Impact of moral case deliberation in healthcare settings: a literature review

Fostering moral reflectivity in community pharmacists through moral case deliberation using the dilemma method

BACKGROUND

Moral case deliberation has been successfully implemented in multidisciplinary groups of secondary care professionals to support ethical decision making. It has not yet been reported for community pharmacists.

AIM

This study investigated whether moral case deliberation fosters moral reflectivity in community pharmacists.

METHOD

Two moral case deliberations with 14 community pharmacists were guided by two facilitators. One session was described and illustrated with participants' quotes, detailing each reflection step of the method. An adapted version of the Maastricht evaluation questionnaire was used to understand the effects of the moral case deliberation on participants' moral reflectivity skills both quantitatively and qualitatively.

RESULTS

In a 2-h session, pharmacists reflected on a moral dilemma concerning double anticoagulant therapy of one presenter pharmacist. Participants discussed the pros and cons of two potential actions: dispensing the medication as prescribed without contacting the patient or contacting the patient first. Deliberation highlighted the importance of understanding the patient's perspective, leading the presenter and two others to shift towards the latter action. The evaluation questionnaire revealed that all 14 participants felt supported by the deliberation and the facilitator in recognising the dilemma's moral dimension and understanding their own and others' values behind arguments and how these influenced different perspectives. They all felt encouraged to critically reflect, to ask open questions and to delay judgements. The method helped all to morally justify their final decision, with six participants arriving at a decision different from their initial perspective towards the dilemma's resolution.

CONCLUSION

This study demonstrates that moral case deliberation enables pharmacists to critically examine their reasoning and reach morally sound resolutions, supporting pharmacists' professionalism and ethical decision-making.

Addressing spirituality-related moral challenges in palliative care: perspectives of spiritual counselors

Spiritual beliefs are increasingly important toward the end-of-life as they shape perspectives on good care, life, and death. However, in pluralistic societies, the spiritual beliefs of patients and care providers may differ. Care providers can find it difficult to be responsive to spiritual diversity and to how different belief systems of patients and their families may influence perspectives on care and dying. This can lead to moral challenges. Dialogical clinical ethics support (CES) helps care providers to jointly reflect on and deal with moral challenges. However, while spirituality shapes perspectives on good care, it is rarely addressed explicitly in CES sessions. We interviewed ten spiritual counselors of different denominations in The Netherlands to explore spirituality-related moral challenges in the delivery of palliative care, and to gain insight into their perspectives on what is needed to make both dialogues with patients and family and dialogical CES more responsive to spiritual diversity.

Digital ethical reflection in home nursing care: Nurse leaders' and nurses' experiences

BACKGROUND

Nurse leaders increasingly need effective tools that facilitate the prioritisation of ethics and help staff navigate ethical challenges and prevent moral distress. This study examined experiences with a new digital tool for ethical reflection, tailored to improve the capabilities of both leaders and employees in the context of municipal long-term care.

AIM

The aim was to explore the experiences of nurse leaders and nurses in using Digital Ethical Reflection as a tool for ethics work in home nursing care.

RESEARCH DESIGN

The study employed a qualitative design, incorporating individual and focus group interviews for data collection. Qualitative content analysis was used to analyse the data.

PARTICIPANTS AND RESEARCH CONTEXT

The participants comprised six nurse leaders and 13 nurses, representing six home care zones across two Norwegian municipalities.

ETHICAL CONSIDERATIONS

The study involved informed, voluntary participation and was approved by the Norwegian Agency for Shared Services in Education and Research.

FINDINGS

Four themes were developed: a constant walk on the edge between engagement and discouragement and lost in translation describe the process, while tuning in to the ethical dimension and navigating ethical uncertainties illuminate the experienced significance of Digital Ethical Reflection.

CONCLUSION

Success with Digital Ethical Reflection in home nursing care depends on clear leadership planning, nurses' understanding of the tool's purpose, and active use of digital registrations. Support from ethically interested nurses enhances overall engagement. Further research is needed to explore the potential of Digital Ethical Reflection as an additional tool in long-term care ethics work.

A User-Driven Framework for Dose Selection in Pregnancy: Proof of Concept for Sertraline

Despite growing knowledge of pregnancy-induced changes in physiology that may alter maternal and fetal pharmacokinetics, evidence-based antenatal doses are lacking for most drugs. Pharmacokinetic modeling and expanding clinical data in pregnancy may support antenatal doses. We aimed to develop and pilot a comprehensive and user-driven Framework for Dose Selection in Pregnancy to support the clinical implementation of a best-evidence antenatal dose for sertraline. After initial development and evaluation by experts, the framework prototype was piloted to formulate an antenatal dosing strategy for sertraline in depression and anxiety disorders. Next, the framework was reviewed and assessed for usability by a multidisciplinary working committee of end-users comprising healthcare practitioners, experts from other disciplines including pharmacometrics, reproductive toxicology and medical ethics, alongside pregnant women and a partner. The resulting framework encompasses the following: rationale for drug selection, a comprehensive analysis of pharmacokinetic and dose-related efficacy and safety data, and implementation aspects including feasibility and desirability of the recommended antenatal dose based on a structured maternal and fetal benefit-risk assessment. An antenatal dose recommendation for sertraline, as a case study, was formulated using this approach and endorsed for clinical use by the working committee. Future applications of the framework for other drugs can further demonstrate its suitability for developing best evidence, acceptable and clinically feasible antenatal doses.

Preventing burnout from moral distress among prehospital emergency personnel through action research and targeted clinical ethics support

Ethical challenges are integral to health care and are associated with moral distress among health professionals. Moral distress can turn into burnout with a range of negative effects for professionals, patients, relatives, collaborators, and the organisation. Based on action research a focus group study was conducted inclucing prehospital personnel from the emergency services in the Region of Southern Denmark. Results showed that ethical challenges arise in contexts of (1) caring for patients, (2) managing organisational demands, (3) collaborating. Ethical challenges are addressed informally among personnel in emergency vehicles, at ambulance stations, outside working hours, and ocationally involve family or friends with a background in healthcare. Prehospital physicians have the added opportunity to address ethically sensitive issues during monthly meetings. Voicing ethical challenges presupposes confidence, trust, and feeling safe in relation to colleagues, management, and the organisation. Existing forms of ethics support do not lend themselves to the present organisational setup of the studied emergency services. Targeted clinical ethics support initiatives are needed to address moral distress, prevent burnout, and build a supportive working environment. Initiatives must be developed collaboratively and tested bottom-up to identify and eliminate barriers for implementation.

What is a High-Quality Moral Case Deliberation?-Facilitators' Perspectives in the Euro-MCD Project

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.

