews were transcribed, and the data were analysed using systematic text condensation. RESULTS The study's 16 interviews resulted in the identification of some specific categories that challenged the cooperation between the two parties. We identified three main categories: 1. Beneficence, the act of doing good, 2. The risk of harming patients' autonomy 3. Non-maleficence, which is the obligation not to inflict harm on others. CONCLUSION This study provides an in-depth insight into the ethical challenges between prehospital clinicians and voluntary first responders from the perspective of the prehospital clinicians. Both programs are considered to have value but only when treating patients with cardiac arrest. Our study highlights potential areas of improvement in the two Danish voluntary programs in their current form.
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Affiliation(s)
- Oliver Beierholm Sørensen
- Department of Clinical Research, University of Southern Denmark, 5000, Odense, Denmark
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, 5000, Odense, Denmark
| | - Louise Milling
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, 5000, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark, 5000, Odense, Denmark
- Department of Cardiology, Nord Zealand Hospital, 3400, Hillerød, Denmark
| | - Eva Laerkner
- Department of Anaesthesiology and Intensive Care Medicine, Odense University Hospital, 5000, Odense, Denmark
- Department of Clinical Research, Research Unit in Anesthesiology, University of Southern Denmark, 5000, Odense, Denmark
| | - Søren Mikkelsen
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, 5000, Odense, Denmark.
- Department of Regional Health Research, University of Southern Denmark, 5000, Odense, Denmark.
- Department of Anaesthesiology and Intensive Care Medicine, Odense University Hospital, 5000, Odense, Denmark.
| | - Henriette Bruun
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, 5000, Odense, Denmark
- Department of Regional Health Research, University of Southern Denmark, 5000, Odense, Denmark
- Psychiatric Department Middelfart, Mental Health Services in the Region of Southern Denmark, 5500, Middelfart, Denmark
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Metselaar S, Molewijk B. Fostering moral resilience through moral case deliberation. Nurs Ethics 2023; 30:730-745. [PMID: 37946387 DOI: 10.1177/09697330231183085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Moral distress forms a major threat to the well-being of healthcare professionals, and is argued to negatively impact patient care. It is associated with emotions such as anger, frustration, guilt, and anxiety. In order to effectively deal with moral distress, the concept of moral resilience is introduced as the positive capacity of an individual to sustain or restore their integrity in response to moral adversity. Interventions are needed that foster moral resilience among healthcare professionals. Ethics consultation has been proposed as such an intervention. In this paper, we add to this proposition by discussing Moral Case Deliberation (MCD) as a specific form of clinical ethics support that promotes moral resilience. We argue that MCD in general may contribute to the moral resilience of healthcare professionals as it promotes moral agency. In addition, we focus on three specific MCD reflection methods: the Dilemma Method, the Aristotelian moral inquiry into emotions, and CURA, a method consisting of four main steps: Concentrate, Unrush, Reflect, and Act. In practice, all three methods are used by nurse ethicists or by nurses who received training to facilitate reflection sessions with these methods. We maintain that these methods also have specific elements that promote moral resilience. However, the Dilemma Method fosters dealing well with tragedy, the latter two promote moral resilience by including attention to emotions as part of the reflection process. We will end with discussing the importance of future empirical research on the impact of MCD on moral resilience, and of comparing MCD with other interventions that seek to mitigate moral distress and promote moral resilience.
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Affiliation(s)
- Suzanne Metselaar
- Department of Ethics, Law, and Humanities, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands
| | - Bert Molewijk
- Department of Ethics, Law, and Humanities, Amsterdam University Medical Centers Location VUmc, Amsterdam, The Netherlands
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Lauridsen S, Schou-Juul F, Folker AP, Simonsen P, Phil ME, Skov SS. Developing the CARE intervention to enhance ethical self-efficacy in dementia care through the use of literary texts. BMC Med Ethics 2023; 24:45. [PMID: 37386381 PMCID: PMC10311821 DOI: 10.1186/s12910-023-00926-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 06/22/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Dementia care is essential to promote the well-being of patients but remains a difficult task prone to ethical issues. These issues include questions like whether manipulating a person with dementia is ethically permissible if it promotes her best interest or how to engage with a person who is unwilling to recognize that she has dementia. To help people living with dementia and their carers manage ethical issues in dementia care, we developed the CARE intervention. This is an intervention focused on promoting the ethical self-efficacy of people living with dementia and carers, i.e., their confidence that they can manage ethical issues when they occur. The purpose of this paper is to explain and discuss how we have developed the CARE intervention to promote the ethical self-efficacy of people living with dementia, their family, and professional carers through a specific and, we believe, new use of literary texts. METHODS The CARE intervention has been developed in two phases: First, we conducted a needs assessment of the occurrence of ethical issues in dementia care and the need for an intervention to support people living with dementia and their carers in managing such issues. Second, in a design phase, we developed the CARE intervention to meet identified needs. RESULTS To address identified ethical issues in dementia care we designed the CARE intervention as a workshop format where people living with dementia and carers can meet, discuss literary texts, and deliberate on how to solve such issues. The workshop is structured by the following elements: An agenda of ethical issues, a collection of literary cases exemplifying ethical issues, a moderator with an understanding of dementia care, and an overview of the ethical principles relevant to the discussion of ethical issues. >This workshop concept is operationalized in three applications tailored to meet the specific ethical issues of each of the study´s three target groups: people living with dementia and family carers, professional and family carers, and professional carers. CONCLUSION We conclude the paper by stating that it is possible to develop an intervention that promotes the ethical self-efficacy of people living with dementia and family and professional carers.
