Implementing ethics reflection groups in hospitals: an action research study evaluating barriers and promotors

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.

A systematic scoping review of group reflection in medical education

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.

Ethical Issues in Clinical Decision-Making about Involuntary Psychiatric Treatment: A Scoping Review

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.

Training nurses to facilitate and implement CURA in palliative care institutions: development and evaluation of a blended learning program

BACKGROUND

Healthcare professionals in palliative care are found to be confronted with moral challenges on a frequent basis. CURA is a low-threshold instrument for dialogical ethical reflection that was developed to deal with these challenges. A previous study identified the need of healthcare professionals to be trained to introduce CURA in their organization, initiate and facilitate reflections with CURA, and contribute to the implementation of CURA. The aim of this study was to develop and evaluate a training for professionals to become 'CURA-ambassadors'.

METHODS

The training was developed in a participatory way in two cycles. We trained 72 healthcare professionals. The training was evaluated by means of a questionnaire and six semi-structured interviews.

RESULTS

The study resulted in a blended learning training combining training sessions with an e-module and with practicing with organizing and facilitating CURA in daily healthcare practice. The main objectives of the training are to enable CURA-ambassadors to introduce CURA within their organization, initiate and facilitate ethical reflections using CURA, and contribute to the implementation of CURA. Participants were generally positive about the training program and the trainers. Technical difficulties related to the e-module were mentioned as main point of improvement.

DISCUSSION

The training program can generate ownership, responsibility, and competency among CURA-ambassadors, which are essential foundations for implementing complex interventions in healthcare practice. The training program received positive evaluations shortly after completing the program. This study adds to our understanding of what is needed for healthcare professionals to use CURA, in order to support them in dealing with moral challenges and to foster their moral resilience. Further research is needed to assess whether participants experience the training as sufficient and effective when using and implementing CURA structurally in their organizations over a longer period of time.

Developing the CARE intervention to enhance ethical self-efficacy in dementia care through the use of literary texts

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.

Developing and Testing Digital Ethical Reflection in Long-Term Care: Nurses' Experiences

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.

Model for developing context-sensitive responses to vulnerability in research: managing ethical dilemmas faced by frontline research staff in Kenya

Health research in low-resource settings often involves individuals and populations defined as 'vulnerable'. There is growing attention in the literature to the ethical dilemmas that frontline research staff face while conducting such research. However, there is little documented as to how research staff might support one another in identifying and handling these dilemmas in different contexts. Over the course of conducting empirical ethics research embedded in the Childhood Acute Illness & Nutrition Network, we developed an approach to examine and respond to the ethical issues and dilemmas faced by the study teams, particularly frontline staff. In this paper we describe the specific tools and approach we developed, which centred on regular cross-team ethics reflection sessions, and share lessons learnt. We suggest that all studies involving potentially vulnerable participants should incorporate activities and processes to support frontline staff in identifying, reflecting on and responding to ethical dilemmas, throughout studies. We outline the resources needed to do this and share piloted tools for further adaptation and evaluation. Such initiatives should complement and feed into-and certainly not in any way replace or substitute for-strong institutional ethics review, safeguarding and health and safety policies and processes, as well broader staff training and career support initiatives.

Unintended consequences: a qualitative study exploring the impact of collecting implementation process data with phone interviews on implementation activities

Background

Qualitative data are crucial for capturing implementation processes, and thus necessary for understanding implementation trial outcomes. Typical methods for capturing such data include observations, focus groups, and interviews. Yet little consideration has been given to how such methods create interactions between researchers and study participants, which may affect participants’ engagement, and thus implementation activities and study outcomes. In the context of a clinical trial, we assessed whether and how ongoing telephone check-ins to collect data about implementation activities impacted the quality of collected data, and participants’ engagement in study activities.

Methods

Researchers conducted regular phone check-ins with clinic staff serving as implementers in an implementation study. Approximately 1 year into this trial, 19 of these study implementers were queried about the impact of these calls on study engagement and implementation activities. The two researchers who collected implementation process data through phone check-ins with the study implementers were also interviewed about their perceptions of the impact of the check-ins.

Results

Study implementers’ assessment of the check-ins’ impact fell into three categories: (1) the check-ins had no effect on implementation activities, (2) the check-ins served as a reminder about study participation (without relating a clear impact on implementation activities), and (3) the check-ins caused changes in implementation activities. The researchers similarly perceived that the phone check-ins served as reminders and encouraged some implementers’ engagement in implementation activities; their ongoing nature also created personal connections with study implementers that may have impacted implementation activities. Among some study implementers, anticipation of the check-in calls also improved their ability to recount implementation activities and positively affected quality of the data collected.

Conclusion

These results illustrate the potential impact of qualitative data collection on implementation activities during implementation science trials. Mitigating such effects may prove challenging, but acknowledging these consequences—or even embracing them, perhaps by designing data collection methods as implementation strategies—could enhance scientific rigor. This work is presented to stimulate debate about the complexities involved in capturing data on implementation processes using common qualitative data collection methods.

Trial registration

ClinicalTrials.gov, NCT02325531. Registered 15 December 2014.

The Hidden Curriculum Challenges in Learning Professional Ethics Among Iranian Medical Students: A Qualitative Study

BACKGROUND

Medical ethics is a vital quality for the doctors which has been seriously taken into consideration in recent years. Identifying the factors affecting medical ethics may help to develop more effective ways to promote this quality in medical education. This study was aimed to explain the challenges of hidden curriculum in learning the professional ethics among Iranian medical students.

MATERIALS AND METHODS

This qualitative study was performed on 15 medical interns of Kermanshah University of Medical Sciences in 2019 using grounded theory (GT). Sampling was started by purposive sampling and continued through theoretical sampling until complete data saturation. Data collection and analysis were done simultaneously. Data were interpreted by the constant comparative method according to Strauss and Corbin's approach.

RESULTS

The results showed that the challenges of hidden curriculum for learning the professional ethics by medical students included a number of key concepts. Analyzing these concepts and taking into account the commonalities, we obtained six subthemes using a reduction inductive method, the main theme of which was "the challenge of hidden curriculum in learning the professional medical ethics". The subthemes included "decreased interest in medicine", "false beliefs", "curriculum weakness", "materialism and economic problems", "avoidance of responsibility", and "underlying problems of the medical profession".

CONCLUSION

The findings indicated six challenges in the hidden curriculum for learning the professional medical ethics. These challenges can be considered a threat or an obstacle to achieving the goals of professional ethics. Therefore, curriculum planners, education policymakers, and teachers should plan and implement the professional ethics curriculum based on these factors.

Hospital ethics reflection groups: a learning and development resource for clinical practice

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.