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Romøren M, Hermansen KB, Sævareid TJL, Brøderud L, Westbye SF, Wahl AK, Thoresen L, Rostoft S, Førde R, Ahmed M, Aas E, Midtbust MH, Pedersen R. Implementation of advance care planning in the routine care for acutely admitted patients in geriatric units: protocol for a cluster randomized controlled trial. BMC Health Serv Res 2024; 24:220. [PMID: 38374100 PMCID: PMC10875743 DOI: 10.1186/s12913-024-10666-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 01/31/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Acutely ill and frail older adults and their next of kin are often poorly involved in treatment and care decisions. This may lead to either over- or undertreatment and unnecessary burdens. The aim of this project is to improve user involvement and health services for frail older adults living at home, and their relatives, by implementing advance care planning (ACP) in selected hospital wards, and to evaluate the clinical and the implementation interventions. METHODS This is a cluster randomized trial with 12 hospital units. The intervention arm receives implementation support for 18 months; control units receive the same support afterwards. The ACP intervention consists of 1. Clinical intervention: ACP; 2. Implementation interventions: Implementation team, ACP coordinator, network meetings, training and supervision for health care personnel, documentation tools and other resources, and fidelity measurements with tailored feedback; 3. Implementation strategies: leadership commitment, whole ward approach and responsive evaluation. Fidelity will be measured three times in the intervention arm and twice in the control arm. Here, the primary outcome is the difference in fidelity changes between the arms. We will also include 420 geriatric patients with one close relative and an attending clinician in a triadic sub-study. Here, the primary outcomes are quality of communication and decision-making when approaching the end of life as perceived by patients and next of kin, and congruence between the patient's preferences for information and involvement and the clinician's perceptions of the same. For patients we will also collect clinical data and health register data. Additionally, all clinical staff in both arms will be invited to answer a questionnaire before and during the implementation period. To explore barriers and facilitators and further explore the significance of ACP, qualitative interviews will be performed in the intervention units with patients, next of kin, health care personnel and implementation teams, and with other stakeholders up to national level. Lastly, we will evaluate resource utilization, costs and health outcomes in a cost-effectiveness analysis. DISCUSSION The project may contribute to improved implementation of ACP as well as valuable knowledge and methodological developments in the scientific fields of ACP, health service research and implementation science. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT05681585. Registered 03.01.23.
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Affiliation(s)
- Maria Romøren
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway.
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - Karin Berg Hermansen
- Department for Health Sciences in Aalesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Aalesund, Norway
| | | | - Linn Brøderud
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Siri Færden Westbye
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Astrid Klopstad Wahl
- Department for Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Lisbeth Thoresen
- Department for Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Siri Rostoft
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Reidun Førde
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Marc Ahmed
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Eline Aas
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway
- Division of Health Science, Norwegian Institute of Public Health, Oslo, Norway
| | - May Helen Midtbust
- Department for Health Sciences in Aalesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Aalesund, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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Ihle-Hansen H, Pedersen R, Westbye SF, Sævareid TJL, Brøderud L, Larsen MH, Hermansen K, Rostoft S, Romøren M. Patient preferences in geriatric wards, a survey of health care professionals' practice, experience and attitudes. Eur Geriatr Med 2024; 15:153-158. [PMID: 38282088 PMCID: PMC10876711 DOI: 10.1007/s41999-023-00922-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 12/13/2023] [Indexed: 01/30/2024]
Abstract
PURPOSE We aimed to identify whether health care professionals (HCP) examine their patient and next-of-kin preferences, and to study whether medical decisions follow these preferences. METHOD A cross-sectional web-based survey was conducted with multidisciplinary HCP from 12 geriatric wards in the South-Eastern Norway Regional Health Authority. RESULTS Of the 289 HCPs responding (response rate 61%), mean age 37.8 years (SD 11.3), 235 (81.3%) women, 12.4 (SD 9.6) years of experience and 67 (23.2%) medical doctors, only half report clarifying patients' preferences. The majority reported that they did not inform, involve and treat in line with such preferences. However, 53% believe that HCP, patients and next-of-kin should make clinical decisions together. DISCUSSION Our findings indicate a lack of engagement in conversation and inclusion of patient preferences when providing health interventions in geriatric wards. Measures for change of culture are needed.
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Affiliation(s)
- Hege Ihle-Hansen
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.
- Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
- Department of Neurology, Oslo University Hospital, Oslo, Norway.
| | - R Pedersen
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
- Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - S F Westbye
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
- Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - T J L Sævareid
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - L Brøderud
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - M H Larsen
- Lovisenberg Diaconal University College, Oslo, Norway
| | - K Hermansen
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Health Sciences, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Aalesund, Norway
| | - S Rostoft
- Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - M Romøren
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
- Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Amundsen R, Thorarinsdottir S, Larmo A, Pedersen R, Andersen TE, Møller M, Bahr R. #ReadyToplay: hamstring injuries in women's football - a two-season prospective cohort study in the Norwegian women's premier league. SCI MED FOOTBALL 2024:1-9. [PMID: 38243669 DOI: 10.1080/24733938.2024.2305389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2024] [Indexed: 01/21/2024]
Abstract
In this two-season prospective cohort study (2020-2021), we aimed to describe the characteristics, clinical findings and magnetic resonance imaging (MRI) findings of hamstring injuries in the Norwegian women's premier league. Hamstring injuries were examined by team physiotherapists using a standardised clinical examination and injury form. Injury location and severity (modified Peetrons classification) were graded based on MRI by two independent radiologists. Fifty-three hamstring injuries were clinically examined, 31 of these with MRI. Hamstring injuries caused 8 days (median) lost from football (interquartile range: 3-15 days, range: 0-188 days), most were non-contact and occurred during sprinting. Gradual-onset (53%) and sudden-onset injuries (47%) were evenly distributed. The injuries examined with MRI were classified as grade 0 (52%), grade 1 (16%) or grade 2 (29%). One proximal tendinopathy case was not graded. Grade 2 injuries caused more time loss than grade 0 (19 ± 8 vs. 7 ± 7 days, p = 0.002). Of injuries with MRI changes, 60% were in the m. biceps femoris, mainly the muscle-tendon junction, and 40% in the m. semimembranosus, most in the proximal tendon. Compared to previous findings from men's football, a higher proportion of hamstring injuries in women's football had a gradual onset and involved the m. semimembranosus, particularly its proximal tendon.
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Affiliation(s)
- R Amundsen
- Oslo Sports Trauma Research Center, Institute of Sports Medicine, Norwegian School of Sports Sciences, Oslo, Norway
| | - S Thorarinsdottir
- Oslo Sports Trauma Research Center, Institute of Sports Medicine, Norwegian School of Sports Sciences, Oslo, Norway
| | - A Larmo
- Radiology Department, Evidia Norge AS, Oslo, Norway
| | - R Pedersen
- Radiology Department, Unilabs Norge AS, Oslo, Norway
| | - T E Andersen
- Oslo Sports Trauma Research Center, Institute of Sports Medicine, Norwegian School of Sports Sciences, Oslo, Norway
- The Norwegian Football Association Medical Centre (Idrettens helsesenter), The Norwegian Football Association, Oslo, Norway
| | - M Møller
- Oslo Sports Trauma Research Center, Institute of Sports Medicine, Norwegian School of Sports Sciences, Oslo, Norway
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - R Bahr
- Oslo Sports Trauma Research Center, Institute of Sports Medicine, Norwegian School of Sports Sciences, Oslo, Norway
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Hestmark L, Romøren M, Heiervang KS, Hansson KM, Ruud T, Benth JŠ, Norheim I, Weimand B, Pedersen R. Correction to: Implementation of Guidelines on Family Involvement for Persons with Psychotic Disorders (IFIP): A Cluster Randomised Controlled Trial. Adm Policy Ment Health 2023; 50:1010-1012. [PMID: 37610592 PMCID: PMC10543823 DOI: 10.1007/s10488-023-01291-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Affiliation(s)
- Lars Hestmark
- Centre for Medical Ethics, University of Oslo, Postbox, Blindern, Oslo, 1130, 0318, Norway.
| | - Maria Romøren
- Centre for Medical Ethics, University of Oslo, Postbox, Blindern, Oslo, 1130, 0318, Norway
| | - Kristin Sverdvik Heiervang
- Centre for Medical Ethics, University of Oslo, Postbox, Blindern, Oslo, 1130, 0318, Norway
- Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
- Center for Mental Health and Substance Abuse, Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
| | | | - Torleif Ruud
- Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, University of Oslo, Campus Ahus, Oslo, Norway
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Irene Norheim
- Division of Mental Health and Addiction, Vestre Viken Hospital Trust, Lier, Norway
| | - Bente Weimand
- Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
- Center for Mental Health and Substance Abuse, Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
- Faculty of Health Sciences, OsloMet Oslo Metropolitan University, Oslo, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, University of Oslo, Postbox, Blindern, Oslo, 1130, 0318, Norway
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Hofstad T, Nyttingnes O, Markussen S, Johnsen E, Killackey E, McDaid D, Rinaldi M, Dean K, Brinchmann B, Douglas K, Gröning L, Bjørkly S, Palmstierna T, Strømme MF, Blindheim A, Rugkåsa J, Hofmann BM, Pedersen R, Widding‐Havneraas T, Rypdal K, Mykletun A. Long term outcomes and causal modelling of compulsory inpatient and outpatient mental health care using Norwegian registry data: Protocol for a controversies in psychiatry research project. Int J Methods Psychiatr Res 2023; 33:e1980. [PMID: 37421245 PMCID: PMC10807697 DOI: 10.1002/mpr.1980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/19/2023] [Indexed: 07/10/2023] Open
Abstract
OBJECTIVES Compulsory mental health care includes compulsory hospitalisation and outpatient commitment with medication treatment without consent. Uncertain evidence of the effects of compulsory care contributes to large geographical variations and a controversy on its use. Some argue that compulsion can rarely be justified and should be reduced to an absolute minimum, while others claim compulsion can more frequently be justified. The limited evidence base has contributed to variations in care that raise issues about the quality/appropriateness of care as well as ethical concerns. To address the question whether compulsory mental health care results in superior, worse or equivalent outcomes for patients, this project will utilise registry-based longitudinal data to examine the effect of compulsory inpatient and outpatient care on multiple outcomes, including suicide and overall mortality; emergency care/injuries; crime and victimisation; and participation in the labour force and welfare dependency. METHODS By using the natural variation in health providers' preference for compulsory care as a source of quasi-randomisation we will estimate causal effects of compulsory care on short- and long-term trajectories. CONCLUSIONS This project will provide valuable insights for service providers and policy makers in facilitating high quality clinical care pathways for a high risk population group.