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Affiliation(s)
- Sigurd Lauridsen
- The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.
| | - Frederik Schou-Juul
- The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Anna Paldam Folker
- The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Peter Simonsen
- Department Department of Language, Culture, History and Communication, University of Southern Denmark, Odense, Denmark
| | - Marie-Elisabeth Phil
- Department Department of Language, Culture, History and Communication, University of Southern Denmark, Odense, Denmark
| | - Sofie Smedegaard Skov
- The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
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Molewijk B, Pedersen R, Kok A, Førde R, Aasland O. Two years of ethics reflection groups about coercion in psychiatry. Measuring variation within employees' normative attitudes, user involvement and the handling of disagreement. BMC Med Ethics 2023; 24:29. [PMID: 37173770 PMCID: PMC10182617 DOI: 10.1186/s12910-023-00909-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] [Received: 12/21/2020] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Research on the impact of ethics reflection groups (ERG) (also called moral case deliberations (MCD)) is complex and scarce. Within a larger study, two years of ERG sessions have been used as an intervention to stimulate ethical reflection about the use of coercive measures. We studied changes in: employees' attitudes regarding the use of coercion, team competence, user involvement, team cooperation and the handling of disagreement in teams. METHODS We used panel data in a longitudinal design study to measure variation in survey scores from multidisciplinary employees from seven departments within three Norwegian mental health care institutions at three time points (T0-T1-T2). Mixed models were used to account for dependence of data in persons who participated more than once. RESULTS In total, 1068 surveys (from 817 employees who did and did not participate in ERG) were included in the analyses. Of these, 7.6% (N = 62) responded at three points in time, 15.5% (N = 127) at two points, and 76.8% (N = 628) once. On average, over time, respondents who participated in ERG viewed coercion more strongly as offending (p < 0.05). Those who presented a case in the ERG sessions showed lower scores on User Involvement (p < 0.001), Team Cooperation (p < 0.01) and Constructive Disagreement (p < 0.01). We observed significant differences in outcomes between individuals from different departments, as well as between different professions. Initial significant changes due to frequency of participation in ERG and case presentation in ERG did not remain statistically significant after adjustment for Departments and Professions. Differences were generally small in absolute terms, possibly due to the low amount of longitudinal data. CONCLUSIONS This study measured specific intervention-related outcome parameters for describing the impact of clinical ethics support (CES). Structural implementation of ERGs or MCDs seems to contribute to employees reporting a more critical attitude towards coercion. Ethics support is a complex intervention and studying changes over time is complex in itself. Several recommendations for strengthening the outcomes of future CES evaluation studies are discussed. CES evaluation studies are important, since-despite the intrinsic value of participating in ERG or MCD-CES inherently aims, and should aim, at improving clinical practices.
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Affiliation(s)
- Bert Molewijk
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway.