Positioning Ethics When Direct Patient Care is Prioritized: Experiences from Implementing Ethics Case Reflection Rounds in Childhood Cancer Care

Caring for children with cancer involves complex ethical challenges. Ethics Case Reflection (ECR) rounds can be offered to support teams to reflect on challenges and what should be done in patient care. A training course, for facilitators of ECR rounds, has been offered to healthcare professionals (HCPs) in childhood cancer care by a Nordic working group on ethics. During/after the course, the trainees implemented and facilitated ECR rounds in their clinical setting. The aim was to explore the trainees' experiences of implementing ECR rounds in childhood cancer care. HCPs, who participated as trainees in the course, participated in 3 focus group interviews (n = 22) and 27 individual interviews (n = 17). Interview data were analysed concurrently with data collection following classic grounded theory. Positioning ethics is the core category in this study, used to resolve the main concern of doing ethics in a context where direct patient care is prioritized. Being able to take time for ethics reflections, not perceived as the key priority, was considered a luxury in the clinical setting. Strategies for positioning ethics include allying, promoting ethics reflection, scheduling ethics reflection, and identifying ethical dilemmas. These strategies can be more or less successful and vary in intensity. The prioritisation of direct patient care is not surprising, but polarisation between care and ethics needs to be questioned and ethics reflection need to be integrated in standard care. Ethical competence seems to be central in doing ethics and more knowledge on the promotion of ethical competence in practice and education is needed.

Understanding mealtime behavioral problems in nursing home residents living with dementia: a group concept mapping approach

BACKGROUND

Persons with dementia frequently experience mealtime behavioral problems that can result in reduced or lack of intake of food or fluids. Multiple underlying causes and expressions of mealtime behavioral problems complicate its interpretation and intervention, because problems originating from cognitive and functional decline and behavioral changes may interact. Healthcare professionals and family caregivers may encounter a variety of practical and moral dilemmas in dealing with these problems. We aimed at a better understanding of mealtime behavioral problems and related complex issues in nursing home residents with dementia from a daily practice perspective.

METHODS

We used a mixed-method Group Concept Mapping approach in this study, and collected data online with a panel of 67 healthcare professionals, researchers and relatives from across The Netherlands. The participants contributed to either or all of the following phases: (1) the generation of ideas (brainstorm), (2) sorting, and (3) rating of the ideas. Subsequent phases included data analysis with Groupwisdom® software and interpretation of the results. Multidimensional scaling and hierarchical cluster analysis resulted in a concept map visualizing the coherence and importance of ideas. Bridging values were calculated, with low values indicating a distinct, clear concept.

RESULTS

Brainstorming resulted in 285 statements representing 85 ideas. The concept map visualized three categories capturing ten clusters which describe the management of mealtime behavioral problems, causes of mealtime behavioral problems, and expressions and interpretations of mealtime behavioral problems. Concepts reflecting direct consequences, ethical components, and considerations to handle challenging situations overlapped on the concept map with the highest bridging values (range 0.58-0.87).

CONCLUSION

This study added to unraveling the complex nature of mealtime behavioral problems, as perceived in practice. It is recommended to comprehensively analyze all components in the management of these problems, in particular being aware of ethical factors and align care for residents with dementia accordingly.

Effectiveness of CURA: Healthcare professionals' moral resilience and moral competences

Background: Clinical ethics support instruments aim to support healthcare professionals in dealing with moral challenges in clinical practice. CURA is a relatively new instrument tailored to the wishes and needs of healthcare professionals in palliative care, especially nurses. It aims to foster their moral resilience and moral competences.Aim: To investigate the effects of using CURA on healthcare professionals regarding their Moral Resilience and Moral Competences.Design: Single group pre-/post-test design with two questionnaires.Methods: Questionnaires used were the Rushton Moral Resilience Scale measuring Moral Resilience and the Euro-MCD, measuring Moral Competences. Respondents mainly consisted of nurses and nurse assistants who used CURA in daily practice. Forty-seven respondents contributed to both pre- and post-test with 18 months between both tests. Analysis was done using descriptive statistics and Wilcoxon signed rank tests. This study followed the SQUIRE checklist.Ethical considerations: This study was approved by the Institutional Review Board of Amsterdam UMC. Informed consent was obtained from all respondents.Results: The total Moral Resilience score and the scores of two subscales of the RMRS, that is, Responses to Moral Adversity and Relational Integrity, increased significantly. All subscales of the Euro-MCD increased significantly at posttest. Using CURA more often did not lead to significant higher scores on most (sub) scales.Conclusion: This study indicates that CURA can be used to foster moral resilience and moral competences of healthcare professionals. CURA therefore is a promising instrument to support healthcare professionals in dealing with moral challenges in everyday practice.

Evaluation of an interactive education workshop on hospital pharmacists' ethical reasoning: an observational study

BACKGROUND

Pharmacists are often faced with scenarios in practice that require application of ethical reasoning and decision-making skills. There is limited research on the ethical decision-making processes of hospital pharmacists. Pharmacists who are compassionate and put the interests of their patients first are thought to positively impact on patient care, but there are often complex health-care system pressures in the hospital setting that cause pharmacists to behave in ways that may conflict with professional values and behaviours. This multisite study aimed to evaluate an interactive education workshop on hospital pharmacists' ethical reasoning skills and explore the need for ongoing training and support.

METHODS

This mixed-methods study was carried out across two health services including three hospitals. It incorporated a pre-workshop survey, a feedback survey immediately post-workshop and a third survey four weeks after the workshop. Semi-structured interviews were conducted with hospital pharmacists at least four weeks after the ethics workshop.

RESULTS

In total, 32 participants completed the pre-workshop survey, nominating peers/colleagues as the most common source of support they would consult to inform ethical decision-making (17/118 sources of support). Almost all (n = 31/33; 94%) strongly agreed/agreed that the education session provided them with ethical reasoning skills and a process/framework which they could use when faced with an ethical issue. Pre- and post-survey responses showed increased self-confidence in identifying the regulatory frameworks applicable to pharmacy privacy requirements (p = 0.011) and ethical issues applicable to pharmacy privacy requirements (p = 0.002), as well as applying ethical reasoning to scenarios that involve pharmacy privacy dilemmas/issues (p = 0.004). Participants' self confidence in knowing where to find support when faced with clinical and non-clinical ethics questions was improved (p = 0.002 and p = 0.003 respectively). Participants supported the introduction of quarterly ethics cafes after the workshop, compared to before the workshop (p = 0.001).

CONCLUSION

Hospital pharmacists rely on discussions with colleagues to brainstorm how to address ethical issues. This study showed that a targeted interactive education workshop facilitated familiarity with ethics resources and decision-making processes. It also demonstrated that this approach could be used to enhance hospital pharmacists' readiness, confidence, and capabilities to recognise and respond to challenging ethical issues.

Illuminating Medical Education Through Moral Case Deliberations: A Narrative Review

In the field of medical education, moral case deliberations refer to a structured process, wherein health professionals together discuss and analyze moral issues or ethical dilemmas encountered in their clinical practice. The purpose of the current review is to explore the merits of moral case deliberations, identify the components, enumerate the strategies that can be used for implementation, and enlist the potential challenges and the remedial measures to overcome them. Moral case deliberations can be implemented in medical education in several ways that can be seamlessly integrated into the existing medical curriculum without stretching the overall duration of the training period. The path to successfully implement moral case deliberations in a medical school has its own share of challenges, and we must be aware of them to adopt countermeasures to overcome them. In conclusion, moral case deliberations play a vital role in augmenting ethical competence and establishing a culture of reflective practice among medical students. As medical students are bound to encounter multiple ethical dilemmas in their future clinical practice, it is our responsibility to incrementally expose them to such cases as a part of their undergraduate training to eventually prepare them for effective healthcare delivery.

