Intensivists' ethical perceptions about decisions to withhold or withdraw treatment: A clinical ethics empirical investigation

BACKGROUND

Intensive care professional societies have issued policy recommendations regarding decisions to withhold and/or withdraw treatment (Wh&Wd) that consistently classify them as ethically equivalent and ethically neutral. However, on the ground they are often perceived as "active" and morally problematic. Moreover, recent studies have highlighted personal "variability" in the way such decisions are made. Therefore, it seemed necessary to explore intensivists' different ethical perceptions about Wh&Wd decisions.

METHODS

A qualitative retrospective and multicentered study was conducted in seven intensive care units belonging to the Paris Hospital Trust (AP-HP), which involved in-depth interviews with 44 intensivists of different ages and levels of professional experience. An inductive ("grounded theory"-inspired), multidisciplinary clinical ethics approach was used that aimed at eliciting and retrieving practitioners' ethical intuitions about different Wh&Wd decisions. Interview transcripts were analyzed using a "thematic analysis" approach.

RESULTS

Practitioners' perceptions of Wh&Wd decisions vary along two continuous dimensions: active/passive and ethically problematic/unproblematic. Three groups have been identified: those who consider Wh&Wd decisions 1) as passive and unproblematic, 2) as active and problematic, and 3) as active and unproblematic. More interestingly, these groups can be differently characterized with respect to three other ethically relevant considerations: the role of consensus during the collegial decision-making procedure, the difference between withholding and withdrawing decisions, and the definition of one's own overarching professional goal.

CONCLUSION

The study results allow for recognition of intensivists' moral distress about Wh&Wd decisions and open new perspectives to deal with their deep-rooted variability, most notably by working on the rationale and format of the collegial decision-making procedure.

Moral caring competency and moral distress among Ghanaian nurses in adult care settings: A descriptive-correlational study

Background

Nurses in adult care settings frequently encounter moral distress due to the daily ethical obligations they must fulfill. In contrast to other healthcare professionals, nurses often grapple with a heightened frequency of moral dilemmas, resulting in increased moral distress.

Objective

This study aimed to explore the levels and relationship between moral caring competency and moral distress among Ghanaian nurses in adult care settings.

Methods

This quantitative study utilized a descriptive-correlational design. A multistage sampling was used to select three public hospitals. Simple random sampling was used to recruit 231 nurses from the three public hospitals. Data were collected from June to July 2023 using validated questionnaires. The study utilized frequency and percentages, mean and standard deviation, and Spearman's Correlation.

Results

The nurses had a low level of moral caring competency (M = 2.18, SD = 0.340). The composite moral distress score was 227.31, indicating a high level of moral distress among the nurses. Furthermore, there was a moderate, negative significant relationship between moral caring competency and moral distress (rs = -.474, N = 231, p <0.001).

Conclusions

Nurses in public hospitals had limited personal cognitive, affective, and psychomotor abilities to address patient moral issues. The nurses also experience significant moral distress when delivering patient care. Furthermore, to decrease the level of moral distress, moral caring competency should be strengthened among nurses. Therefore, it is recommended that nurse administrators provide adequate organizational support and implement continuous moral training to improve nurses' moral caring competency and mitigate their moral distress. Healthcare policymakers are encouraged to develop or refine policies to navigate moral dilemmas and reduce moral distress among nurses. Future studies employing qualitative designs can explore the influence of culture on moral caring competency within the Ghanaian setting.

Ethical climate, moral resilience, and ethical competence of head nurses

BACKGROUND

The ethical competence of head nurses plays a pivotal role in nursing ethics. Ethical climate is a prerequisite for ethical competence, and moral resilience can positively influence an individual's ethical competence. However, few studies have focused on the relationship between ethical climate, moral resilience, and ethical competence among them.

OBJECTIVES

To investigate the relationship between ethical climate, moral resilience, and ethical competence, and examine the mediating role of moral resilience between ethical climate and ethical competence among head nurses.

DESIGN

A quantitative, cross-sectional study.