- Department of Ethics, Law and Humanities, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Almar Kok
- Department of Epidemiology and Data Science and Department of Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
- Aging and Later Life, Amsterdam Public Health Institute, Amsterdam, The Netherlands
| | - Reidun Førde
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Olaf Aasland
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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Jakobsen L, Olsen RM, Brinchmann BS, Devik SA. Developing and Testing Digital Ethical Reflection in Long-Term Care: Nurses' Experiences. SAGE Open Nurs 2023; 9:23779608221150725. [PMID: 36654853 PMCID: PMC9841835 DOI: 10.1177/23779608221150725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 10/17/2022] [Accepted: 12/26/2022] [Indexed: 01/15/2023] Open
Abstract
Introduction Nurses working in municipal long-term care face ethical challenges that can lead to moral distress and discomfort for the nurse and affect the quality of patient care. Tools and methods that contribute to increased ethical awareness and support for nurses dealing with moral issues are lacking. Technological innovations may be suitable for ethics work, but little research has been conducted on how such solutions could be designed or their potential benefit. Therefore, this study contributes knowledge about the development and testing of a digital tool for ethics support among nurses. Objective To investigate how digital ethical reflection can support ethics work among nurses working in long-term care. Methods A digital ethical reflection tool was designed and tested in nursing homes and home nursing care in collaboration with two Norwegian municipalities. The study used sequential explanatory mixed-methods design. Over a 6-week period, at the end of each shift, nurses digitally reported the ethical challenges they had experienced. Their responses and experiences were described using descriptive statistics. Additionally, focus group interviews were conducted and analyzed using reflexive thematic analysis (TA). Results During the study period, 17 nurses reported a total of 223 registrations, with 24.8% stating that they had been in an ethically difficult situation. The digital reporting was perceived as practically applicable and helped to increase nurses' awareness of morally charged situations. The value of the registrations was found to depend on manager participation and the application of the obtained information. The participating nurses become aware that they lacked an arena for meaningful dialogue with and recognition from their manager. Conclusions Information obtained through digital reflection can form the basis for ethical reflections at the departmental level. Digital reflection has the potential to become a tool for managers in their support for employees facing ethical challenges when providing long-term care.
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Affiliation(s)
- Lena Jakobsen
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway,Lena Jakobsen, Faculty of Nursing and Health Sciences, Nord University, PO Box 1490, 8049 Bodø, Norway.
| | - Rose Mari Olsen
- Centre for Care Research Mid-Norway, Faculty of Nursing and Health Sciences, Nord University, Namsos, Norway
| | - Berit Støre Brinchmann
- Faculty of Nursing and Health Sciences, Nord University, Norway and Nordland Regional University, Bodø, Norway
| | - Siri Andreassen Devik
- Centre for Care Research Mid-Norway, Faculty of Nursing and Health Sciences, Nord University, Namsos, Norway
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Hem MH, Molewijk B, Weimand B, Pedersen R. Patients with severe mental illness and the ethical challenges related to confidentiality during family involvement: A scoping review. Front Public Health 2023; 10:960815. [PMID: 36711422 PMCID: PMC9877517 DOI: 10.3389/fpubh.2022.960815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 12/20/2022] [Indexed: 01/13/2023] Open
Abstract
Background Despite evidence on the significant potential value of family involvement during the treatment of patients with severe mental illness, research has shown that family involvement is largely underused. The duty of confidentiality is reported to be a key barrier to family involvement. To develop more insight into this barrier, this scoping review focuses on the following question: What are the reported ethical challenges related to confidentiality when involving family in the treatment of patients with severe mental illness? Methods A systematic search into primary studies was conducted using the following databases: Medline (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), and Web of Science core collection (Clarivate). The PICO (Population, Intervention, Comparison, Outcome) scheme and qualitative content analysis were used to make the ethical challenges more explicit. Results Twelve studies-both qualitative and quantitative-were included. We identified the following main categories of ethical challenges: (1) the best interest of family members vs. confidentiality, (2) the patient's best interest vs. the right to confidentiality, (3) patient trust and alliance as a reason not to involve the relatives or not to share information, and (4) using confidentiality as a smokescreen. We also identified several subcategories and illustrative and concrete examples of ethical challenges. Conclusions Through a systematic examination, we discovered various types of ethical challenges related to confidentiality when involving the family in the treatment of patients with severe mental illness. However, research on these ethical challenges and the constituents of these challenges remains limited and often implicit. An ethical analysis will create knowledge which may facilitate a more balanced and nuanced approach to respecting the principle of confidentiality while also considering other moral principles. The duty of confidentiality does not always have to be a major barrier to family involvement; this insight and using this ethical analysis in the training of healthcare professionals may benefit the patient, the family, and the services.