Integrating the Teaching and Assessment of Moral Reasoning into Undergraduate Medical Education to Advance Health Equity

Moral reasoning skills among medical students have regressed despite the implementation of ethics teachings in medical education curricula. This inability to retain moral reasoning capability is attributed to difficulty transitioning to the principled thinking stage of moral reasoning as well as worsening of ethical decision-making skills during clerkship education due to the "hidden curriculum." Prior studies have examined the efficacy of individual strategies for moral education, but there is insufficient analysis comparing multiple educational interventions and moral reasoning assessment tools. The role and impact of these instruments in medical curricula for the advancement of health equity is reviewed.

How prehospital emergency personnel manage ethical challenges: the importance of confidence, trust, and safety

BACKGROUND

Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. Ethical challenges are associated with moral distress that can lead to burnout. Clinical ethics support has proven useful to address and manage such challenges. This paper explores how prehospital emergency personnel manage ethical challenges. The study is part of a larger action research project to develop and test an approach to clinical ethics support that is sensitive to the context of emergency medicine.

METHODS

We explored ethical challenges and management strategies in three focus groups, with 15 participants in total, each attended by emergency medical technicians, paramedics, and prehospital anaesthesiologists. Focus groups were audio-recorded and transcribed verbatim. The approach to data analysis was systematic text condensation approach.

RESULTS

We stratified the management of ethical challenges into actions before, during, and after incidents. Before incidents, participants stressed the importance of mutual understandings, shared worldviews, and a supportive approach to managing emotions. During an incident, the participants employed moral perception, moral judgments, and moral actions. After an incident, the participants described sharing ethical challenges only to a limited extent as sharing was emotionally challenging, and not actively supported by workplace culture, or organisational procedures. The participants primarily managed ethical challenges informally, often using humour to cope.

CONCLUSION

Our analysis supports and clarifies that confidence, trust, and safety in relation to colleagues, management, and the wider organisation are essential for prehospital emergency personnel to share ethical challenges and preventing moral distress turning into burnout.

The Diversity Compass: a clinical ethics support instrument for dialogues on diversity in healthcare organizations

BACKGROUND

Increasing social pluralism adds to the already existing variety of heterogeneous moral perspectives on good care, health, and quality of life. Pluralism in social identities is also connected to health and care disparities for minoritized patient (i.e. care receiver) populations, and to specific diversity-related moral challenges of healthcare professionals and organizations that aim to deliver diversity-responsive care in an inclusive work environment. Clinical ethics support (CES) services and instruments may help with adequately responding to these diversity-related moral challenges. However, although various CES instruments exist to support healthcare professionals with dealing well with morally challenging situations in healthcare, current tools do not address challenges specifically related to moral pluralism and intersectional aspects of diversity and social justice issues. This article describes the content and developmental process of a novel CES instrument called the Diversity Compass. This instrument was designed with and for healthcare professionals to dialogically address and reflect on moral challenges related to intersectional aspects of diversity and social justice issues that they experience in daily practice.

METHODS

We used a participatory development design to develop the Diversity Compass at a large long-term care organization in a major city in the Netherlands. Over a period of thirteen months, we conducted seven focus groups with healthcare professionals and peer-experts, carried out five expert interviews, and facilitated four meetings with a community of practice consisting of various healthcare professionals who developed and tested preliminary versions of the instrument throughout three cycles of iterative co-creation.

RESULTS

The Diversity Compass is a practical, dialogical CES instrument that is designed as a small booklet and includes an eight-step deliberation method, as well as a guideline with seven recommendations to support professionals with engaging in dialogue when they are confronted with diversity-related moral challenges. The seven recommendations are key components in working toward creating an inclusive and safe space for dialogue to occur.

CONCLUSIONS

The Diversity Compass seeks to support healthcare professionals and organizations in their efforts to facilitate awareness, moral learning and joint reflection on moral challenges related to diversity and social justice issues. It is the first dialogical CES instrument that specifically acknowledges the role of social location in shaping moral perspectives or experiences with systemic injustices. However, to make healthcare more just, an instrument like the Diversity Compass is not enough on its own. In addition to the Diversity Compass, a systemic and structural approach to social justice issues in healthcare organizations is needed in order to foster a more inclusive, safe and diversity-responsive care and work environment in health care organizations.

Effect of Structural Moral Case Deliberation on Burnout Symptoms, Moral Distress, and Team Climate in ICU Professionals: A Parallel Cluster Randomized Trial

OBJECTIVES

Moral case deliberation (MCD) is a team-based and facilitator-led, structured moral dialogue about ethical difficulties encountered in practice. This study assessed whether offering structural MCD in ICUs reduces burnout symptoms and moral distress and strengthens the team climate among ICU professionals.

DESIGN

This is a parallel cluster randomized trial.

SETTING

Six ICUs in two hospitals located in Nijmegen, between January 2020 and September 2021.

SUBJECTS

Four hundred thirty-five ICU professionals.

INTERVENTIONS

Three of the ICUs organized structural MCD. In three other units, there was no structural MCD or other structural discussions of moral problems.

MEASUREMENTS AND MAIN RESULTS

The primary outcomes investigated were the three burnout symptoms-emotional exhaustion, depersonalization, and a low sense of personal accomplishment-among ICU professionals measured using the Maslach Burnout Inventory on a 0-6 scale. Secondary outcomes were moral distress (Moral Distress Scale) on a 0-336 scale and team climate (Safety Attitude Questionnaire) on a 0-4 scale. Organizational culture was an explorative outcome (culture of care barometer) and was measured on a 0-4 scale. Outcomes were measured at baseline and in 6-, 12-, and 21-month follow-ups. Intention-to-treat analyses were conducted using linear mixed models for longitudinal nested data. Structural MCD did not affect emotional exhaustion or depersonalization, or the team climate. It reduced professionals' personal accomplishment (-0.15; p < 0.05) but also reduced moral distress (-5.48; p < 0.01). Perceptions of organizational support (0.15; p < 0.01), leadership (0.19; p < 0.001), and participation opportunities (0.13; p < 0.05) improved.

CONCLUSIONS

Although structural MCD did not mitigate emotional exhaustion or depersonalization, and reduced personal accomplishment in ICU professionals, it did reduce moral distress. Moreover, it did not improve team climate, but improved the organizational culture.

GenderJourney: Participatory development of an ethics support tool to foster dialogue and reflection on shared decision-making in gender-affirming medical care

OBJECTIVE

To describe and reflect on the development process of GenderJourney: an ethics support tool that seeks to foster (dialogue and reflection on) shared decision-making (SDM) in gender-affirming medical care (GAMC).

METHODS

Part of a larger project, this study used a participatory design. We included transgender and gender diverse (TGD) clients and healthcare professionals (HCPs) throughout the study in co-creation workshops. In an iterative process, we (1) established stakeholders' needs, (2) reached a consensus on the aims, content, and design, (3) developed and tested successive renditions, and (4) presented the final version of the tool.