METHODS

A total of 309 Chinese head nurses completed an online survey, including ethical climate questionnaire, Rushton moral resilience scale, and ethical competence questionnaire. Inferential statistical analysis includes Pearson's correlation and a structural equation model.

ETHICAL CONSIDERATIONS

This study received ethical approval from the Institutional Review Board of Xiangya Nursing School of Central South University (No. E2023146).

RESULTS

Head nurses' ethical climate score positively impacted ethical competence (r = 0.208, p < .001), and ethical climate could affect ethical competence through the mediating role of moral resilience.

CONCLUSION

This study emphasized the value of ethical climate in moral resilience of head nurses, ultimately leading to an enhancement in their ethical competence.

Ethical concerns when recruiting children with cancer for research: Swedish healthcare professionals' perceptions and experiences

BACKGROUND

Research is crucial to improve treatment, survival and quality of life for children with cancer. However, recruitment of children for research raises ethical challenges. The aim of this study was to explore and describe ethical values and challenges related to the recruitment of children with cancer for research, from the perspectives and experiences of healthcare professionals in the Swedish context. Another aim was to explore their perceptions of research ethics competence in recruiting children for research.

METHODS

An explorative qualitative study using semi-structured interviews with key informants. Seven physicians and ten nurses were interviewed. Interviews were analysed using inductive qualitative content analysis.

RESULTS

The respondents' ethical challenges and values in recruitment mainly concerned establishing relationships and trust, meeting informational needs, acknowledging vulnerability, and balancing roles and interests. Ensuring ethical competence was raised as important, and interpersonal and communicative skills were highlighted.

CONCLUSION

This study provides empirical insight into recruitment of children with cancer, from the perspectives of healthcare professionals. It also contributes to the understanding of recruitment as a relational process, where aspects of vulnerability, trust and relationship building are important, alongside meeting informational needs. The results provide knowledge on the complexities raised by paediatric research and underpin the importance of building research ethics competence to ensure that the rights and interests of children with cancer are protected in research.

How do ethically competent nurses behave in clinical nursing practice? A qualitative study

AIM

This study explored how ethically competent nurses behave in clinical nursing practice.

BACKGROUND

Nurses' ethical competency is crucial in nursing practice as it promotes patients' safety and quality of care.

METHODS

Using a purposive sampling technique, 20 clinical nurses in South Korea were interviewed via an online video platform. The data were analysed using a thematic analysis based on phenomenological approach.

RESULTS

The main theme found among the participating nurses' ethical competency was caring beyond egocentrism, with two subthemes: (1) patient-centred care based on compassion and (2) responsible behaviour based on nursing professionalism. Factors that enabled this included (1) reasonable work conditions, (2) interpersonal relationships, and (3) nurses' rich personal experiences.

CONCLUSIONS

Nurses' ethical competency depends on how far they can move away from their own egocentrism and act for their clients' benefit, wherein an appropriate workload and warm human relationships with one's colleagues are essential. Nurses should thus receive education on ethics and professionalism and participate in volunteer and leisure activities that cultivate their degree of empathy.

IMPLICATION FOR NURSING MANAGEMENT

Nursing leaders and managers should understand nurses' ethical competency and its enabling factors to devise effective strategies to promote it.

Compliance with the ethical competence framework by head nurses

BACKGROUND

Head nurses have duties in providing nursing care and ethical supervision to the nurses in the unit. Compliance with the ethical competence framework for head nurses is essential in fostering an ethical climate in the organization.

OBJECTIVE

The objective of this research is to study the head nurses' compliance with the ethical competence framework by the Thailand Nursing and Midwifery Council (TNMC).

METHODS

The study is a qualitative research, using in-depth interviews conducted among 20 head nurses practicing in a super tertiary hospital in Bangkok, Thailand. The sample was selected using a criterion sampling method. The head nurses' ethical experience relating to work practice was analyzed by thematic analysis.