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Affiliation(s)
- Tore Hofstad
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
- Centre for Medical EthicsUniversity of OsloOsloNorway
| | - Olav Nyttingnes
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
- Health Services Research UnitAkershus University HospitalLørenskogNorway
| | | | - Erik Johnsen
- Division of PsychiatryHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
- NORMENTCentre of ExcellenceHaukeland University HospitalBergenNorway
| | - Eoin Killackey
- OrygenMelbourneAustralia
- Centre for Youth Mental HealthThe University of MelbourneMelbourneAustralia
| | - David McDaid
- Care Policy and Evaluation CentreDepartment of Health PolicyLondon School of Economics and Political ScienceLondonUK
| | - Miles Rinaldi
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
- Centre for Work and Mental HealthNordland Hospital TrustBodøNorway
- South West London and St George's Mental Health NHS TrustLondonUK
| | - Kimberlie Dean
- Discipline of Psychiatry and Mental HealthSchool of Clinical MedicineUniversity of New South WalesSydneyAustralia
- Justice Health and Forensic Mental Health NetworkSydneyNSWAustralia
| | - Beate Brinchmann
- Centre for Work and Mental HealthNordland Hospital TrustBodøNorway
| | - Kevin Douglas
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
- Department of PsychologySimon Fraser UniversityVancouverBritish ColumbiaCanada
- Regional Centre for Research and Education in Forensic PsychiatryOslo University HospitalOsloNorway
| | - Linda Gröning
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
- Faculty of LawUniversity of BergenBergenNorway
| | - Stål Bjørkly
- Regional Centre for Research and Education in Forensic PsychiatryOslo University HospitalOsloNorway
- Faculty of Health and Social SciencesMolde University CollegeMoldeNorway
| | - Tom Palmstierna
- Department of Clinical NeuroscienceCentre for Psychiatric ResearchKarolinska InstitutetStockholmSweden
- Faculty of Medicine and Health SciencesDepartment of Mental HealthNorwegian University of Science and Technology (NTNU)TrondheimNorway
| | - Maria Fagerbakke Strømme
- Division of PsychiatryHaukeland University HospitalBergenNorway
- NORMENTCentre of ExcellenceHaukeland University HospitalBergenNorway
| | - Anne Blindheim
- Division of PsychiatryHaukeland University HospitalBergenNorway
| | - Jorun Rugkåsa
- Health Services Research UnitAkershus University HospitalLørenskogNorway
- Centre for Care ResearchUniversity of South‐Eastern NorwayPorsgrunnNorway
- Department of Mental HealthOslo Metropolitan UniversityOsloNorway
| | - Bjørn Morten Hofmann
- Centre for Medical EthicsUniversity of OsloOsloNorway
- Faculty of Medicine and Health SciencesDepartment of Health SciencesNorwegian University of Science and TechnologyGjøvikNorway
| | | | - Tarjei Widding‐Havneraas
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
| | - Knut Rypdal
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
| | - Arnstein Mykletun
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
- Centre for Work and Mental HealthNordland Hospital TrustBodøNorway
- UiT—The Arctic University of NorwayTromsøNorway
- Division for Health ServicesNorwegian Institute of Public HealthOsloNorway
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Westbye SF, Rostoft S, Romøren M, Thoresen L, Wahl AK, Pedersen R. Barriers and facilitators to implementing advance care planning in naïve contexts - where to look when plowing new terrain? BMC Geriatr 2023; 23:387. [PMID: 37353744 PMCID: PMC10290291 DOI: 10.1186/s12877-023-04060-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 05/23/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Advance care planning (ACP) is a way of applying modern medicine to the principle of patient autonomy and ensuring that patients receive medical care that is consistent with their values, goals and preferences. Robust evidence supports the benefits of ACP, but it remains an underutilized resource in most countries. This paper goes from the naïve point of view, and seeks to identify the barriers and facilitators to implementation in unfamiliarized contexts and in a whole system approach involving the clinical, institutional and policy level to improve the implementation of ACP. METHODS Qualitative interviews were chosen to enable an explorative, flexible design. Qualitative interviews were conducted with 40 health care professionals and chief physicians in hospitals and in municipalities. The thematic analysis was done following Braun and Clarke's strategy for thematic analysis. RESULTS The main reported barriers were the lack of time and space, a lack of culture and leadership legitimizing ACP, lack of common communication systems, and unclear responsibility about who should initiate, resulting in missed opportunities and overtreatment. Policy development, public and professional education, and standardization of documentation were reported as key to facilitate ACP and build trust across the health care system. CONCLUSIONS Progressively changing the education of health professionals and the clinical culture are major efforts that need to be tackled to implement ACP in unfamiliarized contexts, particularly in contexts where patient's wishes are not legally binding. This will need to be tackled through rectifying the misconception that ACP is only about death, and providing practical training for health professionals, as well as developing policies and legislation on how to include patients and caregivers in the planning of care.
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Affiliation(s)
- Siri Færden Westbye
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, Postboks 1130, Blindern, 0318, Oslo, Norway.
| | - Siri Rostoft
- Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo University Hospital, Oslo, Norway
| | - Maria Romøren
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, Postboks 1130, Blindern, 0318, Oslo, Norway
| | - Lisbeth Thoresen
- Department for Interdisciplinary Health Sciences, Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Astrid Klopstad Wahl
- Department for Interdisciplinary Health Sciences, Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, Postboks 1130, Blindern, 0318, Oslo, Norway
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Brøderud L, Pedersen R, Magelssen M. Balancing burdens of infection control: Norwegian district medical officers' ethical challenges during the COVID-19 pandemic. BMC Health Serv Res 2023; 23:590. [PMID: 37286998 DOI: 10.1186/s12913-023-09573-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 05/17/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND In several countries, district medical officers (DMOs) are public health experts with duties including infection control measures. The Norwegian DMOs have been key actors in the local handling of the COVID-19 pandemic. METHODS The aim of the study was to explore the ethical challenges experienced by Norwegian DMOs during the COVID-19 pandemic, and how the DMOs have handled these challenges. 15 in-depth individual research interviews were performed and analyzed with a manifest approach. RESULTS Norwegian DMOs have had to handle a large range of significant ethical problems during the COVID-19 pandemic. Often, a common denominator has been the need to balance burdens of the contagion control measures for different individuals and groups. In another large set of issues, the challenge was to achieve a balance between safety understood as effective contagion prevention on the one hand, and freedom, autonomy and quality of life for the same individuals on the other. CONCLUSIONS The DMOs have a central role in the municipality's handling of the pandemic, and they wield significant influence. Thus, there is a need for support in decision-making, both from national authorities and regulations, and from discussions with colleagues.
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Affiliation(s)
- Linn Brøderud
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130 Blindern, Oslo, N-0318, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130 Blindern, Oslo, N-0318, Norway
| | - Morten Magelssen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130 Blindern, Oslo, N-0318, Norway.
- MF Norwegian School of Theology, Religion and Society Oslo, Oslo, Norway.
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Hestmark L, Romøren M, Hansson KM, Heiervang KS, Pedersen R. Clinicians' perceptions of family involvement in the treatment of persons with psychotic disorders: a nested qualitative study. Front Psychiatry 2023; 14:1175557. [PMID: 37293406 PMCID: PMC10244542 DOI: 10.3389/fpsyt.2023.1175557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/02/2023] [Indexed: 06/10/2023] Open
Abstract
Background Family involvement in mental health care ranges from basic practices to complex interventions such as Family psychoeducation, the latter being a well-documented treatment for psychotic disorders. The aim of this study was to explore clinicians' perceptions of the benefits and disadvantages of family involvement, including possible mediating factors and processes. Methods Nested in a randomised trial, which purpose was to implement Basic family involvement and support and Family psychoeducation in Norwegian community mental health centres during 2019-2020, this qualitative study is based on eight focus groups with implementation teams and five focus groups with ordinary clinicians. Using a purposive sampling strategy and semi-structured interview guides, focus groups were audio-recorded, transcribed verbatim, and analysed with reflexive thematic analysis. Results Four main themes were identified as perceived benefits: (1) Family psychoeducation-a concrete framework, (2) Reducing conflict and stress, (3) A triadic understanding, and (4) Being on the same team. Themes 2-4 formed an interconnected triad of mutually reinforcing elements and were further linked to three important clinician-facilitated sub-themes: a space for relatives' experiences, emotions and needs; a space for patients and relatives to discuss sensitive topics and an open line of communication between clinician and relative. Although far less frequent, three main themes were identified as perceived disadvantages or challenges: (1) Family psychoeducation-occasional poor model fit or difficulties following the framework, (2) Getting more involved than usual, and (3) Relatives as a potentially negative influence-important nonetheless. Conclusions The findings contribute to the understanding of the beneficial processes and outcomes of family involvement, as well as the critical role of the clinician in achieving these and possible challenges. They could also be used to inform future quantitative research on mediating factors and implementation efforts.
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Affiliation(s)
- Lars Hestmark
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Maria Romøren
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | | | - Kristin Sverdvik Heiervang
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
- Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
- Faculty of Health and Social Sciences, Center for Mental Health and Substance Abuse, University of South-Eastern Norway, Drammen, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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Hansson KM, Romøren M, Hestmark L, Heiervang KS, Weimand B, Norheim I, Pedersen R. "The most important thing is that those closest to you, understand you": a nested qualitative study of persons with psychotic disorders' experiences with family involvement. Front Psychiatry 2023; 14:1138394. [PMID: 37255680 PMCID: PMC10225600 DOI: 10.3389/fpsyt.2023.1138394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/18/2023] [Indexed: 06/01/2023] Open
Abstract
Introduction Family interventions constitute effective treatment for persons with psychotic disorders. However, the active ingredients and beneficial processes of these interventions are insufficiently examined, and qualitative explorations of patients` experiences are lacking. This study was nested in a cluster randomised trial that implemented national guidelines on family involvement in Norwegian community mental health centres, including family psychoeducation and basic family involvement and support. The aim of this sub-study was to explore how patients with psychotic disorders experience systematic family involvement, and its significance. Methods We conducted semi-structured, individual interviews with 13 persons with a psychotic disorder after systematic family involvement. The participants were recruited through purposive sampling. Qualitative content analysis guided the analysis. Results Participants reported overall positive experiences with systematic family involvement. It was significant that the relatives increasingly understood more about psychosis and their situation, while they themselves also gained more insight into the relatives` situation. The participants emphasised the need to enable both patients and relatives to safely share experiences in a containing space, led by professionals. Shared understanding and awareness of each other's situation further improved communication, coping with the illness, reduced stress, and stimulated a more caring family environment. The therapist seemed crucial to facilitate these beneficial communication processes, and also to provide continuous support to the relatives. Reported challenges included that the participants felt vulnerable in the initial phase, a need for tailored approaches, and too late start-up. Conclusion Findings from this study suggest that persons with psychotic disorders may benefit greatly from participating in systematic family involvement. This study also gives new insight into possible mediators of positive outcomes both for the patients and the relatives. Systematic family involvement should be implemented a standard approach in the early phase of the disease, using a step-wise and tailored process.
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Affiliation(s)
- Kristiane M. Hansson
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Maria Romøren
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Lars Hestmark
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Kristin Sverdvik Heiervang
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
- Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
- Center for Mental Health and Substance Abuse, Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
| | - Bente Weimand
- Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
- Center for Mental Health and Substance Abuse, Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
| | - Irene Norheim
- Division of Mental Health and Addiction, Vestre Viken Hospital Trust, Drammen, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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Molewijk B, Pedersen R, Kok A, Førde R, Aasland O. Two years of ethics reflection groups about coercion in psychiatry. Measuring variation within employees' normative attitudes, user involvement and the handling of disagreement. BMC Med Ethics 2023; 24:29. [PMID: 37173770 PMCID: PMC10182617 DOI: 10.1186/s12910-023-00909-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Research on the impact of ethics reflection groups (ERG) (also called moral case deliberations (MCD)) is complex and scarce. Within a larger study, two years of ERG sessions have been used as an intervention to stimulate ethical reflection about the use of coercive measures. We studied changes in: employees' attitudes regarding the use of coercion, team competence, user involvement, team cooperation and the handling of disagreement in teams. METHODS We used panel data in a longitudinal design study to measure variation in survey scores from multidisciplinary employees from seven departments within three Norwegian mental health care institutions at three time points (T0-T1-T2). Mixed models were used to account for dependence of data in persons who participated more than once. RESULTS In total, 1068 surveys (from 817 employees who did and did not participate in ERG) were included in the analyses. Of these, 7.6% (N = 62) responded at three points in time, 15.5% (N = 127) at two points, and 76.8% (N = 628) once. On average, over time, respondents who participated in ERG viewed coercion more strongly as offending (p < 0.05). Those who presented a case in the ERG sessions showed lower scores on User Involvement (p < 0.001), Team Cooperation (p < 0.01) and Constructive Disagreement (p < 0.01). We observed significant differences in outcomes between individuals from different departments, as well as between different professions. Initial significant changes due to frequency of participation in ERG and case presentation in ERG did not remain statistically significant after adjustment for Departments and Professions. Differences were generally small in absolute terms, possibly due to the low amount of longitudinal data. CONCLUSIONS This study measured specific intervention-related outcome parameters for describing the impact of clinical ethics support (CES). Structural implementation of ERGs or MCDs seems to contribute to employees reporting a more critical attitude towards coercion. Ethics support is a complex intervention and studying changes over time is complex in itself. Several recommendations for strengthening the outcomes of future CES evaluation studies are discussed. CES evaluation studies are important, since-despite the intrinsic value of participating in ERG or MCD-CES inherently aims, and should aim, at improving clinical practices.