RESULTS

The final tool aims to (A) elucidate the client's care request and corresponding treatment preferences, (B) foster an explicit dialogue between TGD client and HCP about expected/preferred decisional roles and collaboration, (C) stimulate a systematic joint reflection on and handling of SDM-related ethical challenges.

CONCLUSION

The GenderJourney provides non-directive ethics support to jointly reflect on and foster good SDM, including its inherent ethical challenges. Future studies should focus on its implementation and actual contribution to good SDM.

PRACTICE IMPLICATIONS

GenderJourney may be used in GAMC to support the dialogue on what good SDM entails and the identification, discussion, and handling of SDM-related ethical challenges.

Fostering moral resilience through moral case deliberation

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.

Descriptions of long-term impact from inter-professional ethics communication in groups

BACKGROUND

On a daily basis, healthcare professionals deal with various ethical issues and it can be difficult to determine how to act best. Clinical ethics support (CES) has been developed to provide support for healthcare professionals dealing with complex ethical issues. A long-term perspective of participating in inter-professional dialogue and reflective-based CES sessions is seemingly sparse in the literature.

RESEARCH AIM

The aim was to describe experiences of impact of Inter-professional Ethics Communication in groups (IEC) based on Habermas' theory of communicative actions, after 6 months from the perspective of an inter-professional team.

RESEARCH DESIGN

A qualitative inductive approach was chosen, and individual interviews (n = 13) were conducted. Interview data were analysed using qualitative content analysis.

PARTICIPANTS

The participants, 10 females and two males, represented assistant nurses, registered nurses, physicians, occupational therapists, physiotherapists, welfare officers and psychologists. Each had attended at least four IEC sessions.

ETHICAL CONSIDERATIONS

The study was approved by the Regional Ethical Review Board in Umeå, Sweden, and it has been undertaken in accordance with the Helsinki Declaration.

FINDINGS

Overall, the descriptions expressed a perceived achievement of a deepened and integrated ethical awareness that increased the participants' awareness of ethically difficult situations as well as their own ethical thinking, actions and approaches in daily work. Perspectives were shared and the team become more welded. They carried the memories of the reflections within them, which was perceived as supportive when encountered new ethically situations.

DISCUSSION

Putting words to unarticulated thoughts may stimulate repeated reflections, leading to new insights and alternative thoughts.

CONCLUSION

The outcome of IEC sessions 6 months following the last session can be described as an incorporated knowledge that enables actions in ethically difficult situations based on an ethical awareness both at a 'We-level' and an 'I-level'.

Two years of ethics reflection groups about coercion in psychiatry. Measuring variation within employees' normative attitudes, user involvement and the handling of disagreement

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.

Complex interplay between moral distress and other risk factors of burnout in ICU professionals: findings from a cross-sectional survey study

BACKGROUND

Burnout threatens intensive care unit (ICU) professionals' capacity to provide high-quality care. Moral distress is previously considered a root cause of burnout, but there are other risk factors of burnout such as personality, work-life balance and culture. This study aimed to disentangle the associations of ICU professionals' moral distress and other risk factors with the components of burnout-emotional exhaustion, depersonalisation and personal accomplishment-suggesting informed burnout prevention strategies.

METHODS

Cross-sectional survey completed in 2019 of ICU professionals in two Dutch hospitals. The survey included validated measure for burnout (the Dutch Maslach Burnout Inventory), moral distress (Moral Distress Scale), personality (short Big Five Inventory), work-home balance (Survey Work-Home Interaction Nijmegen) and organisational culture (Culture of Care Barometer). Each of the three components of burnout was analysed as a separate outcome, and for each of the components, a separate regression analysis was carried out.

RESULTS

251 ICU professionals responded to the survey (response rate: 53.3%). Burnout prevalence was 22.7%. Findings showed that moral distress was associated with emotional exhaustion (β=0.18, 95% CI 0.9 to 0.26) and depersonalisation (β=0.19, 95% CI 0.10 to 0.28) and with increased emotional exhaustion mediated by negative work-to-home spillover (β=0.09, 95% CI 0.04 to 0.13). Support from direct supervisors mitigates the association between moral distress and emotional exhaustion (β=0.16, 95% CI 0.04 to 0.27).

CONCLUSIONS

Understanding moral distress as a root cause of burnout is too simplified. There is an important interplay between moral distress and work-home imbalance. Interventions that support individual coping with moral distress and a work-home imbalance, and the support of direct supervisors, are paramount to prevent burnout in physicians and nurses.

The Contribution of Moral Case Deliberation to Teaching RCR to PhD Students

Teaching responsible conduct of research (RCR) to PhD students is crucial for fostering responsible research practice. In this paper, we show how the use of Moral Case Deliberation-a case reflection method used in the Amsterdam UMC RCR PhD course-is particularity valuable to address three goals of RCR education: (1) making students aware of, and internalize, RCR principles and values, (2) supporting reflection on good conduct in personal daily practice, and (3) developing students' dialogical attitude and skills so that they can deliberate on RCR issues when they arise. What makes this method relevant for RCR education is the focus on values and personal motivations, the structured reflection on real experiences and dilemmas and the cultivation of participants' dialogical skills. During these structured conversations, students reflect on the personal motives that drive them to adhere to the principles of good science, thereby building connections between those principles and their personal values and motives. Moreover, by exploring personal questions and dilemmas related to RCR, they learn how to address these with colleagues and supervisors. The reflection on personal experiences with RCR issues and questions combined with the study of relevant normative frameworks, support students to act responsibly and to pursue RCR in their day-to-day research practice in spite of difficulties and external constraints.

Moral distress reduction using moral case deliberation in Japan: A mixed-methods study

AIMS

This study aims to develop and examine the effectiveness of a support program for reducing moral distress of nurses, based on the moral case deliberation methodology, and to study the feasibility of its implementation.

METHODS

Study design was an intervention study with pre/post-comparison. The support program included a short lecture and three moral case deliberation sessions for nurses working in an acute care hospital. The Measure of Moral Distress for Healthcare Professionals (MMD-HP) and the Euro-MCD (Moral Case Deliberation) 2.0 scale were used for pre/post-comparison, using the Wilcoxon's signed-rank test. Furthermore, post-intervention interviews were conducted with consenting participants to determine the reasons for changes in pre/post-intervention quantitative data. Of the 34 participants, 29 completed the post-questionnaire and were included in the quantitative data analysis, and 27 were included in the qualitative data analysis.

RESULTS

The mean MMD-HP total scores increased from 147.5 ± 61.0 to 159.3 ± 66.7, but not significantly (p = .375). The mean score of moral competence, a sub-scale of the Euro-MCD 2.0, increased significantly from 15.4 ± 2.4 to 16.4 ± 2.8 after the intervention (p = .036). A qualitative analysis revealed increased moral sensitivity to ethically difficult situations and improved analytical skills as the reasons for change in scores pre/post-intervention.

CONCLUSION

The results of the qualitative analysis suggested the effectiveness of the intervention. The moral distress score increased, although not significantly, and moral competence also increased, suggesting the participants' values changed after the intervention. It was found that the support program using MCD is expected to improve participants' moral competence.