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Affiliation(s)
- Marit Helene Hem
- Norwegian University of Science and Technology (NTNU) Social Research, Trondheim, Norway,Faculty of Health Studies, VID Specialized University, Oslo, Norway
| | - Bert Molewijk
- Centre for Medical Ethics, Faculty of Medicine, University of Oslo, Oslo, Norway,Department Ethics, Law and Humanities, Amsterdam University Medical Centre (UMC) and Vrije Universiteit, Amsterdam, Netherlands
| | - Bente Weimand
- University of South-Eastern Norway, Faculty of Health and Social Sciences, Drammen, Norway,Division Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, Faculty of Medicine, University of Oslo, Oslo, Norway,*Correspondence: Reidar Pedersen ✉
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11
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Molewijk B. Materialising and fostering organisational morisprudence through ethics support tools. JOURNAL OF MEDICAL ETHICS 2022; 48:991-992. [PMID: 36384891 DOI: 10.1136/jme-2022-108692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/03/2022] [Indexed: 06/16/2023]
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12
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Sirris S. Navigating Dichotomies and Dilemmas Comment on "Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations?". Int J Health Policy Manag 2022; 11:2355-2357. [PMID: 35643420 PMCID: PMC9808283 DOI: 10.34172/ijhpm.2022.6965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 05/11/2022] [Indexed: 01/12/2023] Open
Abstract
The complexity within healthcare typically surfaces in tensions between organizational efficiency and professional values when hospital managers and professionals face dilemmas between economic and clinical considerations. Waitzberg et al, based on interviews with managers and physicians working in Israeli and German hospitals, explore strategies to cope with such dilemmas to safeguard both financial sustainability and patient quality. This short commentary provides some follow-up questions in two ways. First, I highlight the importance of nuancing and hybridizing the dichotomies that lead to dilemmas in the hospital context. Second, I discuss how such dilemmas can be highlighted in systematic group reflection which in turn can inform decision-making.
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13
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Husum TL, Pedersen R, Aasland O. Frequent Violations and Infringements against Users in Mental Health Care Confirmed by Both Users and Professionals - A Quantitative Study. Issues Ment Health Nurs 2022; 43:862-869. [PMID: 35452344 DOI: 10.1080/01612840.2022.2063461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The main task of mental health care services is to provide good quality of care. Despite this, users are sometimes treated badly by staff. The purpose of this study was to investigate violations and infringements towards users in mental health care services, from the perspectives of both staff and users. Data were gathered through an anonymous online questionnaire sent to staff and users in Norway. Staff were recruited in collaboration with professional organisations and users in collaboration with user-organisations.
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Affiliation(s)
- Tonje Lossius Husum
- Centre for Medical Ethics, University of Oslo, Norway.,Oslo Metropolitan University, Oslo, Norway
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14
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Senghor AS, Racine E. How to evaluate the quality of an ethical deliberation? A pragmatist proposal for evaluation criteria and collaborative research. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2022; 25:309-326. [PMID: 35679005 DOI: 10.1007/s11019-022-10091-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 06/15/2023]
Abstract
Ethics designates a structured process by which important human values and meanings of life are understood and tackled. Therein, the ability to discuss openly and reflect on (aka deliberation) understandings of moral problems, on solutions to these problems, and to explore what a meaningful resolution could amount to is highly valued. However, the indicators of what constitutes a high-quality ethical deliberation remain vague and unclear. This article proposes and develops a pragmatist approach to evaluate the quality of deliberation. Deliberation features three important moments: (1) broadening and deepening the understanding of the situation, (2) envisioning action scenarios, (3) coming to a judgment based on the comparative evaluation of scenarios. In this paper, we propose seven criteria to evaluate ethical deliberations: (1) collaborative diversity, (2) experiential literacy, (3) organization of experiences, (4) reflective capacity to instrumentalize the experiences of others, (5) interactional creativity, (6) openness of agents, (7) quality of the reformulation of scenarios. These criteria are explained and applied to the three moments of deliberation. Based on these criteria, three kinds of outcomes for deliberations are identified and discussed: good ethical deliberations, partial ethical deliberations, bad ethical deliberations. Our proposal will guide researchers and practitioners interested in the evaluation of the quality of ethical deliberations. It provides a reference tool that allows them to identify the possible limitations of a deliberation and to implement actions aimed at correcting these limitations in order to achieve the desired qualitative objectives.
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Affiliation(s)
- Abdou Simon Senghor
- Pragmatic Health Ethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, QC, Canada
- Division of Experimental Medicine, McGill University, Montréal, QC, Canada
| | - Eric Racine
- Pragmatic Health Ethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, QC, Canada.
- Division of Experimental Medicine, McGill University, Montréal, QC, Canada.
- Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada.
- Department of Medicine, Department of Social and Preventive Medicine, Université de Montréal, Montréal, QC, Canada.
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15
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Bruun H, Milling L, Mikkelsen S, Huniche L. Ethical challenges experienced by prehospital emergency personnel: a practice-based model of analysis. BMC Med Ethics 2022; 23:80. [PMID: 35962434 PMCID: PMC9373324 DOI: 10.1186/s12910-022-00821-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 08/03/2022] [Indexed: 11/21/2022] Open
Abstract
Background Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. In prehospital emergency medicine, decision-making commonly takes place in everyday life, under time pressure, with limited information about a patient and with few possibilities of consultation with colleagues. This paper explores the ethical challenges experienced by prehospital emergency personnel.