ETHICAL CONSIDERATIONS

The ethical approval of this study was obtained from the Committee for Research Ethics (Social Sciences), Mahidol University, and from the Institutional Review Board of the hospital in which the study was conducted.

RESULTS

From the thematic analysis of the ethical experience practiced by the head nurses, 8 themes and 16 sub-themes were categorized across 5 ethical competencies based on the ethical competence framework by the TNMC. It was found that all the identified themes and sub-themes conformed to the ethical competence framework, and demonstrated the head nurses' compliance with the framework.

DISCUSSION

Head nurses' ethical experience in practice conforms to the ethical competence framework by the TNMC. The framework that is based on the Code of conduct and the nursing culture that places the importance of the seniority system may facilitate the compliance with the ethical competence framework.

CONCLUSION

Head nurses demonstrated compliance with the ethical competence framework by the TNMC. Nevertheless, improvements could be done to the framework by adding details such as more examples of ethical decision-making scenarios, personnel's rights, and social media usage guidelines.

Midwifery students' experiences of support for ethical competence

Background:

Midwifery students are confronted with several ethical dilemmas and challenging situations during clinical midwifery care practice. Since ethical competence of midwifery students is under development, it is important to support the students’ learning progress of ethical issues from diverse viewpoints.

Objective:

From the perspective of didactics of caring science and the context of midwifery students, to explore how midwifery students’ experience supports for ethical competence in midwifery education and investigate how ethically challenging situations have been carried out during clinical midwifery care practice.

Design:

Qualitative, explorative and descriptive design with inductive nature.

Methods:

Focus group interviews with nine Swedish midwifery students. Hans-Georg Gadamer’s philosophical hermeneutics was applied to guide the interpretation.

Ethical considerations:

Ethical principles and scientific guidelines were followed. Informed consent was obtained from the participants. Confidentiality was respected and quotations anonymised.

Results:

Receiving support when ethically challenging situations occur in clinical midwifery practice is important and necessary. One main theme, such as support is a human and caring factor in the midwifery students’ Bildung process on ethical competence, and four subthemes, such as supporting through trust and responsibility; supporting through dignity and respect; supporting through truthfulness and justice; and supporting through dialogue and reflection, were created from the hermeneutical interpretation.

Discussion:

Teaching ethics should be carefully planned, consistent and continue throughout the midwifery education. There is dispersion in the pedagogy of ethical situations, the methods and perceptions associated with it, and in obtaining possible support for students. Developing well-experienced methods could benefit the support of midwifery students’ ethical competence when they experience ethically challenging situations in midwifery care practice.

Attitudes towards learning professional ethics in undergraduate physiotherapy students: A STROBE compliant cross-sectional study

BACKGROUND

Ethics is a key competence to be acquired by physiotherapy students to ensure quality care. However, students may not be aware of the importance of ethics for the development of their clinical practice, in the same way that their attitudes towards Professional Ethics are unknown within their curriculum.

OBJECTIVES

The aim of this study was to identify the attitudes towards learning Professional Ethics among undergraduate students of Physiotherapy Degree and compare the attitude between the educational years.

DESIGN

A cross-sectional study was carried out.

SETTINGS

Physiotherapy Degree at the University of Valencia, Spain.

PARTICIPANTS

In the study 340 physiotherapy students participated.

METHODS

This was a quantitative study with a cross-sectional observational design. The students of the different years of the Physiotherapy Degree had to complete the Attitudes Questionnaire towards Professional Ethics in Physiotherapy in order to analyse the study objective.

RESULTS

The four educational years' scored 3.80 or more in the questionnaire. Second-year students scored the highest (4.25 ± 0.35) and had significantly more favourable attitudes towards learning ethics in relation to the rest of the years (p = 0.007 vs. first; p < 0.001 vs. third and fourth). First-year students (4.09 ± 0.37) obtained a significantly higher score than third (3.86 ± 0.35) and fourth years (3.80 ± 0.33) with p < 0.001 vs. both third and fourth. Finally, in relation to the 3 categories of the items' questionnaire the mean scores showed significant differences between the second year and the rest of the years.