Evaluating interventions to improve ethical decision making in clinical practice: a review of the literature and reflections on the challenges posed

Since the 1980s, there has been an increasing acknowledgement of the importance of recognising the ethical dimension of clinical decision-making. Medical professional regulatory authorities in some countries now include ethical knowledge and practice in their required competencies for undergraduate and post graduate medical training. Educational interventions and clinical ethics support services have been developed to support and improve ethical decision making in clinical practice, but research evaluating the effectiveness of these interventions has been limited. We undertook a systematic review of the published literature on measures or models of evaluation used to assess the impact of interventions to improve ethical decision making in clinical care. We identified a range of measures to evaluate educational interventions, and one tool used to evaluate a clinical ethics support intervention. Most measures did not evaluate the key impact of interest, that is the quality of ethical decision making in real-world clinical practice. We describe the results of our review and reflect on the challenges of assessing ethical decision making in clinical practice that face both developers of educational and support interventions and the regulatory organisations that set and assess competency standards.

Patients with severe mental illness and the ethical challenges related to confidentiality during family involvement: A scoping review

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.

What outcomes of moral case deliberations are perceived important for healthcare professionals to handle moral challenges? A national cross-sectional study in paediatric oncology

Background

In paediatric oncology, healthcare professionals face moral challenges. Clinical ethics support services, such as moral case deliberation (MCD), aim to assist them in dealing with these challenges. Yet, healthcare professionals can have different expectations and goals related to clinical ethics support services.

Methods

In this study, the perceptions held by healthcare professionals (nursing assistants, registered nurses, physicians, and others) regarding the importance of possible outcomes of MCDs, prior to implementation of MCDs, were investigated. A multisite, cross-sectional, quantitative study was performed at all six Paediatric Oncology Centres in Sweden. Healthcare professionals answered the Euro-MCD instrument with 26 potential MCD outcomes using a scale from Not important (1) to Very important (4). Descriptive and comparative statistical analyses were carried out.

Results

All outcomes were rated high, i.e., between 3.12 and 3.78. More open communication, developing skills to analyse ethically difficult situations, better mutual understanding, and deciding on concrete actions were rated as most important. Understanding of ethical theories and critical examination of policies were rated less important. Most often nursing assistants rated higher and physicians lower than the other professions did. Women and participants without previous experience of MCDs perceived outcomes as more important. There were differences between centres as one centre had significantly higher, and one centre had significantly lower ratings compared to the others.

Conclusion

It is clear that healthcare professionals want MCDs to improve teamwork and skills in order to analyse and manage ethically difficult situations. When comparing to previous research about important MCD outcomes, there were similarities in what healthcare professionals consider to be important when handling moral challenges regardless of country and potential differences in healthcare settings and systems, such as paediatric vs. adult care.

How to deal with moral challenges around the decision-making competence in transgender adolescent care? Development of an ethics support tool

BACKGROUND

Decision-making competence is a complex concept in the care for transgender and gender diverse adolescents, since this type of care concerns one's developing gender identity and involves treatment options that often lack international consensus. Even despite competence assessments, moral challenges arise in the decision-making process. Here, traditional forms of clinical ethics support such as moral case deliberation might not fit as these do not provide thematic guidance. This study therefore aimed to develop a practice-oriented ethics support tool to assist care providers when dealing with moral challenges around decision-making competence in transgender adolescent care.

METHODS

The study followed a participatory design to develop a tool in close collaboration with care providers; they had a say in all phases of development and dissemination. Firstly, nine care providers were interviewed about experienced moral challenges and needs for ethics support. Based on this, the structure and content of the tool was constructed and discussed in two focus group meetings, after which four care providers tested the tool and additional feedback was collected from the team and an advisory board. The final tool was presented to all Dutch care providers in transgender adolescent care.

RESULTS

Care providers expressed a need for guidance in defining and assessing decision-making competence. Main moral challenges concerned discussing fertility options with young clients, dealing with co-occurring mental health difficulties and the decision-making role of parents. The final tool, named the Competence Consultant, is an interactive pdf containing four parts: (1) Clarify information; (2) Identify doubts and moral questions; (3) Guidance for conversations and (4) Overview and Conclusions.

DISCUSSION

Developing an ethics support tool in a controversial care setting is highly relevant as it aims to help individual care providers in defining, discussing and dealing with their moral challenges in actual practice. The 'Competence Consultant' for transgender care providers contributes to their moral sensitivity and moral competence. It is an example of the development of innovative and integrative forms of thematic ethics support.

Ethical challenges experienced by prehospital emergency personnel: a practice-based model of analysis

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.

Moral distress among nurses involved in life-prolonging treatments in patients with a short life expectancy: A qualitative interview study

OBJECTIVE

To explore whether nurses in hospital settings experience moral distress when involved in potentially life-prolonging treatments in adults with a short life expectancy.

METHODS

A qualitative study using semi-structured interviews.

RESULTS

23 Registered nurses working in inpatient or outpatient hospital settings participated. The nurses stated they were often not involved in decisions regarding life-prolonging treatments. They reported signs of moral distress such as feeling powerless when they when they were not being listened to in the decision-making process and when confronted with negative treatment outcomes. Nurses felt frustrated when their own values were not reflected in the decision-making or when physicians created unrealistic expectations.

CONCLUSIONS

Hospital nurses experience moral distress when they are involved in life-prolonging treatment because of the patient's advanced condition and their own lack of involvement in the decision-making process about the treatment. In these situations, moral distress is characterised by feelings of powerlessness and frustration.

PRACTICE IMPLICATIONS

Nurses need to be empowered by training programmes that focus on an active role in the decision-making process. Further research is needed to evaluate effective tools and training programmes that help nurses in shared decision-making processes.

Postgraduate nursing students' experiences of practicing ethical communication

BACKGROUND

Ethics communication has been described as a pedagogical form, promoting development of ethical competence among nursing students. The 'one to five method' was developed by this research group as a tool for facilitating ethical communication in groups among healthcare professionals but has not yet been evaluated.

AIM

To explore post-graduate nursing students' experiences of practicing ethical communication in groups.

RESEARCH DESIGN

The study design is qualitative.

PARTICIPANTS AND RESEARCH CONTEXT

The study comprised 12 nursing students on a post-graduate course for Registered Nurses focusing on palliative care. After education the students engaged as participants and facilitators in ethics communication in groups, with support from the 'one to five method'. Data were derived from the students written reflections and subjected to thematic analysis.

ETHICAL CONSIDERATIONS

The study was performed in accordance with the ethical standards in the 2013 Helsinki Declaration and approved by the Ethics Committee of the Medical Faculty at Umeå University.

RESULTS

An overall theme was identified, 'being supported to achieve a democratic dialogue concerning ethical problems' and five themes, related to each step of the 'one to five method'. The themes concerned: putting the experience of an ethical dilemma into words; being confirmed by shared emotions; defining the value conflict using ethical principles; expressing virtues of empathy and raised awareness; jointly finding various action approaches.

DISCUSSION

Regular ethics communication in groups encourages nursing students to actively seek understanding and clarification of ethically difficult situations.

CONCLUSIONS

The results indicate that ethics communication in groups could be a way of developing virtues during education. Interventions using the 'one to five method' need to be further studied among student groups from other healthcare contexts.