Methods The study was grounded in the tradition of action research related to interventions in health care. Ethical challenges were explored in three focus groups, each attended by emergency medical technicians, paramedics, and prehospital anaesthesiologists. The participants, 15 in total, were recruited through an internal information network of the emergency services. Focus groups were audio-recorded and transcribed verbatim. Results The participants described ethical challenges arising when clinical guidelines, legal requirements, and clinicians’ professional and personal value systems conflicted and complicated decision-making processes. The challenges centred around treatment at the end of life, intoxicated and non-compliant patients, children as patients—and their guardians, and the collaboration with relatives in various capacities. Other challenges concerned guarding the safety of oneself, colleagues and bystanders, prioritising scarce resources, and staying loyal to colleagues with different value systems. Finally, challenges arose when summoned to situations where other professionals had failed to make a decision or take action when attending to patients whose legitimate needs were not met by the appropriate medical or social services, and when working alongside representatives of authorities with different roles, responsibilities and tasks. Conclusion From the perspective of the prehospital emergency personnel, ethical challenges arise in three interrelated contexts: when caring for patients, in the prehospital emergency unit, and during external collaboration. Value conflicts may be identified within these contexts as well as across them. A proposed model of analysis integrating the above contexts can assist in shedding light on ethical challenges and value conflicts in other health care settings. The model emphasises that ethical challenges are experienced from a particular professional perspective, in the context of the task at hand, and in a particular, the organisational setting that includes work schedules, medical guidelines, legal requirements, as well as professional and personal value systems.
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Affiliation(s)
- Henriette Bruun
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark. .,Psychiatric Department Middelfart, Mental Health Services in the Region of Southern Denmark, Middelfart, Denmark.
| | - Louise Milling
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Søren Mikkelsen
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark.,The Mobile Emergency Care Unit, Department Anaesthesiology and Intensive Care Medicine, Odense University Hospital, Odense, Denmark
| | - Lotte Huniche
- The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark.,Department of Psychology, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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16
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Stoll J, Westermair AL, Kübler U, Reisch T, Cattapan K, Bridler R, Maier R, Trachsel M. A two-center pilot study on the effects of clinical ethics support on coercive measures in psychiatry. BMC Psychiatry 2022; 22:370. [PMID: 35650555 PMCID: PMC9156353 DOI: 10.1186/s12888-022-04024-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of formal coercion such as seclusion, mechanical restraint, and forced medication is one of the most challenging and complex issues in mental health care, on the clinical, the legal, and the ethical level. Clinical ethics support aims at assisting healthcare practitioners in determining the morally most justifiable course of action in these situations. However, the effectiveness of clinical ethics support has hardly been studied so far. METHODS Monthly moral case deliberation (MCD) was implemented in two acute wards of two different psychiatric hospitals in Switzerland. Frequency and intensity of coercion was measured on ward level (npatients = 405), and the Moral Attentiveness Scale, Knowledge on Coercion Scale, and Staff Attitudes towards Coercion Scale were applied on healthcare practitioner level (nHP = 46). Pre-post-comparisons were conducted using multi-level modeling where appropriate. RESULTS After implementation of MCD, formal coercion was less frequent (particularly seclusion, small effect size; 9.6 vs. 16.7%, p = .034, Cramér's V = .105) and less intense (particularly mechanical restraint, large effect size; 86.8 ± 45.3 vs. 14.5 ± 12.1 h, exact p = .019, r = -.74), and approval for coercive measures among healthcare practitioners was lower when controlling for the number of MCD sessions attended. CONCLUSIONS Clinical ethics support such as MCD may be a hitherto underutilized service for the reduction of coercion, complementing existing strategies and programs. Implementing clinical ethics support may help improve quality of care for persons suffering from severe mental illness.
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Affiliation(s)
- Julia Stoll
- grid.7400.30000 0004 1937 0650Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Anna Lisa Westermair
- grid.7400.30000 0004 1937 0650Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland ,grid.412556.10000 0004 0479 0775Clinical Ethics Unit, University Hospital Basel and University Psychiatric Clinics Basel, Basel, Switzerland ,grid.6612.30000 0004 1937 0642Department of Psychosomatic Medicine, University Hospital and University of Basel, Basel, Switzerland
| | - Ulrike Kübler
- grid.492890.e0000 0004 0627 5312Sanatorium Kilchberg, Zurich, Switzerland
| | - Thomas Reisch
- grid.483141.b0000 0004 0478 9635Psychiatriezentrum Münsingen, Münsingen, Switzerland
| | - Katja Cattapan
- grid.492890.e0000 0004 0627 5312Sanatorium Kilchberg, Zurich, Switzerland ,grid.5734.50000 0001 0726 5157University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - René Bridler
- grid.492890.e0000 0004 0627 5312Sanatorium Kilchberg, Zurich, Switzerland
| | - Robert Maier
- grid.492890.e0000 0004 0627 5312Sanatorium Kilchberg, Zurich, Switzerland
| | - Manuel Trachsel
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland. .,Clinical Ethics Unit, University Hospital Basel and University Psychiatric Clinics Basel, Basel, Switzerland.