CONCLUSIONS

The attitudes towards learning Professional Ethics among students of the Physiotherapy Degree at the university is favourable, although it varies depending on the academic year, with the students in the academic year in which Ethics is taught (i.e. second year students) being the ones with better attitudes.

The ethics of DNR-decisions in oncology and hematology care: a qualitative study

BACKGROUND

In cancer care, do not resuscitate (DNR) orders are common in the terminal phase of the illness, which implies that the responsible physician in advance decides that in case of a cardiac arrest neither basic nor advanced Coronary Pulmonary Rescue should be performed. Swedish regulations prescribe that DNR decisions should be made by the responsible physician, preferably in co-operation with members of the team. If possible, the patient should consent, and significant others should be informed of the decision. Previous studies have shown that physicians and nurses can experience ethical dilemmas in relation to DNR decisions, but knowledge about what ethical reasoning they perform is lacking. Therefore, the aim was to describe and explore what ethical reasoning physicians and nurses apply in relation to DNR-decisions in oncology and hematology care.

METHODS

A qualitative, descriptive and explorative design was used, based on 287 free-text comments in a study-specific questionnaire, answered by 216 physicians and nurses working in 16 oncology and hematology wards in Sweden. Comments were given by 89 participants.

RESULTS

The participants applied a situation-based ethical reasoning in relation to DNR-decisions. The reasons given for this were both deontological and utilitarian in kind. Also, expressions of care ethics were found in the material. Universal rules or guidelines were seen as problematic. Concerning the importance of the subject, nurses to a higher extent underlined the importance of discussing DNR-situations, while physicians described DNR-decisions as over-investigated and not such a big issue in their daily work.

CONCLUSION

The study revealed that DNR-decisions in oncology and hematology care gave rise to ethical considerations. Important ethical values described by the participants were to avoid doing harm and to secure a peaceful and "natural" death with dignity for their dying patients. A preference for the expression "allow for natural death" instead of the traditional term "do not resuscitate" was found in the material.

"There is total silence here" Ethical competence and inter-organizational learning in healthcare governance

PURPOSE

The purpose of this paper is to analyse ethical competence related to healthcare governance and management tasks at the county/regional level in Sweden. The paper also discusses conditions that support or constrain the development and application of such competence.

DESIGN/METHODOLOGY/APPROACH

The study is based on original qualitative data from 13 interviews and 6 meeting observations. Three key groups of actors were included: politicians, civil servants and CEOs in publicly financed health-provider organizations. An abductive analysis was carried out by a stepwise method guided by thematic research questions.

FINDINGS

The informants viewed themselves as having a high degree of ethical responsibility for healthcare practice. However, they did not integrate ethical reflection and dialogue into their work decisions (e.g. regarding budgets, reforms and care agreements). The current organization, control systems and underlying business principles, along with the individuals' understanding of their own and others' roles, tended to constrain the development and use of ethical competence.

PRACTICAL IMPLICATIONS

Qualities of an appropriate ethical competence related to healthcare governance and management, and conditions to develop and use such competence, are suggested.

ORIGINALITY/VALUE

Hardly any empirical research has examined ethical competence related to healthcare governance and management tasks. The paper integrates ethics and theories on learning in organizations and contributes knowledge about ethical competence and the conditions necessary to develop and practise ethical competence in an organizational and inter-organizational context.

Ethical competence in a profession: Healthcare professionals' views

Aim

Ethical competence is a crucial component for enabling good quality care but there is insufficient qualitative research on healthcare professionals' views on ethical competence. The aim of this study was to investigate healthcare professionals' views on ethical competence in a student healthcare context.

Design

A qualitative design and a hermeneutical approach were used.

Methods

The material consists of texts from interviews with healthcare professionals (N = 10) in a student healthcare context. The method was inspired by content analysis.