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Affiliation(s)
- Bert Molewijk
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway.
- Department of Ethics, Law and Humanities, Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Almar Kok
- Department of Epidemiology and Data Science and Department of Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
- Aging and Later Life, Amsterdam Public Health Institute, Amsterdam, The Netherlands
| | - Reidun Førde
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Olaf Aasland
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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Hestmark L, Romøren M, Heiervang KS, Hansson KM, Ruud T, Šaltytė Benth J, Norheim I, Weimand B, Pedersen R. Implementation of Guidelines on Family Involvement for Persons with Psychotic Disorders (IFIP): A Cluster Randomised Controlled Trial. Adm Policy Ment Health 2023; 50:520-533. [PMID: 36797515 PMCID: PMC9934504 DOI: 10.1007/s10488-023-01255-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2023] [Indexed: 02/18/2023]
Abstract
Family involvement is part of the evidence-based treatment for persons with psychotic disorders, yet is under-implemented despite guideline recommendations. This study assessed whether an implementation support programme increased the adherence to guidelines on family involvement, compared to guideline/manual only. In a cluster randomised design, community mental health centre units in South-East Norway went through stratified allocation to the experimental (n = 7) or control (n = 7) arm. Experimental clusters received an implementation support programme including clinical training and supervision, appointing a family coordinator and an implementation team, a toolkit, and fidelity measurements at baseline, 12, 18, and 24 months with on-site feedback and supervision. Control clusters received no such support and had fidelity measurements at baseline and 24 months without feedback. During fidelity measurements, adherence to the guidelines was measured with the basic family involvement and support scale, the general organizational index, and the family psychoeducation fidelity scale, the latter being the primary outcome. The scales consist of 12-14 items rated from 1 to 5. Data was analysed with an independent samples t-test, linear mixed models, and a tobit regression model. At 24 months, the mean scores were 4.00 or higher on all scales in the experimental arm, and the increase in adherence to the guidelines was significantly greater than in the control arm with p-values < 0.001. Large-scale implementation of guidelines on family involvement for persons with psychotic disorders in community mental health centres may be accomplished, with substantial implementation support.Trial Registration: ClinicalTrials.gov Identifier NCT03869177. Registered 11.03.19.
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Affiliation(s)
- Lars Hestmark
- Centre for Medical Ethics, University of Oslo, Postbox 1130, Blindern, 0318, Oslo, Norway.
| | - Maria Romøren
- Centre for Medical Ethics, University of Oslo, Postbox 1130, Blindern, 0318, Oslo, Norway
| | - Kristin Sverdvik Heiervang
- Centre for Medical Ethics, University of Oslo, Postbox 1130, Blindern, 0318, Oslo, Norway
- Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
- Center for Mental Health and Substance Abuse, Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
| | | | - Torleif Ruud
- Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, Campus Ahus, University of Oslo , Oslo, Norway
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Irene Norheim
- Division of Mental Health and Addiction, Vestre Viken Hospital Trust, Lier, Norway
| | - Bente Weimand
- Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
- Center for Mental Health and Substance Abuse, Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
- Faculty of Health Sciences, OsloMet Oslo Metropolitan University, Oslo, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, University of Oslo, Postbox 1130, Blindern, 0318, Oslo, Norway
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Wikstøl D, Horn MA, Pedersen R, Magelssen M. Citizen attitudes to non-treatment decision making: a Norwegian survey. BMC Med Ethics 2023; 24:20. [PMID: 36890542 PMCID: PMC9993678 DOI: 10.1186/s12910-023-00900-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/03/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Decisions about appropriate treatment at the end of life are common in modern healthcare. Non-treatment decisions (NTDs), comprising both withdrawal and withholding of (potentially) life-prolonging treatment are in principle accepted in Norway. However, in practice they may give rise to significant moral problems for health professionals, patients and next of kin. Here, patient values must be considered. It is relevant to study the moral views and intuitions of the general population on NTDs and special areas of contention such as the role of next of kin in decision-making. METHODS Electronic survey to members of a nationally representative panel of Norwegian adults. Respondents were presented with vignettes describing patients with disorders of consciousness, dementia, and cancer where patient preferences varied. Respondents answered ten questions about the acceptability of non-treatment decision making and the role of next of kin. RESULTS We received 1035 complete responses (response rate 40.7%). A large majority, 88%, supported the right of competent patients to refuse treatment in general. When an NTD was in line with the patient's previously expressed preferences, more respondents tended to find NTDs acceptable. More respondents would accept NTDs for themselves than for the vignette patients. In a scenario with an incompetent patient, clear majorities wanted the views of next of kin to be given some but not decisive weight, and more weight if concordant with the patient's wishes. There were, however, large variations in the respondents' views. CONCLUSION This survey of a representative sample of the Norwegian adult population indicates that attitudes to NTDs are often in line with national laws and guidelines. However, the high variance among the respondents and relatively large weight given to next of kin's views, indicate a need for appropriate dialogue among all stakeholders to prevent conflicts and extra burdens. Furthermore, the emphasis given to previously expressed opinions indicates that advance care planning may increase the legitimacy of NTDs and prevent challenging decision-making processes.
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Affiliation(s)
- David Wikstøl
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130, 0318, Blindern, Oslo, Norway
| | | | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130, 0318, Blindern, Oslo, Norway
| | - Morten Magelssen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130, 0318, Blindern, Oslo, Norway. .,MF Norwegian School of Theology, Religion and Society, Oslo, Norway.
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13
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Hem MH, Molewijk B, Weimand B, Pedersen R. Patients with severe mental illness and the ethical challenges related to confidentiality during family involvement: A scoping review. Front Public Health 2023; 10:960815. [PMID: 36711422 PMCID: PMC9877517 DOI: 10.3389/fpubh.2022.960815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 12/20/2022] [Indexed: 01/13/2023] Open
Abstract
Background Despite evidence on the significant potential value of family involvement during the treatment of patients with severe mental illness, research has shown that family involvement is largely underused. The duty of confidentiality is reported to be a key barrier to family involvement. To develop more insight into this barrier, this scoping review focuses on the following question: What are the reported ethical challenges related to confidentiality when involving family in the treatment of patients with severe mental illness? Methods A systematic search into primary studies was conducted using the following databases: Medline (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), and Web of Science core collection (Clarivate). The PICO (Population, Intervention, Comparison, Outcome) scheme and qualitative content analysis were used to make the ethical challenges more explicit. Results Twelve studies-both qualitative and quantitative-were included. We identified the following main categories of ethical challenges: (1) the best interest of family members vs. confidentiality, (2) the patient's best interest vs. the right to confidentiality, (3) patient trust and alliance as a reason not to involve the relatives or not to share information, and (4) using confidentiality as a smokescreen. We also identified several subcategories and illustrative and concrete examples of ethical challenges. Conclusions Through a systematic examination, we discovered various types of ethical challenges related to confidentiality when involving the family in the treatment of patients with severe mental illness. However, research on these ethical challenges and the constituents of these challenges remains limited and often implicit. An ethical analysis will create knowledge which may facilitate a more balanced and nuanced approach to respecting the principle of confidentiality while also considering other moral principles. The duty of confidentiality does not always have to be a major barrier to family involvement; this insight and using this ethical analysis in the training of healthcare professionals may benefit the patient, the family, and the services.
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Affiliation(s)
- Marit Helene Hem
- Norwegian University of Science and Technology (NTNU) Social Research, Trondheim, Norway,Faculty of Health Studies, VID Specialized University, Oslo, Norway
| | - Bert Molewijk
- Centre for Medical Ethics, Faculty of Medicine, University of Oslo, Oslo, Norway,Department Ethics, Law and Humanities, Amsterdam University Medical Centre (UMC) and Vrije Universiteit, Amsterdam, Netherlands
| | - Bente Weimand
- University of South-Eastern Norway, Faculty of Health and Social Sciences, Drammen, Norway,Division Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, Faculty of Medicine, University of Oslo, Oslo, Norway,*Correspondence: Reidar Pedersen ✉
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14
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Nortvedt P, Røise O, Rostoft S, Pedersen R. Man bryr seg mindre jo mer man gjør det. Tidsskr Nor Laegeforen 2022; 142:22-0667. [PMID: 36511753 DOI: 10.4045/tidsskr.22.0667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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15
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Førde R, Pedersen R, Magelssen M. Etiske dilemmaer ved amyotrofisk lateral sklerose og respiratorbehandling. Tidsskriftet 2022; 142:22-0503. [DOI: 10.4045/tidsskr.22.0503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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16
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Hansson KM, Romøren M, Pedersen R, Weimand B, Hestmark L, Norheim I, Ruud T, Hymer IS, Heiervang KS. Barriers and facilitators when implementing family involvement for persons with psychotic disorders in community mental health centres - a nested qualitative study. BMC Health Serv Res 2022; 22:1153. [PMID: 36096844 PMCID: PMC9469513 DOI: 10.1186/s12913-022-08489-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 08/23/2022] [Indexed: 12/03/2022] Open
Abstract
Background The uptake of family involvement in health care services for patients with psychotic disorders is poor, despite a clear evidence base, socio-economic and moral justifications, policy, and guideline recommendations. To respond to this knowledge-practice gap, we established the cluster randomised controlled trial: Implementation of guidelines on Family Involvement for persons with Psychotic disorders in community mental health centres (IFIP). Nested in the IFIP trial, this sub-study aims to explore what organisational and clinical barriers and facilitators local implementation teams and clinicians experience when implementing family involvement in mental health care for persons with psychotic disorders. Methods We performed 21 semi-structured focus groups, including 75 participants in total. Implementation team members were interviewed at the initial and middle phases of the intervention period, while clinicians who were not in the implementation team were interviewed in the late phase. A purposive sampling approach was used to recruit participants with various engagement in the implementation process. Data were analysed using manifest content analysis. Results Organisational barriers to involvement included: 1) Lack of shared knowledge, perceptions, and practice 2) Lack of routines 3) Lack of resources and logistics. Clinical barriers included: 4) Patient-related factors 5) Relative-related factors 6) Provider-related factors. Organisational facilitators for involvement included: 1) Whole-ward approach 2) Appointed and dedicated roles 3) Standardisation and routines. Clinical facilitators included: 4) External implementation support 5) Understanding, skills, and self-efficacy among mental health professionals 6) Awareness and attitudes among mental health professionals. Conclusions Implementing family involvement in health care services for persons with psychotic disorders is possible through a whole-ward and multi-level approach, ensured by organisational- and leadership commitment. Providing training in family psychoeducation to all staff, establishing routines to offer a basic level of family involvement to all patients, and ensuring that clinicians get experience with family involvement, reduce or dissolve core barriers. Having access to external implementation support appears decisive to initiate, promote and evaluate implementation. Our findings also point to future policy, practice and implementation developments to offer adequate treatment and support to all patients with severe mental illness and their families. Trial registration ClinicalTrials.gov Identifier NCT03869177. Registered 11.03.19. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08489-y.