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17
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Aragonés-Calleja M, Sánchez-Martínez V. Current State of Research on Coercion in Mental Health: Umbrella Review Protocol. J Psychosoc Nurs Ment Health Serv 2022; 60:49-55. [PMID: 35522935 DOI: 10.3928/02793695-20220428-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In recent years, international organizations, professionals, and representatives of mental health service users have expressed the need to regulate, limit, and even eliminate coercive measures in psychiatric treatment. The main objective of the current review is to provide a comprehensive synthesis of existing evidence on coercion in mental health care through a protocol for an umbrella review of systematic reviews. This protocol was designed according to the Joanna Briggs Institute guide for methodological development, conduct, and reporting of umbrella reviews. To minimize bias in the process, two independent reviewers selected the studies to be included, extracted, and synthesized; analyzed the data; and assessed risk of bias of each review. The review protocol was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guidelines. This review offers a comprehensive compilation of systematic reviews on coercion developed to date. Coercion causes adverse physical and psychological effects and is an emotional stressor for individuals with psychiatric diagnoses and health care workers. Characterization of coercion across care settings, its impact on clinical outcomes, the perception of those involved, and how coercion could be reduced will also be discussed. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].
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18
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Kana L, Shuman A, De Vries R, Firn J. Taking the burden off: a study of the quality of ethics consultation in the time of COVID-19. JOURNAL OF MEDICAL ETHICS 2022; 48:244-249. [PMID: 33811113 PMCID: PMC8029040 DOI: 10.1136/medethics-2020-107037] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 03/03/2021] [Accepted: 03/20/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND The quality of ethics consults is notoriously difficult to measure. Survey-based assessments cannot capture nuances of consultations. To address this gap, we conducted interviews with health professionals who requested ethics consults during the initial phase of the COVID-19 pandemic. METHOD Healthcare professionals requesting ethics consultation between March 2020 and May 2020 at a tertiary academic medical centre were eligible to participate. We asked participants to comment on the consults they called and thematically analysed responses to identify features associated with optimal quality consultations. RESULTS Of 14 healthcare providers, 8 (57%) were women and professions were as follows: 11 (79%) medical doctors, 1 (7%) social worker, 1 (7%) physician assistant and 1 (7%) nurse practitioner. Two aspects of quality emerged: satisfaction and value. Themes within the domain of satisfaction included: responsiveness of the ethics consultant, willingness to consult, institutional role of the ethics service and identifying areas for improvement. When describing value, respondents spoke of the intrapersonal and interpersonal worth of consultation. CONCLUSION Participants were generally satisfied with ethics consultation services, similar to opinions of those found in pre-COVID-19 survey studies. Our qualitative approach allowed for a richer exploration of the value of ethics consultation during the pandemic and has implications for ethics consultation services more broadly. Ethics consultation-emphasising both the process and outcome-created valuable moral spaces, promoting thoughtful and ethical responses to dilemmas in patient care. Future assessments should incorporate patient and family/surrogate perspectives and explore the domain of education as an additional quality measure.
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Affiliation(s)
- Lulia Kana
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Andrew Shuman
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Raymond De Vries
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Janice Firn
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA
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19
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Andersson H, Svensson A, Frank C, Rantala A, Holmberg M, Bremer A. Ethics education to support ethical competence learning in healthcare: an integrative systematic review. BMC Med Ethics 2022; 23:29. [PMID: 35305627 PMCID: PMC8933936 DOI: 10.1186/s12910-022-00766-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/07/2022] [Indexed: 01/07/2023] Open
Abstract
Background Ethical problems in everyday healthcare work emerge for many reasons and constitute threats to ethical values. If these threats are not managed appropriately, there is a risk that the patient may be inflicted with moral harm or injury, while healthcare professionals are at risk of feeling moral distress. Therefore, it is essential to support the learning and development of ethical competencies among healthcare professionals and students. The aim of this study was to explore the available literature regarding ethics education that promotes ethical competence learning for healthcare professionals and students undergoing training in healthcare professions. Methods In this integrative systematic review, literature was searched within the PubMed, CINAHL, and PsycInfo databases using the search terms ‘health personnel’, ‘students’, ‘ethics’, ‘moral’, ‘simulation’, and ‘teaching’. In total, 40 articles were selected for review. These articles included professionals from various healthcare professions and students who trained in these professions as subjects. The articles described participation in various forms of ethics education. Data were extracted and synthesised using thematic analysis. Results The review identified the need for support to make ethical competence learning possible, which in the long run was considered to promote the ability to manage ethical problems. Ethical competence learning was found to be helpful to healthcare professionals and students in drawing attention to ethical problems that they were not previously aware of. Dealing with ethical problems is primarily about reasoning about what is right and in the patient’s best interests, along with making decisions about what needs to be done in a specific situation. Conclusions The review identified different designs and course content for ethics education to support ethical competence learning. The findings could be used to develop healthcare professionals’ and students’ readiness and capabilities to recognise as well as to respond appropriately to ethically problematic work situations.