Results

One main theme and four subthemes emerged. The main theme was as follows: safeguarding the vulnerability of the other. The subthemes were as follows: using sensitivity to establish a trustful relationship, acting in an objective and flexible manner, using a reflective process in decision-making, and maintaining confidentiality and honesty. Future research should focus on investigating ethical competence from various perspectives in student health care, for example the student perspective or observational studies.

Self-evaluated ethical competence of a practicing physiotherapist: a national study in Finland

Background

Patients have the right to equal, respectful treatment. Nowadays, one third of patient complaints concern health care staff’s behavior towards patients. Ethically safe care requires ethical competence, which has been addressed as a core competence in physiotherapy. It has been defined in terms of character strength, ethical awareness, moral judgment skills in decision-making, and willingness to do good. The purpose of this study was to analyze the ethical competence of practicing physiotherapists.

Method

A self-evaluation instrument (Physiotherapist’s Ethical Competence Evaluation Tool) based on an analysis of a concept “ethical competence” was constructed in 2016 and physiotherapists (n = 839), working in public health services or private practice responded to the questionnaire.

Results

Based on the results, most of the physiotherapists evaluated themselves highly ethically competent in all areas of ethical competence, subscales being Strength, Awareness, Skills and Will. Willingness to do good was evaluated as highest, while character strength, including the strength to support ethical processes and speak on behalf of the patient, was evaluated the lowest. Physiotherapists most commonly consult a colleague when encountering an ethical problem. Other methods for problem solving are not very familiar, neither are the international or national ethical codes of conduct.

Conclusions

This was the first attempt to assess all aspects of ethical competence empirically in a clinical environment in physiotherapy, using a novel self-evaluation instrument. Even if physiotherapists evaluate themselves as competent in ethics, further exploration is needed for ethical awareness. Also the patients’ viewpoints about ethically competent care should be considered, to better ensure ethical safety of the patient.

Healthcare professionals' ethical competence: A scoping review

AIM

The aim of this study was to examine the extent and nature of the available research literature on healthcare professionals' ethical competence and to summarize the research findings in this field.

DESIGN

A scoping review guided by Arksey and O'Malleys methodological framework was conducted.

METHODS

Six databases including Pubmed/Medline, CINAHL, Web of Science Core Collection, PsycInfo, Philosophers' Index, and Scopus were searched systematically. Of 1,476 nonduplicate citations, 17 matched the inclusion criteria.

RESULTS

Findings revealed that healthcare professionals' ethical competence is a limited but topical research area. The focus areas of the studies were conceptualization, measuring, and realization of the ethical competence. The studies provided varying definitions and constructions for ethical competence and a few instruments to measure ethical competence were identified. Research in this area seems to be in a transition phase from theorization to empirical measurement. Methodologically, the research was rather heterogeneous and mainly focused on nurses.

The status of ethics in Swedish health care management: a qualitative study

Background

By tradition, the Swedish health care system is based on a representative and parliamentary form of government. Recently, new management forms, inspired by market principles, have developed. The steering system is both national and regional, in that self-governing county councils are responsible for the financing and provision of health care in different regions. National and local documents regulating Swedish health care mention several ethical values, such as equity in health for the whole population and respect for autonomy and human dignity. It is therefore of interest to investigate the status of such ethical statements in Swedish health care management.

Method

The aim of the present study was to investigate perceptions of the status of ethics in the daily work of politicians, chief civil servants and Chief Executive Officers (CEOs) from care-giver organizations in the county council of Stockholm. A qualitative method was used, based on inductive content analysis of individual interviews with 13 health care managers.

Results

The content analysis resulted in four categories: Low status of ethics; Cost-effectiveness over ethics; Separation of ethics from management; and Lack of opportunities for ethical competence building. The informants described how they prioritized economic concerns over ethics and separated ethics from their daily work. They also expressed that they experienced that this development had been enforced by the marketization of the health care system. Further, they described how they lacked opportunities for ethical discussions, which could have helped develop their ethical competence.