Morisprudence: a theoretical framework for studying the relationship linking moral case deliberation, organisational learning and quality improvement

There is a claim that clinical ethics support services (CESS) improve healthcare quality within healthcare organisations. However, there is lack of strong evidence supporting this claim. Rather, the current focus is on the quality of CESS themselves or on individual learning outcomes. In response, this article proposes a theoretical framework leading to empirical hypotheses that describe the relationship between a specific type of CESS, moral case deliberation and the quality of care at the organisational level. We combine insights from the literature on CESS, organisational learning and quality improvement and argue that moral case deliberation causes healthcare professionals to acquire practical wisdom. At the organisational level, where improving quality is a continuous and collective endeavour, this practical wisdom can be aggregated into morisprudence, which is an ongoing formulation of moral judgements across cases encountered within the organisation. Focusing on the development of morisprudence enables refined scrutinisation of CESS-related quality claims.

Clinical ethics support services in paediatric practice: protocol for a mixed studies systematic review on structures, interventions and outcomes

INTRODUCTION

Clinical ethics support services (CESS) have been developing worldwide with growing interest in evaluating their quality. Paediatric-specific CESSs (p-CESS) have received little attention, and evidence from adult services might not be generalisable. Evidence on service models and practices is crucial to inform further research and debate on quality evaluation and minimum standards for p-CESSs. We aim to systematically identify, appraise and synthesise evidence for p-CESS structures, processes and outcomes.

METHODS AND ANALYSIS

We will conduct a mixed-studies systematic review including peer-reviewed empirical studies published in English or Spanish language providing data on the evaluation and/or impact on any aspect of p-CESS. We will search seven electronic databases: MEDLINE, Philosopher's Index, EMBASE, PsycINFO, LILACS, Web of Science and CINHAL, without filters applied. Search terms will be related to "clinical ethics support" AND "paediatrics" AND "structure/process/outcome". Reference and citation list of included studies will be handsearched. A 10% random sample of retrieved titles/abstracts and all full texts will be independently dual-screened. We will conduct narrative and thematic synthesis for quantitative and qualitative data, respectively, following sequential explanatory synthesis guided by Donabedian's framework of structure, process and outcomes. Quality will be assessed using the Mixed-Methods Appraisal Tool (2018). The review will be reported using the adapted Preferred Reporting Items for Systematic Reviews and Meta-Analyses for reporting systematic reviews of qualitative and quantitative evidence template. Stakeholders will be involved twice in the review process; prior to data extraction and synthesis and after preliminary results.

ETHICS AND DISSEMINATION

As a systematic review of published data, no ethical approval is necessary. Results will be published in a relevant academic peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021280978.

Ethics education to support ethical competence learning in healthcare: an integrative systematic review

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.

Conceptualizing the impact of moral case deliberation: a multiple-case study in a health care institution for people with intellectual disabilities

Background

As moral case deliberations (MCDs) have increasingly been implemented in health care institutions as a form of ethics support, it is relevant to know whether and how MCDs actually contribute to positive changes in care. Insight is needed on what actually happens in daily care practice following MCD sessions. This study aimed at investigating the impact of MCD and exploring how ‘impact of MCD’ should be conceptualized for future research.

Methods

A multiple-case study was conducted in a care organization for people with intellectual disabilities and/or acquired brain injury, by observing MCD sessions as ‘cases’, followed by interviews with health care professionals concerning the follow-up to these cases, and a focus group with involved MCD facilitators. A conceptual scheme concerning the possible impact formed the basis for analysis: (1) individual moral awareness; (2) the actions of health care professionals; (3) collaboration among health care professionals; (4) the concrete situation of the client; (5) the client’s quality of care and life; (6) the organizational and policy level.

Results

According to interviewees, their moral awareness and their collaboration, both among colleagues and with clients’ relatives, improved after MCD. Perceived impact on client situation, quality of care/life and the organizational level varied among interviewees or was difficult to define or link to MCD. Three aspects were added to the conceptual scheme concerning the impact of MCD: (a) preparations and expectations prior to the MCD session; (b) a translational step between the conclusions of the MCD session and practical events in the following period, and (c) collaboration with clients’ relatives. A negative impact of MCD was also found on misunderstandings among participants and disappointment about lack of follow-up.

Conclusions

Concretizing and conceptualizing the ‘impact’ of MCD is complicated as many factors play a role either before or during the transition from MCD to practice. It is important to consider ‘impact’ in a broad sense and to relate it to the goals and context of the MCD in question. Future studies in this field should pay additional attention to the preparations, content and process involved in ethics support, including clients’ and relatives’ experiences.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-022-00747-2.

CURA-An Ethics Support Instrument for Nurses in Palliative Care. Feasibility and First Perceived Outcomes

Evaluating the feasibility and first perceived outcomes of a newly developed clinical ethics support instrument called CURA. This instrument is tailored to the needs of nurses that provide palliative care and is intended to foster both moral competences and moral resilience. This study is a descriptive cross-sectional evaluation study. Respondents consisted of nurses and nurse assistants (n = 97) following a continuing education program (course participants) and colleagues of these course participants (n = 124). Two questionnaires with five-point Likert scales were used. The feasibility questionnaire was given to all respondents, the perceived outcomes questionnaire only to the course participants. Data collection took place over a period of six months. Respondents were predominantly positive on most items of the feasibility questionnaire. The steps of CURA are clearly described (84% of course participants agreed or strongly agreed, 94% of colleagues) and easy to apply (78-87%). The perceived outcomes showed that CURA helped respondents to reflect on moral challenges (71% (strongly) agreed), in perspective taking (67%), with being aware of moral challenges (63%) and in dealing with moral distress (54%). Respondents did experience organizational barriers: only half of the respondents (strongly) agreed that they could easily find time for using CURA. CURA is a feasible instrument for nurses and nurse assistants providing palliative care. However, reported difficulties in organizing and making time for reflections with CURA indicate organizational preconditions ought to be met in order to implement CURA in daily practice. Furthermore, these results indicate that CURA helps to build moral competences and fosters moral resilience.

Improving caring quality for people with dementia in nursing homes using IPOS-Dem: A stepped-wedge cluster randomized controlled trial protocol

AIMS

We aim to evaluate the effectiveness of the Integrated Palliative Care Outcome Scale for people with dementia-based case studies to improve the caring quality for people with dementia in nursing homes by frontline staff and family members.

BACKGROUND

Swiss nursing homes mostly care for people with dementia. This population is at high risk of receiving little to no palliation for their complex needs. The majority of Swiss frontline healthcare staff do not systematically report on the needs of their residents. Additionally, family members do not routinely participate in assessment processes.

DESIGN

We will conduct a stepped-wedge cluster randomized trial of repeated assessment using the Integrated Palliative Care Outcome Scale for people with dementia (IPOS-Dem) and subsequent case studies. Clusters will consist of Swiss nursing homes randomly assigned to one of three sequential intervention time points.