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20
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Differences in Ethical Viewpoints among Civilian–Military Populations: A Survey among Practitioners in Two European Countries, Based on a Systematic Literature Review. SUSTAINABILITY 2022. [DOI: 10.3390/su14031085] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Civilian–military collaboration in humanitarian crises has been encouraged globally; however, little is known about their diverse ethical viewpoints towards challenging and critical situations, which may cause difficulties in the partnership, and influence the outcomes of their mutual activities. The aim of this study was to identify the diversity of viewpoints and ethical decision-making during exceptional circumstances among civilian and military populations from two different countries, each with diverse background and healthcare organization structures. Possible scenarios, based on a systematic review of the literature, were introduced to Swedish and Polish civilian and military healthcare providers. Variations in the participants’ viewpoints and approaches to ethical decision-making were analyzed according to their characteristics, organizational belonging, and nationality. There were differences between both populations but also within the military and civilian groups, respectively. One significant factor influencing ethical viewpoints was participants’ nationality. Differences in ethical viewpoints between multiagency organizations should be considered in planning and implementation of future transdisciplinary and international collaboration in disaster and emergency management. Further studies and renewed educational initiatives are necessary to validate these differences and to navigate civilian–military as well as other multinational partnerships.
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21
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Gerritsen S, Widdershoven G, van der Ham L, van Melle L, Kemper M, Voskes Y. Dealing with care disruption in High and Intensive Care wards: From difficult patients to difficult situations. Int J Ment Health Nurs 2021; 30:317-325. [PMID: 32936986 PMCID: PMC7891438 DOI: 10.1111/inm.12786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/07/2020] [Accepted: 08/14/2020] [Indexed: 11/28/2022]
Abstract
High and Intensive Care is a relatively new care model in Dutch mental health care for clinical admissions. One of the goals is to keep the admission short. For some patients, this goal is not realized, which results in a long-term admission. Often, this is experienced as a disruption. Disruptions in care processes are frequently defined in terms of patient characteristics. Yet, it may be that other factors play a role. The aim of this study is to gain better insight into the perceptions of care professionals of what is characteristic for disruptions at High and Intensive Care wards and how professionals can deal with these. Qualitative research was performed by means of semi-structured interviews and a focus group with professionals. Results show that a focus on patient characteristics is too narrow and that other factors also play an important role. These factors include challenges in the relation between professionals and the patient, a divided team, and a lack of collaboration with ambulatory care. In order to deal with these factors, professionals should invest in the relationship with the patient, identify destructive team processes early, and improve communication with ambulatory care. It is recommended to develop a monitoring tool that includes all these factors. Another recommendation is to organize structured reflection on dilemmas experienced in care. In conclusion, this study shows the importance of going beyond patient characteristics in order to better understand, identify, and deal with disruption at High and Intensive Care wards.
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Affiliation(s)
- Sylvia Gerritsen
- Department of Medical HumanitiesAmsterdam University Medical CenterVU University Medical CenterAmsterdamThe Netherlands
| | - Guy Widdershoven
- Department of Medical HumanitiesAmsterdam University Medical CenterVU University Medical CenterAmsterdamThe Netherlands
| | - Lia van der Ham
- Low Vision ResearchOphthalmologyAmsterdam University Medical CenterVU University Medical CenterAmsterdamThe Netherlands
| | - Laura van Melle
- Department of Medical HumanitiesAmsterdam University Medical CenterVU University Medical CenterAmsterdamThe Netherlands
- Institute for Medical Ethics and History of MedicineRuhr University BochumBochumGermany
| | | | - Yolande Voskes
- Department of Medical HumanitiesAmsterdam University Medical CenterVU University Medical CenterAmsterdamThe Netherlands
- GGZ BreburgTilburgThe Netherlands
- Tranzo, Tilburg UniversityTilburgThe Netherlands
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22
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Abstract
This paper provides a series of reflections on making the case to senior leaders for the introduction of clinical ethics support services within a UK hospital Trust at a time when clinical ethics committees are dwindling in the UK. The paper provides key considerations for those building a (business) case for clinical ethics support within hospitals by drawing upon published academic literature, and key reports from governmental and professional bodies. We also include extracts from documents relating to, and annual reports of, existing clinical ethics support within UK hospitals, as well as extracts from our own proposal submitted to the Trust Board. We aim for this paper to support other ethicists and/or health care staff contemplating introducing clinical ethics support into hospitals, to facilitate the process of making the case for clinical ethics support, and to contribute to the key debates in the literature around clinical ethics support. We conclude that there is a real need for investment in clinical ethics in the UK in order to build the evidence base required to support the wider introduction of clinical ethics support into UK hospitals. Furthermore, our perceptions of the purpose of, and perceived needs met through, clinical ethics support needs to shift to one of hospitals investing in their staff. Finally, we raise concerns over the optional nature of clinical ethics support available to practitioners within UK hospitals.