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Affiliation(s)
| | - Maria Romøren
- Centre for Medical Ethics, University of Oslo, Postbox 1130 Blindern, 0318, Oslo, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, University of Oslo, Postbox 1130 Blindern, 0318, Oslo, Norway
| | - Bente Weimand
- Division of Mental Health Services, Akershus University Hospital, Sykehusveien 25, 1474, Nordbyhagen, Norway.,Center for Mental Health and Substance Abuse, Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway.,Faculty of Health Sciences, OsloMet Oslo Metropolitan University, Oslo, Norway
| | - Lars Hestmark
- Centre for Medical Ethics, University of Oslo, Postbox 1130 Blindern, 0318, Oslo, Norway
| | - Irene Norheim
- Division of Mental Health and Addiction, Vestre Viken Hospital Trust, Drammen, Norway
| | - Torleif Ruud
- Division of Mental Health Services, Akershus University Hospital, Sykehusveien 25, 1474, Nordbyhagen, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Inger Stølan Hymer
- Early Intervention in Psychosis Advisory Unit for South East Norway, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Kristin Sverdvik Heiervang
- Centre for Medical Ethics, University of Oslo, Postbox 1130 Blindern, 0318, Oslo, Norway.,Division of Mental Health Services, Akershus University Hospital, Sykehusveien 25, 1474, Nordbyhagen, Norway.,Center for Mental Health and Substance Abuse, Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
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17
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Husum TL, Pedersen R, Aasland O. Frequent Violations and Infringements against Users in Mental Health Care Confirmed by Both Users and Professionals - A Quantitative Study. Issues Ment Health Nurs 2022; 43:862-869. [PMID: 35452344 DOI: 10.1080/01612840.2022.2063461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The main task of mental health care services is to provide good quality of care. Despite this, users are sometimes treated badly by staff. The purpose of this study was to investigate violations and infringements towards users in mental health care services, from the perspectives of both staff and users. Data were gathered through an anonymous online questionnaire sent to staff and users in Norway. Staff were recruited in collaboration with professional organisations and users in collaboration with user-organisations.
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Affiliation(s)
- Tonje Lossius Husum
- Centre for Medical Ethics, University of Oslo, Norway.,Oslo Metropolitan University, Oslo, Norway
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18
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Brodahl KØ, Storøy HLE, Finset A, Pedersen R. The first steps towards professional distance: A sequential analysis of students' interactions with patients expressing emotional issues in medical interviews. Patient Educ Couns 2022; 105:1237-1243. [PMID: 34949468 DOI: 10.1016/j.pec.2021.09.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/08/2021] [Accepted: 09/14/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Explore sequential patterns in students' interactions with patients expressing emotional concerns in a medical interview. METHODS Concepts and principles from conversation analysis (CA) were used to examine the turn-by-turn sequential organization of student actions in eleven video-taped medical interviews. We used results from an earlier coding with an interaction analysis system (VR-CoDES) in a previously published paper as a point of reference. RESULTS By using CA instead of VR-CoDES as our primary investigative method we observed that student turns previously coded as elicitations to simulated patients' expressions of emotion were often preceded by subtle patient initiatives. Students encouraged further elaboration by displaying their understanding of the emotional issue as a story telling still in progress. Students' expressions of understanding however, gave little room for further elaboration. Finally, students often addressed emotional issues as a medical issue and offered professional advice. CONCLUSIONS Students' actions seemed specifically designed to display interest in the patients' initiatives to talk about emotional experiences without departing from their initial interview task or violating norms for professional conduct. PRACTICE IMPLICATIONS Educators and practitioners should reconsider how the medical interview may shape expectations for professional conduct and can thereby unintentionally restrict students' empathy development.
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Affiliation(s)
| | | | - Arnstein Finset
- Department of Behavioral Sciences in Medicine, University of Oslo, Oslo, Norway
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19
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Valika A, Pedersen R, Sulemanjee N. Reduction in 90 Day Readmission Rates with Ambulatory Pulmonary Artery Pressure Monitoring. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Brodahl KØ, Storøy HLE, Finset A, Pedersen R. Medical students' experiences when empathizing with patients' emotional issues during a medical interview - a qualitative study. BMC Med Educ 2022; 22:145. [PMID: 35246126 PMCID: PMC8895666 DOI: 10.1186/s12909-022-03199-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 02/07/2022] [Indexed: 05/09/2023]
Abstract
BACKGROUND There is evidence that empathy decreases as medical students go through clinical training. However, there are few in-depth studies investigating the students' own experiences when trying to empathize in concrete clinical encounters. We therefore wanted to explore medical students' perceptions, experiences, and reflections when empathizing with patients expressing emotional issues. METHODS A qualitative content analysis of semi-structured interviews with third year medical students (N = 11) was conducted using video-stimulated recall from their own medical interview with a simulated chronically ill patient. Students were led to believe that the patient was real. RESULTS Five themes which may influence student empathy during history-taking were identified through analysis of interview data: (1) Giving priority to medical history taking, (2) Interpreting the patient's worry as lack of medical information, (3) Conflict between perspectives, (4) Technical communication skill rather than authentic and heart-felt and (5) The distant professional role. CONCLUSIONS The participating students described conflicts between a medical agenda, rules and norms for professional conduct and the students' own judgments when trying to empathize with the patient. To our knowledge, this is the first study ever to document the students' own perspective in concrete situations as well as how these reported experiences and reflections affect their empathy towards patients. Since we now know more about what is likely to hinder medical students' empathy, educators should actively encourage group reflection and discussion in order to avoid these negative effects of history taking both inside and outside of the clinical setting.
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Affiliation(s)
- Knut Ørnes Brodahl
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166, Fredrik Holsts hus, 0450, Oslo, Norway.
| | | | - Arnstein Finset
- Department of Behavioral Sciences in Medicine, University of Oslo, Oslo, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166, Fredrik Holsts hus, 0450, Oslo, Norway
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Brodahl KØ, Finset A, Storøy HLE, Pedersen R. Medical students' expressions of empathy: A qualitative study of verbal interactions with patients expressing emotional issues in a medical interview. Patient Educ Couns 2021; 104:2936-2943. [PMID: 34275669 DOI: 10.1016/j.pec.2021.03.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 03/10/2021] [Accepted: 03/17/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Explore medical students' verbal responses to patients expressing emotional issues in a medical interview. METHODS Eleven third-year students were instructed to conduct a medical interview with a simulated chronically ill patient while being videotaped (but were led to believe that the patient was real). An interaction analysis system (VR-CoDES) was used to identify patient utterances containing emotional expressions as well as student utterances responding to these emotional expressions. A qualitative content analysis of student utterances was then conducted. RESULTS Four categories that depicted student responses were identified: (1) questions focusing on a medico-professional agenda, (2) allowing disclosure of emotions without explicit acknowledgment of emotions, (3) attempts at reassurance, and (4) explicit recognition of emotions, but most often on a factual and descriptive level. CONCLUSIONS Our analysis indicate that these students gave priority to medico-professional tasks and responsibilities in their responses. They demonstrated some interest in the patient's emotional experiences whilst most often leaving out their own personal perspectives. PRACTICE IMPLICATIONS Communication skills curricula should address how the medical interview affects empathy and interaction with patients and encourage discussion and reflection on how to retrieve medical information while paying adequate attention to the patient's and own emotions, experiences, and perspectives.
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Affiliation(s)
| | - Arnstein Finset
- Department of Behavioral Medicine, University of Oslo, Oslo, Norway
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22
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Sævareid TJL, Pedersen R, Magelssen M. Positive attitudes to advance care planning - a Norwegian general population survey. BMC Health Serv Res 2021; 21:762. [PMID: 34334131 PMCID: PMC8327435 DOI: 10.1186/s12913-021-06773-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 07/19/2021] [Indexed: 12/02/2022] Open
Abstract
Background Authorities recommend advance care planning and public acceptance of it is a prerequisite for widespread implementation. Therefore, we did the first study of the Norwegian public with an aim of getting knowledge on their attitudes to issues related to advance care planning. Methods An electronic survey to a nationally representative web panel of Norwegian adults. Results From 1035 complete responses (response rate 40.7%), we found that more than nine out of ten of the general public wanted to participate in advance care planning, believed it to be useful for many, and wanted to make important healthcare decisions themselves. Almost nine out of ten wanted to be accompanied by next of kin during advance care planning. Most (69%) wanted health care personnel to initiate advance care planning and preferred it to be timed to serious illness with limited lifetime (68%). Only about 9% stated that health care personnel should have the final say in healthcare decisions in serious illness. Conclusions Developing and implementing advance care planning as a public health initiative seems warranted based on the results of this study. Patient perspectives should be promoted in decision-making processes. Nevertheless, training of health care personnel should emphasise voluntariness and an individual approach to initiating, timing and conducting advance care planning because of individual variations.
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Affiliation(s)
| | - Reidar Pedersen
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166, Frederik Holsts hus, 0450, Oslo, Norway
| | - Morten Magelssen
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166, Frederik Holsts hus, 0450, Oslo, Norway
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Jorem J, Dahlberg J, Pedersen R. J. Jorem and colleagues respond. Tidsskr Nor Laegeforen 2021; 141:21-0400. [PMID: 34107663 DOI: 10.4045/tidsskr.21.0400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Hestmark L, Heiervang KS, Pedersen R, Hansson KM, Ruud T, Romøren M. Family involvement practices for persons with psychotic disorders in community mental health centres - a cross-sectional fidelity-based study. BMC Psychiatry 2021; 21:285. [PMID: 34078306 PMCID: PMC8170939 DOI: 10.1186/s12888-021-03300-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 05/17/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Family involvement for persons with psychotic disorders is supported by scientific evidence, as well as legal and ethical considerations, and recommended in clinical practice guidelines. This article reports a cross-sectional measurement of the level of implementation of such guidelines in fifteen community mental health centre units in Norway, and presents a novel fidelity scale to measure basic family involvement and support. The aim was to investigate current family involvement practices comprehensively, as a basis for targeted quality improvement. METHODS We employed three fidelity scales, with 12-14 items, to measure family involvement practices. Items were scored from 1 to 5, where 1 equals no implementation and 5 equals full implementation. Data was analysed using descriptive statistics, a non-parametric test, and calculation of interrater reliability for the scales. RESULTS The mean score was 2.33 on the fidelity scale measuring basic family involvement and support. Among patients with psychotic disorders, only 4% had received family psychoeducation. On the family psychoeducation fidelity assessment scale, measuring practice and content, the mean score was 2.78. Among the eight units who offered family psychoeducation, it was 4.34. On the general organizational index scale, measuring the organisation and implementation of family psychoeducation, the mean score was 1.78. Among the units who offered family psychoeducation, it was 2.46. As a measure of interrater reliability, the intra-class correlation coefficient was 0.99 for the basic family involvement and support scale, 0.93 for the family psychoeducation fidelity assessment scale and 0.96 for the general organizational index scale. CONCLUSIONS The implementation level of the national guidelines on family involvement for persons with psychotic disorders was generally poor. The quality of family psychoeducation was high, but few patients had received this evidence-based treatment. Our novel fidelity scale shows promising psychometric properties and may prove a useful tool to improve the quality of health services. There is a need to increase the implementation of family involvement practices in Norway, to reach a larger percentage of patients and relatives. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT03869177 . Registered 11.03.19.