METHODS

The study population will consist of people with dementia living in nursing homes with and without specialized dementia care facilities. Over 16 months, staff working at the frontline and family members will assess the needs and concerns of people with dementia using IPOS-Dem. Depending on sequence allocation, facilitated case studies will start after 3, 6 or 9 months. The primary outcome will be caring quality measured by QUALIDEM. The secondary outcome will be symptoms and concerns, as indicated by the IPOS-Dem sum-score. The Zürich Ethics Committee approved the study in 2019 (2019-01847).

IMPACT

The results of this study will contribute to improving the effectiveness of person-centred care for people with dementia. Collaboration between healthcare staff and family members will be systematically developed and built upon thorough assessment using the IPOS-Dem and related case studies. The use of IPOS-Dem will offer all frontline staff a systematic approach to have an independent voice within the nursing process, regardless of their qualification or grade.

Does teaching medical ethics ensure good knowledge, attitude, and reported practice? An ethical vignette-based cross-sectional survey among doctors in a tertiary teaching hospital in Nepal

BACKGROUND

Importance of awareness of medical ethics and its integration into medical curriculum has been frequently highlighted. Study 1 aimed to assess the knowledge, attitude, and reported practices of medical ethics among clinicians at Patan Academy of Health Sciences, a tertiary care teaching hospital in Nepal. Study 2 was conducted to assess whether there was a difference in knowledge, attitude, and reported practices of medical ethics among doctors who received formal medical ethics education during undergraduate studies and those who did not.

METHODS

Two cross-sectional surveys using self-administered questionnaires were conducted. Study 1 included 72 participants; interns, medical officers, and consultants working at Patan Academy of Health Sciences. Study 2 was a comparative study conducted among 54 medical officers who had received formal medical ethics education (Group 1) and 60 medical officers who did not (Group 2).

RESULTS

Participants who had completed post-graduate education had higher knowledge (p = 0.050), practice (p < 0.001), and overall combined scores (p = 0.011). Participants with ethics education had higher knowledge (p < 0.001), attitude (p = 0.001), practice (p < 0.001), and overall score (p < 0.001). Most participants preferred consulting colleagues if an ethical dilemma arose. Fewer participants had heard of the Declaration of Helsinki. Most participants thought doctors to be most capable of judging what is best for the patient (Study 1: 70.42%, Study 2 Group 1: 42.59%, Group 2: 80%). Case scenarios in which participants demonstrated poor practice were ethical issues concerning truth-telling, end-of-life decisions, treating HIV/AIDS patients, treating a minor, and reporting colleague's errors.

CONCLUSIONS

This study found that participants who have received medical ethics education have higher knowledge, attitude, and practice scores. The results further justify the need for medical ethics education to be a part of the core medical curriculum. A blame-free environment where seniors can be approached for advice should be created. Research ethics should also be given attention. During medical ethics training, ethical issues where doctors perform poorly should be given more priority and should be discussed in a country-specific context.

Clinical ethics case consultation in a university department of cardiology and intensive care: a descriptive evaluation of consultation protocols

BACKGROUND

Clinical ethics case consultations (CECCs) provide a structured approach in situations of ethical uncertainty or conflicts. There have been increasing calls in recent years to assess the quality of CECCs by means of empirical research. This study provides detailed data of a descriptive quantitative and qualitative evaluation of a CECC service in a department of cardiology and intensive care at a German university hospital.

METHODS

Semi-structured document analysis of CECCs was conducted in the period of November 1, 2018, to May 31, 2020. All documents were analysed by two researchers independently.

RESULTS

Twenty-four CECCs were requested within the study period, of which most (n = 22; 92%) had been initiated by physicians of the department. The patients were an average of 79 years old (R: 43-96), and 14 (58%) patients were female. The median length of stay prior to request was 12.5 days (R: 1-65 days). The most frequent diagnoses (several diagnoses possible) were cardiology-related (n = 29), followed by sepsis (n = 11) and cancer (n = 6). Twenty patients lacked decisional capacity. The main reason for a CECC request was uncertainty about the balancing of potential benefit and harm related to the medically indicated treatment (n = 18). Further reasons included differing views regarding the best individual treatment option between health professionals and patients (n = 3) or between different team members (n = 3). Consensus between participants could be reached in 18 (75%) consultations. The implementation of a disease specific treatment intervention was recommended in five cases. Palliative care and limitation of further disease specific interventions was recommended in 12 cases.

CONCLUSIONS

To the best of our knowledge, this is the first in-depth evaluation of a CECC service set up for an academic department of cardiology and intensive medical care. Patient characteristics and the issues deliberated during CECC provide a starting point for the development and testing of more tailored clinical ethics support services and research on CECC outcomes.

Does participation in ethics discussions have an impact on ethics decision-making? A cross-sectional study among healthcare professionals in paediatric oncology

PURPOSE

The overall aim of this study was to describe perceptions of the decision-making process in relation to participation/non-participation in ethics discussions among healthcare professionals in paediatric oncology.

METHODS

Healthcare professionals, working at three paediatric units where ethics discussions where performed answered a study-specific questionnaire focusing on perceptions of involvement, influence, responsibility and understanding of ethics decision-making. Statistical analyses included descriptive statistics, non-parametric paired t-tests and correlation tests.

RESULTS

Participation in ethics discussions was related to perceptions of greater involvement and the possibility of influencing decisions, as well as formal/shared responsibility for the ethics decisions related to patient care. Medical doctors and registered nurses perception of involvement in decisions, possibility to influence and responsibility decreased when they were not present during the ethics discussion or when no ethics discussion was conducted at all. Healthcare professionals had a generally good understanding of the ethical issues and the ethics decisions. The whole group considered medical doctors to be the most important participants in the ethics discussions, followed by patients/family. Healthcare professionals wanted more teamwork and viewed ethics discussions as very helpful for teamwork when dealing with ethical issues in paediatric oncology.

CONCLUSIONS

Ethics discussions in paediatric oncology practice increases the involvement within and the understanding of the decision-making process about ethical decisions. The understanding is not always dependent on participation, indicating a great trust in team members. Based on these findings the implementation of a structure for ethics support in paediatric oncology where patients/families are integrated is recommended.

Perceptions of important outcomes of moral case deliberations: a qualitative study among healthcare professionals in childhood cancer care

Background

In childhood cancer care, healthcare professionals must deal with several difficult moral situations in clinical practice. Previous studies show that morally difficult challenges are related to decisions on treatment limitations, infringing on the child's integrity and growing autonomy, and interprofessional conflicts. Research also shows that healthcare professionals have expressed a need for clinical ethics support to help them deal with morally difficult situations. Moral case deliberations (MCDs) are one example of ethics support. The aim of this study was to describe the MCD-related outcomes that healthcare professionals in childhood cancer care considered important, before MCDs were implemented, in order to facilitate the implementation of MCDs in childhood cancer care in Sweden.

Methods

This study is based on qualitative data. Healthcare professionals, mostly representing registered nurses, nursing assistants and physicians, working at childhood cancer care centres in Sweden, were invited to respond to the translated and content validated European MCD Outcomes Instrument, before participating in regular MCDs. Answers to the main open-ended question, included in the questionnaire, was analysed according to systematic text condensation.