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23
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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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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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Muldrew DHL, Kaasalainen S, McLaughlin D, Brazil K. Ethical issues in nursing home palliative care: a cross-national survey. BMJ Support Palliat Care 2018; 10:e29. [DOI: 10.1136/bmjspcare-2018-001643] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/19/2018] [Accepted: 11/28/2018] [Indexed: 11/03/2022]
Abstract
ObjectivesWith an increased dependency on nursing homes to provide care to the ageing population, it is likely that ethical issues will also increase. This study aimed to identify the type of ethical issues and level of associated distress experienced by nurses providing palliative care in nursing homes in the UK and Canada, and pilot the Ethical issues in Palliative Care for Nursing Homes (EPiCNH) instrument in Canada.MethodsA cross-sectional survey design was used. One hundred and twenty-three nurses located in 21 nursing homes across the UK and Canada completed the EPiCNH instrument.ResultsFrequent ethical issues include upholding resident autonomy, managing family distress, lack of staff communication and lack of time in both countries. Higher levels of distress resulted from poor communication, insufficient training, lack of time and family disagreements. Nurses in Canada experienced a greater frequency of ethical issues (p=0.022); however, there was no statistical difference in reported distress levels (p=0.53). The survey was positively rated for ease of completion, relevance and comprehensiveness.ConclusionsNurses’ reported comparable experiences of providing palliative care in UK and Canadian nursing homes. These findings have implications on the practice of care in nursing homes, including how care is organised as well as capacity of staff to care for residents at the end of life. Training staff to take account of patient and family values during decision-making may address many ethical issues, in line with global policy recommendations. The EPiCNH instrument has demonstrated international relevance and applicability.
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Defining and categorizing outcomes of Moral Case Deliberation (MCD): concept mapping with experienced MCD participants. BMC Med Ethics 2018; 19:88. [PMID: 30454047 PMCID: PMC6245560 DOI: 10.1186/s12910-018-0324-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 10/22/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To support healthcare professionals in dealing with ethically difficult situations, Clinical Ethics Support (CES) services like Moral Case Deliberation (MCD) are increasingly implemented. To assess the impact of CES, it is important to evaluate outcomes. Despite general claims about outcomes from MCD experts and some qualitative research, there exists no conceptual analysis of outcomes yet. Therefore, the aim of this study was to systematically define and categorize MCD outcomes. An additional aim was to compare these outcomes with the outcomes in the Euro-MCD Instrument from 2014, to further validate this Instrument. METHODS The concept mapping method was used and involves qualitative and quantitative steps including brainstorming, individual structuring, computation of concept maps (by principal component analysis and cluster analysis), group interpretation and utilization. In total, 12 experienced MCD participants from a variety of professional backgrounds participated in two sessions. RESULTS The focus group brainstorm resulted in a list of 85 possible MCD outcomes, of which a point map and concept maps were constructed. After a thorough discussion of each cluster, final consensus was reached on the names and position of 8 clusters of MCD outcomes: 1) Organisation and Policy; 2) Team development; 3) Personal development focused on the Other Person; 4) Personal development as Professional, focused on Skills; 5) Personal development as Professional, focused on Knowledge; 6) Personal development as an Individual; 7) Perception and Connection; and 8) Concrete action. CONCLUSIONS This study explored and categorized MCD outcomes in a concept mapping focus group. When comparing the results with the Euro-MCD Instrument, our study confirms that outcomes of MCD can be categorized in clusters referring to the organisational level, team development, personal development (both as an individual and a professional) and the concrete case-level. In developing CES evaluation tools, it is important to be explicit if an outcome refers to the individual or the team, to knowledge or skills, to the organisation or the specific case. The findings will be used in the further validation of the Euro-MCD Instrument. The current study further contributes to the field of evaluating CES in general and defining outcomes of MCD in particular.
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