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Affiliation(s)
- Lars Hestmark
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Fredrik Holsts hus, 0450, Oslo, Norway.
| | - Kristin Sverdvik Heiervang
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Fredrik Holsts hus, 0450, Oslo, Norway
- Division of Mental Health Services, Akershus University Hospital, Sykehusveien 25, 1474, Nordbyhagen, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Fredrik Holsts hus, 0450, Oslo, Norway
| | | | - Torleif Ruud
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Fredrik Holsts hus, 0450, Oslo, Norway
- Division of Mental Health Services, Akershus University Hospital, Sykehusveien 25, 1474, Nordbyhagen, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Maria Romøren
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Fredrik Holsts hus, 0450, Oslo, Norway
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Jorem J, Dahlberg J, Pedersen R. Vaccination without consent – best for the people or the patient? Tidsskr Nor Laegeforen 2021; 141:21-0220. [PMID: 33876610 DOI: 10.4045/tidsskr.21.0220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Solbakk JH, Bentzen HB, Holm S, Heggestad AKT, Hofmann B, Robertsen A, Alnæs AH, Cox S, Pedersen R, Bernabe R. Back to WHAT? The role of research ethics in pandemic times. Med Health Care Philos 2021; 24:3-20. [PMID: 33141289 PMCID: PMC7607543 DOI: 10.1007/s11019-020-09984-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 05/06/2023]
Abstract
The Covid-19 pandemic creates an unprecedented threatening situation worldwide with an urgent need for critical reflection and new knowledge production, but also a need for imminent action despite prevailing knowledge gaps and multilevel uncertainty. With regard to the role of research ethics in these pandemic times some argue in favor of exceptionalism, others, including the authors of this paper, emphasize the urgent need to remain committed to core ethical principles and fundamental human rights obligations all reflected in research regulations and guidelines carefully crafted over time. In this paper we disentangle some of the arguments put forward in the ongoing debate about Covid-19 human challenge studies (CHIs) and the concomitant role of health-related research ethics in pandemic times. We suggest it might be helpful to think through a lens differentiating between risk, strict uncertainty and ignorance. We provide some examples of lessons learned by harm done in the name of research in the past and discuss the relevance of this legacy in the current situation.
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Affiliation(s)
- Jan Helge Solbakk
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Blindern, Box 1130, 0318, Oslo, Norway.
| | - Heidi Beate Bentzen
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Blindern, Box 1130, 0318, Oslo, Norway
- Faculty of Law, Norwegian Research Center for Computers and Law, University of Oslo, Oslo, Norway
| | - Søren Holm
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Blindern, Box 1130, 0318, Oslo, Norway
- Department of Law, School of Social Science, Centre for Social Ethics and Policy, University of Manchester, Manchester, UK
| | - Anne Kari Tolo Heggestad
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Blindern, Box 1130, 0318, Oslo, Norway
- Faculty of Health Studies, VID Specialized University, Oslo, Bergen, Stavanger and Sandnes, Norway
| | - Bjørn Hofmann
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Blindern, Box 1130, 0318, Oslo, Norway
- Department of Health Sciences, The Norwegian University for Science and Technology, Gjøvik, Norway
| | - Annette Robertsen
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Blindern, Box 1130, 0318, Oslo, Norway
- Division of Emergencies and Critical Care, Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway
- Department of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anne Hambro Alnæs
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Blindern, Box 1130, 0318, Oslo, Norway
| | - Shereen Cox
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Blindern, Box 1130, 0318, Oslo, Norway
| | - Reidar Pedersen
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Blindern, Box 1130, 0318, Oslo, Norway
| | - Rose Bernabe
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Blindern, Box 1130, 0318, Oslo, Norway
- The Faculty of Health and Social Sciences, University of Southeastern Norway, Kongsberg, Norway
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Wikstøl D, Pedersen R, Magelssen M. Public attitudes and health law in conflict: somatic vs. mental care, role of next of kin, and the right to refuse treatment and information. BMC Health Serv Res 2021; 21:3. [PMID: 33390168 PMCID: PMC7780687 DOI: 10.1186/s12913-020-05990-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 12/01/2020] [Indexed: 11/26/2022] Open
Abstract
Background Norwegian law and regulations regarding patient autonomy and the use of coercion are in conflict with the Convention on the Rights of Persons with Disabilities (CRPD) and the Oviedo Convention on several points. A new law concerning the use of coercion in Norwegian health services has been proposed. In this study we wanted to investigate the attitudes of the Norwegian lay populace with regards to some of these points of conflict. Methods An electronic questionnaire with 9 propositions about patient autonomy, the use of coercion, the role of next of kin, and equality of rights and regulations across somatic and mental health care was completed by 1617 Norwegian adults (response rate 8.5%). Results A majority of respondents support the patient’s right to refuse treatment and information in serious illness, that previously expressed treatment preferences should be respected, that next of kin’s right to information and authority in clinical decision-making should be strengthened, and that this kind of legal regulations should be equal across somatic and mental health care. Conclusions The findings in this study suggest that the opinions of the Norwegian lay populace are in conflict with the national law on several points relating to patient autonomy, the role of next of kin and use of coercive measures, and different legal regulation of somatic vs. mental health care. The study suggests that the populace is more in line with the CRPD, which supports equal rights across somatic and mental health care, and the Oviedo Convention, which does not allow for the same degree of strong paternalism regarding coercive measures as the current Norwegian law. This can be taken to support the recently proposed legislation on the use and limitation of coercion in Norwegian health services. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-05990-0.
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Affiliation(s)
- David Wikstøl
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130 Blindern, N-0318, Oslo, Norway.
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130 Blindern, N-0318, Oslo, Norway
| | - Morten Magelssen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130 Blindern, N-0318, Oslo, Norway
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Abstract
Because of the transfer of responsibility from hospitals to community-based settings, providers in home-based care have more responsibilities and a wider range of tasks and responsibilities than before, often with limited resources. The increased responsibilities and the complexity of tasks and patient groups may lead to several ethical challenges. A systematic search in the databases MEDLINE, CINAHL, and SveMed+ was carried out in February 2019 and August 2020. The research question was translated into a modified PICO (Population, Intervention, Comparison, and Outcome) worksheet. A total of 40 articles were included. The review is conducted according to the Vancouver Protocol. The main findings from the systematic literature review show that ethical challenges experienced by healthcare and social care providers in home-based care are related to autonomy and balancing ethical principles, decisions regarding intensity of care, challenges related to priority settings, truth-telling, and balancing the professional role. Findings regarding ethical challenges within home-based care are in line with findings from institutional healthcare and social care settings. However, some significant differences from the institutional context are also highlighted.
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Larsen BH, Magelssen M, Dunlop O, Pedersen R, Førde R. Ethical dilemmas in hospitals during the COVID-19 pandemic. Tidsskr Nor Laegeforen 2020; 140:20-0851. [PMID: 33322868 DOI: 10.4045/tidsskr.20.0851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Saevareid TJL, Pedersen R, Thoresen L. Nursing home residents with cognitive impairment can participate in advance care planning: A qualitative study. J Adv Nurs 2020; 77:879-888. [PMID: 33230934 DOI: 10.1111/jan.14661] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 09/16/2020] [Accepted: 11/03/2020] [Indexed: 01/23/2023]
Abstract
AIMS To describe advance care planning in nursing homes when residents with cognitive impairment and/or their next of kin participated and identify associated challenges. DESIGN A qualitative study of nine advance care planning conversations in four Norwegian nursing home wards. During the implementation of advance care planning, we purposively sampled residents with cognitive impairment, their next of kin and healthcare personnel. The implementation followed a "whole-ward" approach aimed at involving the whole ward in fostering an inclusive, holistic advance care planning discussion. Involving as many residents as possible, preferably together with their next of kin, were central. METHODS From observed and audio-recorded advance care planning conversations that took place from November 2015 to June 2016, we conducted a thematic analysis of the transcripts and field notes. Reporting adhered to the COREQ guidelines. RESULTS Residents actively relayed their preferences regarding healthcare and end-of-life issues, despite the cognitive impairment. Next of kin provided constructive support and conversations were largely resident-focused. However, involving residents was also challenging, findings included: residents' preferences were often vague, relevant medical information from healthcare personnel lacked and the next of kin were sometimes unaware of the resident's previously held preferences. Moreover, residents tended to focus more on the past and present than the future end-of-life care. CONCLUSIONS Residents with cognitive impairment can participate actively and meaningfully in advance care planning, if the healthcare personnel actively listens. However, several challenges can arise. Supported decision-making can improve communication and resident involvement, reinforcing a relational understanding of autonomy. IMPACT Persons with cognitive impairment should be invited to participate in advance care planning. Their participation may make its benefits and more person-centred care attainable to persons that are often not involved. Successful involvement of persons with cognitive impairment in advance care planning may rely on robust implementation.
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Affiliation(s)
| | | | - Lisbeth Thoresen
- Centre for Medical Ethics, University of Oslo, Oslo, Norway.,Department of Interdisciplinary Health Sciences, University of Oslo, Oslo, Norway
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Hestmark L, Romøren M, Heiervang KS, Weimand B, Ruud T, Norvoll R, Hansson KM, Norheim I, Aas E, Landeweer EGM, Pedersen R. Implementation of guidelines on family involvement for persons with psychotic disorders in community mental health centres (IFIP): protocol for a cluster randomised controlled trial. BMC Health Serv Res 2020; 20:934. [PMID: 33036605 PMCID: PMC7547488 DOI: 10.1186/s12913-020-05792-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 10/01/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Family involvement for persons with psychotic disorders is under-implemented in mental health care, despite its firm scientific, economic, legal and moral basis. This appears to be the case in Norway, despite the presence of national guidelines providing both general recommendations on family involvement and support in the health- and care services, and specific guidance on family interventions for patients with psychotic disorders. The aim of this project is to improve mental health services and the psychosocial health of persons with psychotic disorders and their relatives, by implementing selected recommendations from the national guidelines in community mental health centres, and to evaluate this process. METHODS The trial is cluster randomised, where 14 outpatient clusters from community mental health centres undergo stratified randomisation with an allocation ratio of 1:1. The seven intervention clusters will receive implementation support for 18 months, whereas the control clusters will receive the same support after this implementation period. The intervention consists of: 1. A basic level of family involvement and support. 2. Family psychoeducation in single-family groups. 3. Training and guidance of health care personnel. 4. A family coordinator and 5. Other implementation measures. Fidelity to the intervention will be measured four times in the intervention arm and two times in the control arm, and the differences in fidelity changes between the arms constitute the primary outcomes. In each arm, we aim to include 161 patients with psychotic disorders and their closest relative to fill in questionnaires at inclusion, 6 months and 12 months, measuring psychosocial health and satisfaction with services. Clinicians will contribute clinical data about patients at inclusion and 12 months. Use of health and welfare services and work participation, for both patients and relatives, will be retrieved from national registries. We will also perform qualitative interviews with patients, relatives, health care personnel and leaders. Finally, we will conduct a cost-effectiveness analysis and a political economy analysis. DISCUSSION This project, with its multilevel and mixed methods approach, may contribute valuable knowledge to the fields of family involvement, mental health service research and implementation science. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT03869177 . Registered 11.03.19.