Results

Data was collected from 161 responses from the healthcare professionals. The responses included healthcare professionals’ perceptions of which MCD-related outcomes they found important for handling moral challenges. Three different themes of important outcomes from the analysis of the data are presented as follows: Interprofessional well-being in team interactions on a team level; Professional comfort when dealing with moral challenges on a personal level; and Improved quality of care for the child and the family on a care level.

Conclusions

Healthcare professionals in childhood cancer care considered it important that ethics support could enhance the well-being of interprofessional teams, support healthcare professionals on an individual level and improve quality of care. The results of this study can be used in current and future training for MCD-facilitators. When knowing the context specific important MCD-outcomes, the sessions could be adapted. Managers in childhood cancer care would benefit from knowing about the specific important outcomes for their target group because they could then create relevant working conditions for clinical ethics support.

Interprofessional health-care ethics education for medical and nursing students in Germany: an interprofessional education and practice guide

Early interprofessional learning among nursing and medical students provides various benefits for future collaboration among professionals, and high-quality care for patients. Expert committees, thus, urge the integration of interprofessional education (IPE) in undergraduate studies to achieve significant sustainable improvements in health-care practice. In Germany, IPE interventions are already implemented in some health-care disciplines, but Health-care Ethics are scarcely regarded in undergraduate education. There are, however, several reasons why Health-care Ethics is particularly appropriate for teaching in an interprofessional format. Thus, after reviewing the legal framework and the current curricula of both professions, an IPE course on Health-care Ethics for medical and nursing students was developed and implemented, consisting of seven classes of 180 minutes each. Drawing on the evaluation results after two rounds of the course, this interprofessional education and practice guide reports on challenges, obstacles and perspectives for improvement of an IPE course on Health-care Ethics. It aims to provide guidance for teaching pioneers and innovators who implement similar projects and to foster practice-oriented and open discussion about the possibilities and limits of IPE in Health-care Ethics.

Evaluating the effectiveness of clinical ethics committees: a systematic review

Clinical Ethics Committees (CECs), as distinct from Research Ethics Committees, were originally established with the aim of supporting healthcare professionals in managing controversial clinical ethical issues. However, it is still unclear whether they manage to accomplish this task and what is their impact on clinical practice. This systematic review aims to collect available assessments of CECs' performance as reported in literature, in order to evaluate CECs' effectiveness. We retrieved all literature published up to November 2019 in six databases (PubMed, Ovid MEDLINE, Scopus, Philosopher's Index, Embase and Web of Science), following PRISMA guidelines. We included only articles specifically addressing CECs and providing any form of CECs performance assessment. Twenty-nine articles were included. Ethics consultation was the most evaluated of CECs' functions. We did not find standardized tools for measuring CECs' efficacy, but 33% of studies considered "user satisfaction" as an indicator, with 94% of them reporting an average positive perception of CECs' impact. Changes in patient treatment and a decrease of moral distress in health personnel were reported as additional outcomes of ethics consultation. The highly diverse ways by which CECs carry out their activities make CECs' evaluation difficult. The adoption of shared criteria would be desirable to provide a reliable answer to the question about their effectiveness. Nonetheless, in general both users and providers consider CECs as helpful, relevant to their work, able to improve the quality of care. Their main function is ethics consultation, while less attention seems to be devoted to bioethics education and policy formation.

A Qualitative Study on Experiences and Perspectives of Members of a Dutch Medical Research Ethics Committee

The aim of this research was to gain insight into the experiences and perspectives of individual members of a Medical Research Ethics Committee (MREC) regarding their individual roles and possible tensions within and between these roles. We conducted a qualitative interview study among members of a large MREC, supplemented by a focus group meeting. Respondents distinguish five roles: protector, facilitator, educator, advisor and assessor. Central to the role of protector is securing valid informed consent and a proper risk-benefit analysis. The role of facilitator implies that respondents want to think along with and assist researchers in order to help medical science progress. As educators, the respondents want to raise ethical and methodological awareness of researchers. The role of advisor implies that respondents bring in their own expertise. The role of assessor points to contributing to the overall evaluation of the research proposal. Various tensions were identified within and between roles. Within the role of protector, a tension is experienced between paternalism and autonomy. Between the role of protector and facilitator tensions occur when the value of a study is questioned while risks and burdens for the subjects are negligible. Within the role of assessor, a tension is felt between the implicit nature of judgments and the need for more explicit formulations. Awareness of various roles and responsibilities may prevent one-sided views on MREC work, not only by members themselves, but also by researchers. Tensions within and between the roles require reflection by MREC members.

Implementing clinical ethics committees as a complex intervention: presentation of a feasibility study in community care

Background

How should clinical ethics support services such as clinical ethics committees (CECs) be implemented and evaluated? We argue that both the CEC itself and the implementation of the CEC should be considered as ‘complex interventions’.

Main text

We present a research project involving the implementation of CECs in community care in four Norwegian municipalities. We show that when both the CEC and its implementation are considered as complex interventions, important consequences follow – both for implementation and the study thereof. Emphasizing four such sets of consequences, we argue, first, that the complexity of the intervention necessitates small-scale testing before larger-scale implementation and testing is attempted; second, that it is necessary to theorize the intervention in sufficient depth; third, that the identification of casual connections charted in so-called logic models allows the identification of factors that are vital for the intervention to succeed and which must therefore be studied; fourth, that an important part of a feasibility study must be to identify and chart as many as possible of the causally important contextual factors.

Conclusion

The conceptualization of the implementation of a CEC as a complex intervention shapes the intervention and the way evaluation research should be performed, in several significant ways. We recommend that researchers consider whether a complex intervention approach is called for when studying CESS implementation and impact.

Field-Testing the Euro-MCD Instrument: Important Outcomes According to Participants Before and After Moral Case Deliberation

Ethics support services like Moral Case Deliberation (MCD) intend to support healthcare professionals in ethically difficult situations. To assess outcomes of MCD, the Euro-MCD Instrument has been developed. Field studies to test this instrument are needed and have been conducted, examining important outcomes before MCD participation and experienced outcomes. The current study aimed to (1) describe how participants’ perceive the importance of MCD outcomes after MCD; (2) compare these perceptions with those before MCD participation; and (3) test the factor structure of these outcomes. Swedish, Norwegian and Dutch healthcare professionals rated the importance of outcomes in the Euro-MCD Instrument after four and eight MCDs. Ratings were compared with those before MCD participation using paired and independent samples t-tests. The factor structure was tested using exploratory factor analyses. After 4 and 8 MCDs, 443 respectively 247 respondents completed the instrument. More than 69% rated all MCD outcomes as ‘quite’ or ‘very’ important, especially outcomes from Enhanced Collaboration, Improved Moral Reflexivity and Improved Moral Attitude. Significant differences for 16 outcomes regarding ratings before and after MCD participation were not considered meaningful. Factor analyses suggested three categories, which seemingly resemble the domains Improved Moral Reflexivity, Enhanced Collaboration and a combination of Improved Moral Attitude and Enhanced Emotional Support. After participation in MCDs, respondents confirmed the importance of outcomes in the Euro-MCD Instrument. The question on perceived importance and the categorization of outcomes need reconsideration. The revised instrument will be presented elsewhere, based on all field studies and theoretical reflections.