Conclusions

In order to improve the status of ethics in health care management, ethical considerations and analyses must be integrated in the regular work tasks of politicians, chief civil servants and CEOs; such as decision-making, budgeting and reform work. Further, opportunities for ethical dialogues on a regular basis should be organized, in order to improve ethical competence on the management level. New steering forms, less focused upon market principles, might also be needed, in order to improve the status of ethics in the health care management organization.

Ethical competence

Background:

Exploring the concept of ethical competence in the context of healthcare is essential as it pertains to better quality of care. The concept still lacks a comprehensive definition covering the aspects of ethical expertise, ethical knowledge and action of a health professional.

Objective:

This article aims to report an analysis of the concept of ethical competence.

Method:

A modified strategy suggested by Walker and Avant was used to analyse the concept.

Results:

As a result, the concept of ethical competence can be defined in terms of character strength, ethical awareness, moral judgement skills and willingness to do good. Virtuous professional, experience of a professional, human communication, ethical knowledge and supporting surroundings in the organisation can be seen as prerequisites for ethical competence. Ethical competence results in the best possible solutions for the patient, reduced moral distress at work and development and democratisation of society.

Conclusion:

The results of the analysis establish a basis for an instrument to evaluate health professionals’ ethical competence. It will guide educators, as well as managers in healthcare, to support the development of ethical conduct in healthcare.

Written institutional ethics policies on euthanasia: an empirical-based organizational-ethical framework

As euthanasia has become a widely debated issue in many Western countries, hospitals and nursing homes especially are increasingly being confronted with this ethically sensitive societal issue. The focus of this paper is how healthcare institutions can deal with euthanasia requests on an organizational level by means of a written institutional ethics policy. The general aim is to make a critical analysis whether these policies can be considered as organizational-ethical instruments that support healthcare institutions to take their institutional responsibility for dealing with euthanasia requests. By means of an interpretative analysis, we conducted a process of reinterpretation of results of former Belgian empirical studies on written institutional ethics policies on euthanasia in dialogue with the existing international literature. The study findings revealed that legal regulations, ethical and care-oriented aspects strongly affected the development, the content, and the impact of written institutional ethics policies on euthanasia. Hence, these three cornerstones-law, care and ethics-constituted the basis for the empirical-based organizational-ethical framework for written institutional ethics policies on euthanasia that is presented in this paper. However, having a euthanasia policy does not automatically lead to more legal transparency, or to a more professional and ethical care practice. The study findings suggest that the development and implementation of an ethics policy on euthanasia as an organizational-ethical instrument should be considered as a dynamic process. Administrators and ethics committees must take responsibility to actively create an ethical climate supporting care providers who have to deal with ethical dilemmas in their practice.

Making researchers moral: Why trustworthiness requires more than ethics guidelines and review

Research ethics, once a platform for declaring intent, discussing moral issues and providing advice and guidance to researchers, has developed over time into an extra-legal regulatory system, complete with steering documents (ethics guidelines), overseeing bodies (research ethics committees) and formal procedures (informed consent). The process of institutionalizing distrust is usually motivated by reference to past atrocities committed in the name of research and the need to secure the trustworthiness of the research system. This article examines some limitations of this approach. First, past atrocities cannot provide the necessary justification unless institutionalized distrust is a necessary or efficient means to prevent future ones – and there are several reasons to doubt this. Second, the efficacy of ethics review in safeguarding morally acceptable research depends on the moral competence and integrity of individual researchers – the very qualities that institutionalized distrust calls into question. Third, ethics guidelines cannot, as is sometimes assumed, educate or guide researchers in moral behaviour unless they already possess considerable capacity for moral judgment. Fourth, institutionalized distrust is a potential threat to the moral competence and integrity of researchers by encouraging a blinkered view of ethical issues, inducing moral heteronomy through incentives, and alienating them to research ethics. We conclude that the moral problem posed by inappropriate short-term behaviour on behalf of researchers is dwarfed by the potential long-term consequences if their moral competence is allowed to deteriorate. Measures must therefore be taken to ensure that researchers are equipped to take their individual responsibility and are not obstructed from so doing.