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Affiliation(s)
- Lars Hestmark
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Fredrik Holsts hus, 0450, Oslo, Norway.
| | - Maria Romøren
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Fredrik Holsts hus, 0450, Oslo, Norway
| | - Kristin Sverdvik Heiervang
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Fredrik Holsts hus, 0450, Oslo, Norway
- Division of Mental Health Services, Akershus University Hospital, Sykehusveien 25, 1474, Nordbyhagen, Norway
| | - Bente Weimand
- Division of Mental Health Services, Akershus University Hospital, Sykehusveien 25, 1474, Nordbyhagen, Norway
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
- School of Nursing and Midwifery, Queens University, Belfast, Northern Ireland
| | - Torleif Ruud
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Fredrik Holsts hus, 0450, Oslo, Norway
- Division of Mental Health Services, Akershus University Hospital, Sykehusveien 25, 1474, Nordbyhagen, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Reidun Norvoll
- Work Research Institute, Oslo Metropolitan University, Oslo, Norway
| | | | - Irene Norheim
- Division of Mental Health and Addiction, Vestre Viken Hospital Trust, Lier, Norway
| | - Eline Aas
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Elisabeth Geke Marjan Landeweer
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Fredrik Holsts hus, 0450, Oslo, Norway
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Reidar Pedersen
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Fredrik Holsts hus, 0450, Oslo, Norway
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Magelssen M, Karlsen H, Pedersen R, Thoresen L. Implementing clinical ethics committees as a complex intervention: presentation of a feasibility study in community care. BMC Med Ethics 2020; 21:82. [PMID: 32873310 PMCID: PMC7466831 DOI: 10.1186/s12910-020-00522-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/18/2020] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Morten Magelssen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130 Blindern, N-0318, Oslo, Norway.
| | - Heidi Karlsen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130 Blindern, N-0318, Oslo, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130 Blindern, N-0318, Oslo, Norway
| | - Lisbeth Thoresen
- Department of Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
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Rostoft S, van den Bos F, Pedersen R, Hamaker ME. Shared decision-making in older patients with cancer - What does the patient want? J Geriatr Oncol 2020; 12:339-342. [PMID: 32839118 DOI: 10.1016/j.jgo.2020.08.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/06/2020] [Accepted: 08/10/2020] [Indexed: 11/28/2022]
Abstract
Shared decision-making in cancer care, where we move away from the paternalistic "the doctor knows best" attitude to involving the patient in decisions regarding her or his health, is now universally accepted in western societies. However, in many situations this is easier said than done. For instance, if the interaction with the patient is not performed in a skillful manner, shared decision-making can make the patient feel unsafe - shouldn't the specialist know how to treat a serious disease such as cancer? Why would the doctor ask the patient about this? In other cases, what the patient wants in unrealistic, for example a severely frail patient aged 85 years with more than one life-limiting comorbidity who is diagnosed with an advanced cancer and has a goal of living to be at least 100 years. And what does a patient with advanced dementia want in the context of a cancer disease? In this perspectives piece, we will describe different scenarios that may arise within geriatric oncology and shared decision-making, make recommendations about how to handle such situations, and provide some food for thought.
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Affiliation(s)
- Siri Rostoft
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Frederiek van den Bos
- Department of Geriatric Medicine, University Medical Centre Utrecht, the Netherlands
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute for Health and Society, The Medical Faculty, University of Oslo, Oslo, Norway
| | - Marije E Hamaker
- Department of Geriatric Medicine, Diakonessenhuis Utrecht, the Netherlands
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Husum TL, Thorvarsdottir V, Aasland O, Pedersen R. 'It comes with the territory' - Staff experience with violation and humiliation in mental health care - A mixed method study. Int J Law Psychiatry 2020; 71:101610. [PMID: 32768105 DOI: 10.1016/j.ijlp.2020.101610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND The aim of this study was to investigate staff's experiences with violation and humiliation during work in mental health care (MHC). A total of 1160 multi-professional MHC staff in Norway responded to an online questionnaire about their experiences with different kinds of violation and humiliation in the MHC setting. In addition, a sample of professionals (eight MHC nurses) were recruited for in-depth individual interviews. METHOD The study used an explorative mixed method with a convergent parallel design; this included a web-based questionnaire to MHC staff in combination with individual interviews. The sample is considered to be equivalent to staff groups in MHC in Norway. RESULTS Between 70 and 80% of the staff reported experiencing rejection, being treated with disrespect, condescending behaviour or verbal harassment. Male workers were significantly more often victims of serious physical violence, and women were significantly more often targets for sexual harassment. In interviews, participants said they considered being exposed to violence and humiliation to be part of the job when working in MHC, and that experience, as well as social support from colleagues, helped MHC practitioners to cope better with violent situations and feel less humiliated at work. DISCUSSION A high amount of MHC staff report experiences of being violated and humiliated during work. The participants' perceptions of the users and their behaviour seem to influence their experience of feeling violated and humiliated. Knowledge about the dynamics of aggression between staff and users in MHC may be used in safeguarding staff and users, prevent coercion and heighten the quality of care.
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Affiliation(s)
| | | | - Olaf Aasland
- Centre for Medical Ethics, University of Oslo, Norway
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Affiliation(s)
| | - Reidun Førde
- Senter for medisinsk etikk, Universitetet i Oslo
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Stolper M, Pedersen R, Molewijk B. Examining the Doing of Ethics Support Staff. A Dialogical Approach Toward Assessing the Quality of Facilitators of Moral Case Deliberation. Am J Bioeth 2020; 20:42-44. [PMID: 32116179 DOI: 10.1080/15265161.2020.1714805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Magelssen M, Pedersen R, Miljeteig I, Ervik H, Førde R. Importance of systematic deliberation and stakeholder presence: a national study of clinical ethics committees. J Med Ethics 2020; 46:66-70. [PMID: 31488518 DOI: 10.1136/medethics-2018-105190] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 03/29/2019] [Accepted: 08/25/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Case consultation performed by clinical ethics committees (CECs) is a complex activity which should be evaluated. Several evaluation studies have reported stakeholder satisfaction in single institutions. The present study was conducted nationwide and compares clinicians' evaluations on a range of aspects with the CEC's own evaluation. METHODS Prospective questionnaire study involving case consultations at 19 Norwegian CECs for 1 year, where consultations were evaluated by CECs and clinicians who had participated. RESULTS Evaluations of 64 case consultations were received. Cases were complex with multiple ethical problems intertwined. Clinicians rated the average CEC consult highly, being both satisfied with the process and perceiving it to be useful across a number of aspects. CEC evaluations corresponded well with those of clinicians in a large majority of cases. Having next of kin/patients present was experienced as predominantly positive, though practised by only half of the CECs. The educational function of the consult was evaluated more positively when the CEC used a systematic deliberation method. CONCLUSIONS CEC case consultation was found to be a useful service. The study is also a favourable evaluation of the Norwegian CEC system, implying that it is feasible to implement well-functioning CECs on a large scale. There are good reasons to involve the stakeholders in the consultations as a main rule.
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Affiliation(s)
| | | | - Ingrid Miljeteig
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
- Bergen Center for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Håvard Ervik
- Clinical Ethics Committee, Møre og Romsdal Hospital Trust, Ålesund, Norway
| | - Reidun Førde
- Centre for Medical Ethics, University of Oslo, Oslo, Norway
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Thoresen L, Pedersen R, Lillemoen L, Gjerberg E, Førde R. Advance care planning in Norwegian nursing homes - limited awareness of the residents' preferences and values? A qualitative study. BMC Geriatr 2019; 19:363. [PMID: 31870302 PMCID: PMC6929496 DOI: 10.1186/s12877-019-1378-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 12/08/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND 52% of all deaths in Norway occur in nursing homes. Still advance care planning (ACP) is scarce and heterogeneous. To improve the implementation and practice of ACP in nursing homes, knowledge about health care professionals' views on ACP is vital. The objective of this study is to explore nurses and physicians' aims and experiences with carrying out ACP in nursing homes. METHODS Semi-structured group interviews were conducted with 20 health care professionals, recruited from nursing homes where ACP was performed regularly. Qualitative content analysis was used to analyse the data. RESULTS The primary aim of the nursing home professionals when doing ACP in nursing homes were to build alliances with next of kin to avoid misunderstandings and future conflicts. Two main experiences with ACP were described: i) due to the sensitivity of ACP issues, it was important to balance directness with being sensitive, and ii) when the physicians raised questions concerning future medical treatment, the answers from residents as well as next of kin were often hesitant and unclear. CONCLUSION Our study add insights into how ACP is practiced in nursing homes and the professionals' agenda. A focus on medical issues and achieving consensus with next of kin may result in lack of involvement of the residents and limited awareness of the residents' needs. Interdisciplinary approaches, ACP-training and tailored guidelines may improve the implementation and practice of ACP.
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Affiliation(s)
- Lisbeth Thoresen
- Department of Interdisciplinary Health Sciences, Harald Schjelderups hus Forskningsveien 3a/2b, Post Box 1089, 0373, Oslo, Norway.
| | | | | | | | - Reidun Førde
- Centre for Medical Ethics, University of Oslo, Oslo, Norway
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Sævareid TJL, Thoresen L, Gjerberg E, Lillemoen L, Pedersen R. Improved patient participation through advance care planning in nursing homes-A cluster randomized clinical trial. Patient Educ Couns 2019; 102:2183-2191. [PMID: 31200952 DOI: 10.1016/j.pec.2019.06.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 05/29/2019] [Accepted: 06/03/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To improve patient participation in advance care planning in nursing homes where most patients have some degree of cognitive impairment. METHODS This was a pair-matched cluster randomized clinical trial with eight wards in eight Norwegian nursing homes. We randomized one ward from each of the matched pairs to the intervention group. We included all patients above 70. The primary outcome was prevalence of documented patient participation in end-of-life treatment conversations. The intervention included implementation support using a whole-ward approach where regular staff perform advance care planning and invite all patients and next of kin to participate. RESULTS In intervention group wards the patients participated more often in end-of-life treatment conversations (p < 0.001). Moreover, the patient's preferences, hopes AND worries (p = 0,006) were more often documented, and concordance between provided TREATMENT and patient preferences (p = 0,037) and next of kin participation in advance care planning with the patient (p = 0,056) increased. CONCLUSION Improved patient participation - also when cognitively impaired - is achievable through advance care planning in nursing homes using a whole-ward approach. PRACTICE IMPLICATIONS Patients with cognitive impairment should be included in advance care planning supported by next of kin. A whole-ward approach may be used to implement advance care planning. TRIAL REGISTRATION ISRCTN registry (ID ISRCTN69571462) - retrospectively registered.
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Affiliation(s)
- Trygve J L Sævareid
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Frederik Holsts hus, 0450, Oslo, Norway.
| | - Lisbeth Thoresen
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Frederik Holsts hus, 0450, Oslo, Norway; Department of Health Sciences, University of Oslo, Forskningsveien 3A Harald Schjelderups hus, 0373, Oslo, Norway.
| | - Elisabeth Gjerberg
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Frederik Holsts hus, 0450, Oslo, Norway.
| | - Lillian Lillemoen
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Frederik Holsts hus, 0450, Oslo, Norway.
| | - Reidar Pedersen
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Frederik Holsts hus, 0450, Oslo, Norway.
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Bruun H, Huniche L, Stenager E, Mogensen CB, Pedersen R. Hospital ethics reflection groups: a learning and development resource for clinical practice. BMC Med Ethics 2019; 20:75. [PMID: 31651308 PMCID: PMC6813973 DOI: 10.1186/s12910-019-0415-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 10/09/2019] [Indexed: 11/13/2022] Open
Abstract
Background An ethics reflection group (ERG) is one of a number of ethics support services developed to better handle ethical challenges in healthcare. The aim of this article is to evaluate the significance of ERGs in psychiatric and general hospital departments in Denmark. Methods This is a qualitative action research study, including systematic text condensation of 28 individual interviews and 4 focus groups with clinicians, ethics facilitators and ward managers. Short written descriptions of the ethical challenges presented in the ERGs also informed the analysis of significance. Results A recurring ethical challenge for clinicians, in a total of 63 cases described and assessed in 3 ethical reflection groups, is to strike a balance between respect for patient autonomy, paternalistic responsibility, professional responsibilities and institutional values. Both in psychiatric and general hospital departments, the study participants report a positive impact of ERG, which can be divided into three categories: 1) Significance for patients, 2) Significance for clinicians, and 3) Significance for ward managers. In wards characterized by short-time patient admissions, the cases assessed were retrospective and the beneficiaries of improved dialogue mainly future patients rather than the patients discussed in the specific ethical challenge presented. In wards with longer admissions, the patients concerned also benefitted from the dialogue in the ERG. Conclusion This study indicates a positive significance and impact of ERGs; constituting an interdisciplinary learning resource for clinicians, creating significance for themselves, the ward managers and the organization. By introducing specific examples, this study indicates that ERGs have significance for the patients discussed in the specific ethical challenge, but mostly indirectly through learning among clinicians and development of clinical practice. More research is needed to further investigate the impact of ERGs seen from the perspectives of patients and relatives.
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Affiliation(s)
- H Bruun
- Focused Research Unit in Psychiatry, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | - L Huniche
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - E Stenager
- Focused Research Unit in Psychiatry, Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - C B Mogensen
- Focused Research Unit in Emergency Medicine, Institute for Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - R Pedersen
- Center for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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Bruun H, Pedersen R, Stenager E, Mogensen CB, Huniche L. Implementing ethics reflection groups in hospitals: an action research study evaluating barriers and promotors. BMC Med Ethics 2019; 20:49. [PMID: 31311525 PMCID: PMC6636139 DOI: 10.1186/s12910-019-0387-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 07/01/2019] [Indexed: 11/30/2022] Open
Abstract
Background An ethics reflection group (ERG) is one of a range of ethics support services developed to better handle ethical challenges in healthcare. The aim of this article is to evaluate the implementation process of interdisciplinary ERGs in psychiatric and general hospital departments in Denmark. To our knowledge, this is the first study of ERG implementation to include both psychiatric and general hospital departments. Methods The implementation and evaluation strategies are inspired by action research, using a qualitative approach and systematic text condensation of 28 individual interviews and 4 focus groups with clinicians, ethics facilitators and ward managers. Results The implementation process was influenced by both structural factors and factors related to clinicians having different values, interests and experiences. Structural barriers and promotors in the process to implement ERG included the following sub-categories: Organizational factors, recruitment and training of ethics facilitators, the deliberation model, planning and recruitment of participants to the ERGs, the support of the ward managers and the project group. Barriers and promotors found among clinicians included the following sub-categories: Expectations and pre-understandings of ERGs, understandings of a physician’s job, challenges experienced by ethics facilitators. At the end of the study, when it was decided that the ERGs should be continued, the implementation strategies were remodeled by the participants to meet new challenges. Conclusion The study of ERG implementation identified important structural and professional barriers and promotors that are likely to be relevant to anyone wanting to implement ethics support services across various types of healthcare services.
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Affiliation(s)
- Henriette Bruun
- Focused Research Unit in Psychiatry, Institute of Regional Health Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, 5000, Odense C, Denmark.
| | - Reidar Pedersen
- Center for medical Ethics, Institute of Health and Society, University of Oslo, Kirkevejen 166, 0450, Oslo, Norway
| | - Elsebeth Stenager
- Focused Research Unit in Psychiatry, Institute of Regional Health Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, 5000, Odense C, Denmark
| | - Christian Backer Mogensen
- Focused Research Unit in Emergency Medicine Institute for Regional Health Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, 5000, Odense C, Denmark
| | - Lotte Huniche
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark
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Sævareid TJL, Førde R, Thoresen L, Lillemoen L, Pedersen R. Significance of advance care planning in nursing homes: views from patients with cognitive impairment, their next of kin, health personnel, and managers. Clin Interv Aging 2019; 14:997-1005. [PMID: 31213786 PMCID: PMC6549780 DOI: 10.2147/cia.s203298] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/18/2019] [Indexed: 01/23/2023] Open
Abstract
Purpose: Advance care planning (ACP) performed by regular staff, which also includes patients with cognitive impairment and their next of kin, is scarcely studied. Thus, we planned an implementation study including key stakeholders (patients, next of kin, and health care personnel) using a whole-ward/system approach to ACP. We explored how they experienced ACP and its significance. Patients and methods: This qualitative study is part of a mixed-method implementation study of ACP. In four nursing homes, we did qualitative interviews and audio-recordings of meetings. We completed 20 individual semistructured interviews with participants soon after ACP conversations. The interviews included patients with cognitive impairment, their next of kin, and health care personnel. We also conducted four focus group interviews with staff and managers in the nursing homes and audio-recorded four network meetings with the project teams implementing ACP. Results: All participants appreciated taking part in ACP. Patients and next of kin focused more on the past and present than future treatment preferences. Still, ACP seemed to contribute to a stronger patient focus on end-of-life conversations. More generally, ACP seemed to contribute to valuable information for future decision-making, trusting relations, improved end-of-life communication, and saving time and resources. Conclusion: Safeguarding a strong patient focus on ACP and fostering a person-centered care culture in nursing home wards seem to be achievable through implementation of ACP that includes regular staff, patients with cognitive impairment, and their next of kin.
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Affiliation(s)
| | - Reidun Førde
- Centre for Medical Ethics, University of Oslo, Oslo, Norway
| | - Lisbeth Thoresen
- Centre for Medical Ethics, University of Oslo, Oslo, Norway.,Department of Health Sciences, University of Oslo, Oslo, Norway
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Husum TL, Legernes E, Pedersen R. "A plea for recognition" Users' experience of humiliation during mental health care. Int J Law Psychiatry 2019; 62:148-153. [PMID: 30616849 DOI: 10.1016/j.ijlp.2018.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 11/12/2018] [Accepted: 11/12/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Studies reveal that users of mental health care services sometimes experience humiliation during care. These experiences may influence the users' recovery process and treatment satisfaction. METHOD Thirteen informants with experience in mental health services were recruited for semi-structured interviews. Informants were recruited through collaboration with users' organisations. Modified text condensation was used for analysis of the qualitative data. RESULTS Users' experiences with humiliation in mental health care were sorted into three main themes. These are themes related to different perspectives between staff and users; themes related to violence of user autonomy; and experiences related to staff attitudes. DISCUSSION The service users in this study spoke about many different kinds of experiences with humiliation during care. It was a main finding that the feeling of not being recognized for one's own perception of the situation was experienced as a humiliation. This study is a contribution to a better understanding of the humiliation process between staff and users in mental health care services. The findings may be used to improve interaction between staff and users, improve quality of care and to prevent such experiences.
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Schei E, Johnsrud RE, Mildestvedt T, Pedersen R, Hjörleifsson S. Trustingly bewildered. How first-year medical students make sense of their learning experience in a traditional, preclinical curriculum. Med Educ Online 2018; 23:1500344. [PMID: 30064330 PMCID: PMC6070970 DOI: 10.1080/10872981.2018.1500344] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
BACKGROUND Traditional preclinical curricula based on memorization of scientific facts constitute learning environments which may negatively influence both factual understanding and professional identity development in medical students. Little is known of how students themselves experience and interpret such educational milieus. OBJECTIVE To investigate first-year medical students' view of the physician role, and their perception of the relevance and quality of teaching in a science-based preclinical curriculum. DESIGN Focus group interviews with thematic text analysis. RESULTS Students portrayed the good physician as communicative, humble, and open, combining biomedical knowledge and moral strength. When asked how medical school supported the development of such characteristics, two partly contradictory discourses emerged. The critical discourse identified decontextualized knowledge, poor pedagogy, lack of critical thinking, and contact with faculty. Students who voiced critical comments also articulated trust that the system would provide the competence they needed, that basic biological knowledge is needed before clinical practice, and that being on your own conveys freedom and responsibility, and helps you grow up. CONCLUSION Trust in the educational system, within a substandard learning environment, created cognitive dissonance that students resolved through rationalization, whereby they negated that factual overload and lack of relevance, reflection, and personal feedback was problematic. The cost of this mechanism is possibly that inferior teaching is perceived as normal, necessary, and good enough. If so, these future physicians' ability to critically evaluate and create quality in medical education and practice, may be weakened.
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Affiliation(s)
- Edvin Schei
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- CONTACT Edvin Schei Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, N-5018, Bergen, Norway
| | - Ruth E. Johnsrud
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Thomas Mildestvedt
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Stefán Hjörleifsson
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Sævareid TJL, Lillemoen L, Thoresen L, Førde R, Gjerberg E, Pedersen R. Implementing advance care planning in nursing homes - study protocol of a cluster-randomized clinical trial. BMC Geriatr 2018; 18:180. [PMID: 30103692 PMCID: PMC6090595 DOI: 10.1186/s12877-018-0869-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 07/31/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Close to half of all deaths in Norway occur in nursing homes, which signals a need for good communication on end-of-life care. Advance care planning (ACP) is one means to that end, but in Norwegian nursing homes, ACP is not common. This paper describes the protocol of a project evaluating an ACP-intervention in Norwegian nursing homes. The aims of this research project were to promote the possibility for conversations about the end of life with patients and relatives; promote patient autonomy; create a better foundation for important decisions in the case of medical emergencies and at the end of life; and gain experiences in order to find out what characterizes good ACP and good implementation strategies. METHODS/DESIGN This study was a mixed method study including a cluster-randomized clinical trial. Eight nursing home wards or "clusters" were pair-matched, and one ward from each pair was randomly selected for a 12-month intervention. The intervention consisted of implementing an ACP-guideline. Implementation strategies were training and supervision of project teams and staff in using the guideline, written information to patients and next of kin, and information meetings with nursing home staff. The project was evaluated using both quantitative and qualitative data, and both outcome and process evaluation. Quantitative data included patient chart reviews of ACP, diagnoses, patient preferences for decision-making and treatment, values and wishes that are more general, documented life-prolonging treatment and hospitalizations, and concordance between patient wishes and treatment. The primary outcome was documented ACP. Qualitative data included observations of conversations, interviews with patients, next of kin and health care personnel, logs from project coordinators and conversations, and transcripts from meetings with project teams in the intervention group. DISCUSSION This project attempted to increase the quality and use of ACP in Norwegian nursing homes (NH). A mixed methods approach, inclusion of patients with dementia, attempts to involve, as many patients as possible, and a sustainable implementation plan adapted to real life in nursing homes were strengths of the project.
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Affiliation(s)
| | - Lillian Lillemoen
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Frederik Holsts hus, 0450 Oslo, Norway
| | - Lisbeth Thoresen
- Department of Health Sciences, University of Oslo, Forskningsveien 3A Harald Schjelderups hus, 0373 Oslo, Norway
| | - Reidun Førde
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Frederik Holsts hus, 0450 Oslo, Norway
| | - Elisabeth Gjerberg
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Frederik Holsts hus, 0450 Oslo, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, University of Oslo, Kirkeveien 166 Frederik Holsts hus, 0450 Oslo, Norway
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Svendsen EJ, Pedersen R, Moen A, Bjørk IT. Exploring perspectives on restraint during medical procedures in paediatric care: a qualitative interview study with nurses and physicians. Int J Qual Stud Health Well-being 2018; 12:1363623. [PMID: 28889788 PMCID: PMC5653956 DOI: 10.1080/17482631.2017.1363623] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The aim of this study was to explore nurses’ and physicians’ perspectives on and reasoning about the use of restraint during medical procedures on newly admitted preschoolers in somatic hospital care. We analysed qualitative data from individual interviews with a video recall session at the end with seven physicians and eight nurses. They had earlier participated in video recorded peripheral vein cannulations on preschool children. The data were collected between May 2012 and May 2013 at a paediatric hospital unit in Norway. The analysis resulted in three main themes: (1) disparate views on the concept of restraint and restraint use (2), ways to limit the use of physical restraint and its negative consequences, and (3) experience with the role of parents and their influence on restraint. Perspectives from both healthcare professions were represented in all the main themes and had many similarities. The results of this study may facilitate more informed and reflective discussions of restraint and contribute to higher awareness of restraint in clinical practice. Lack of guidance and scientific attention to restraint combined with conflicting interests and values among healthcare providers may result in insecurity, individual dogmatism, and a lack of shared discussions, language, and terminology.
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Affiliation(s)
- Edel Jannecke Svendsen
- a Department of Nursing, Institute of Health and Society, Faculty of Medicine , University of Oslo , Oslo , Norway
| | - Reidar Pedersen
- b Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine , University of Oslo , Oslo , Norway
| | - Anne Moen
- a Department of Nursing, Institute of Health and Society, Faculty of Medicine , University of Oslo , Oslo , Norway
| | - Ida Torunn Bjørk
- a Department of Nursing, Institute of Health and Society, Faculty of Medicine , University of Oslo , Oslo , Norway
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Svendsen EJ, Moen A, Pedersen R, Bjørk IT. "But Perhaps they could Reduce the Suffering?" Parents' Ambivalence toward Participating in Forced Peripheral Vein Cannulation Performed on their Preschool-Aged Children. J Pediatr Nurs 2018; 41:e46-e51. [PMID: 29548603 DOI: 10.1016/j.pedn.2018.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 03/06/2018] [Accepted: 03/07/2018] [Indexed: 11/18/2022]
Abstract
PURPOSE The purpose of this study was to provide a better understanding of how parents experience the use of restraint during the performance of peripheral vein cannulation (PVC) on their child. DESIGN/METHODS Qualitative, semi-structured interviews were performed with seven parents and one close relative who had accompanied their 3-5-year-old child while the child resisted the medical procedure of PVC. The analysis was guided by symbolic interactionism and resulted in two themes. RESULTS The first theme that emerged, "Negotiating What Quality of Performance Should be Expected", was based on 1) Parents expected child-friendly encounters, 2) Performance of PVC caused unexpected and unnecessary suffering for the child, and 3) Parents explained and excused the performance of PVC. The second theme: "Negotiating One's Own Role and Participation in a Child's Suffering During the Procedure", was based on 1) Parents desired to be acknowledged and approached for suggestions regarding ways to ease the trauma surrounding the procedure, 2) Parents expressed uncertainty regarding the consequences that the procedure would have for the children, and 3) Parents desired to play a protective role, and they tended to engage in self-criticism. CONCLUSION When the PVC was less child-friendly, poorly planned and chaotic or performed with lacking skills, the parents became unwilling partners in the unnecessary suffering of the child. A practical implication is that if pediatric health care providers are aiming for the reduction of restraint, they must better understand parents' expectations and experiences and ensure that the use of restraint is used as the last resort.
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Affiliation(s)
- Edel Jannecke Svendsen
- Department of Nursing, Institute of Health and Society, Faculty of Medicine, University of Oslo, Postboks 1130 Blindern, 0318 Oslo, Norway.
| | - Anne Moen
- Department of Nursing, Institute of Health and Society, Faculty of Medicine, University of Oslo, Postboks 1130 Blindern, 0318 Oslo, Norway.
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, Postboks 1130 Blindern, 0318 Oslo, Norway.
| | - Ida Torunn Bjørk
- Department of Nursing, Institute of Health and Society, Faculty of Medicine, University of Oslo, Postboks 1130 Blindern, 0318 Oslo, Norway.
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Bruun H, Lystbaek SG, Stenager E, Huniche L, Pedersen R. Ethical challenges assessed in the clinical ethics Committee of Psychiatry in the region of Southern Denmark in 2010-2015: a qualitative content analyses. BMC Med Ethics 2018; 19:62. [PMID: 29914461 PMCID: PMC6006832 DOI: 10.1186/s12910-018-0308-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 06/04/2018] [Indexed: 11/16/2022] Open
Abstract
Background The aim of this article is to give more insight into what ethical challenges clinicians in mental healthcare experience and discuss with a Clinical Ethics Committee in psychiatry in the Region of Southern Denmark. Ethical considerations are an important part of the daily decision-making processes and thereby for the quality of care in mental healthcare. However, such ethical challenges have been given little systematic attention – both in research and in practices. Methods A qualitative content analysis of 55 written case-reports from the Clinical Ethics Committee. The Committee offers clinicians in mental healthcare structured ethical analyses of ethical challenges and makes a thorough written case-report. Results The ethical challenges are grouped into three overarching topics: 1. Clinicians and their relation to patients and relatives. 2. Clinicians and institutional aspects of mental healthcare 3. Clinicians and mental healthcare in a wider social context. Through presentation of illustrative examples the complexity of daily clinical life in mental healthcare becomes evident, as well as typical interests, values and arguments. Conclusions This qualitative study indicates that difficult ethical challenges are an inherent part of mental healthcare that requires time, space and competence to be dealt with adequately.
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Affiliation(s)
- H Bruun
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark. .,Psychiatric hospitals, the Region of Southern Denmark, Toldbodgade 45, 5000, Odense, Denmark.
| | - S G Lystbaek
- Psychiatric hospitals, the Region of Southern Denmark, Toldbodgade 45, 5000, Odense, Denmark
| | - E Stenager
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Psychiatric hospitals, the Region of Southern Denmark, Toldbodgade 45, 5000, Odense, Denmark
| | - L Huniche
- User Perspectives, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - R Pedersen
- Center for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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Hem MH, Molewijk B, Gjerberg E, Lillemoen L, Pedersen R. The significance of ethics reflection groups in mental health care: a focus group study among health care professionals. BMC Med Ethics 2018; 19:54. [PMID: 29871682 PMCID: PMC5989396 DOI: 10.1186/s12910-018-0297-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 05/24/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Professionals within the mental health services face many ethical dilemmas and challenging situations regarding the use of coercion. The purpose of this study was to evaluate the significance of participating in systematic ethics reflection groups focusing on ethical challenges related to coercion. METHODS In 2013 and 2014, 20 focus group interviews with 127 participants were conducted. The interviews were tape recorded and transcribed verbatim. The analysis is inspired by the concept of 'bricolage' which means our approach was inductive. RESULTS Most participants report positive experiences with participating in ethics reflection groups: A systematic and well-structured approach to discuss ethical challenges, increased consciousness of formal and informal coercion, a possibility to challenge problematic concepts, attitudes and practices, improved professional competence and confidence, greater trust within the team, more constructive disagreement and room for internal critique, less judgmental reactions and more reasoned approaches, and identification of potential for improvement and alternative courses of action. On several wards, the participation of psychiatrists and psychologists in the reflection groups was missing. The impact of the perceived lack of safety in reflection groups should not be underestimated. Sometimes the method for ethics reflection was utilised in a rigid way. Direct involvement of patients and family was missing. CONCLUSION This focus group study indicates the potential of ethics reflection groups to create a moral space in the workplace that promotes critical, reflective and collaborative moral deliberations. Future research, with other designs and methodologies, is needed to further investigate the impact of ethics reflection groups on improving health care practices.
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Affiliation(s)
- Marit Helene Hem
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, P.O.Box 1130, Blindern, NO-0318 Oslo, Norway
- VID Specialized University, Faculty of Health Studies, Box 184, Vinderen, NO-0319 Oslo, Norway
| | - Bert Molewijk
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, P.O.Box 1130, Blindern, NO-0318 Oslo, Norway
- Department Metamedica, APHVU University medical centre/VUmc), Amsterdam, the Netherlands
| | - Elisabeth Gjerberg
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, P.O.Box 1130, Blindern, NO-0318 Oslo, Norway
| | - Lillian Lillemoen
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, P.O.Box 1130, Blindern, NO-0318 Oslo, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, P.O.Box 1130, Blindern, NO-0318 Oslo, Norway
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Klomstad K, Pedersen R, Førde R, Romøren M. Involvement in decisions about intravenous treatment for nursing home patients: nursing homes versus hospital wards. BMC Med Ethics 2018; 19:34. [PMID: 29739393 PMCID: PMC5941318 DOI: 10.1186/s12910-018-0258-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 02/26/2018] [Indexed: 11/10/2022] Open
Abstract
Background Many of the elderly in nursing homes are very ill and have a reduced quality of life. Life expectancy is often hard to predict. Decisions about life-prolonging treatment should be based on a professional assessment of the patient’s best interest, assessment of capacity to consent, and on the patient’s own wishes. The purpose of this study was to investigate and compare how these types of decisions were made in nursing homes and in hospital wards. Methods Using a questionnaire, we studied the decision-making process for 299 nursing home patients who were treated for dehydration using intravenous fluids, or for bacterial infections using intravenous antibiotics. We compared the 215 (72%) patients treated in nursing homes to the 84 (28%) nursing home patients treated in the hospital. Results The patients’ capacity to consent was considered prior to treatment in 197 (92%) of the patients treated in nursing homes and 56 (67%) of the patients treated in hospitals (p < 0.001). The answers indicate that capacity to consent can be difficult to assess. Patients that were considered capable to consent, were more often involved in the decision-making in nursing homes than in hospital (90% vs. 52%). Next of kin and other health personnel were also more rarely involved when the nursing home patient was treated in hospital. Whether advance care planning had been carried out, was more often unknown in the hospital (69% vs. 17% in nursing homes). Hospital doctors expressed more doubt about the decision to admit the patient to the hospital than about the treatment itself. Conclusions This study indicates a potential for improvement in decision-making processes in general, and in particular when nursing home patients are treated in a hospital ward. The findings corroborate that nursing home patients should be treated locally if adequate health care and treatment is available. The communication between the different levels of health care when hospitalization is necessary, must be better. Trial registration ClinicalTrials.gov NCT01023763 (12/1/09) [The registration was delayed one month after study onset due to practical reasons]. Electronic supplementary material The online version of this article (10.1186/s12910-018-0258-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kristin Klomstad
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, P.O box 1130 Blindern, 0318, Oslo, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, P.O box 1130 Blindern, 0318, Oslo, Norway
| | - Reidun Førde
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, P.O box 1130 Blindern, 0318, Oslo, Norway
| | - Maria Romøren
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, P.O box 1130 Blindern, 0318, Oslo, Norway. .,Antibiotic centre for primary care, Department of General Practice, Institute of Health and Society, Faculty of Medicine, University of Oslo, P.O box 1130 Blindern, 0318, Oslo, Norway.
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