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Experiences of being in ethically difficult care situations and an intervention with clinical ethics support
Umeå University, Faculty of Medicine, Department of Nursing.
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Studies show that healthcare professionals often experience ethical difficulties in their relations with patients, relatives, and other professionals and in relation to organisational issues, and these can sometimes be difficult to handle. Failing to act or to relate in accordance with one’s values for what is good and right might cause a troubled conscience that is connected to feelings of guilt and ill-being. Ethical issues related to the care of patients with end-stage renal disease have been described, but no studies in this context have been found that explore registered nurses’ (RNs’) and physicians’ experiences of being in ethically difficult situations that give rise to a troubled conscience. The importance of communicating ethical issues in order to understand and handle ethically difficult care situations has been emphasized. Various forms of clinical ethics support (CES) have been described and evaluated, but studies on the communication processes and the organisation of CES interventions are sparse and no study describing a CES intervention based on Habermas’ theory of communicative action has been found.

Aim: The overall aim was to increase our understanding about being in ethically difficult care situations and about how communication concerning ethical issues in healthcare can be promoted. More specifically, the aim of studies I and II was to illuminate experiences of being in ethically difficult situations giving rise to a troubled conscience among RNs and physicians, while studies III and IV aimed to describe the communication of value conflicts (III) and the organisation and performance of a CES intervention (IV).

Methods: In studies I and II narrative interviews with ten RNs (I) and five physicians (II), were performed in a dialysis care context. The interviews were analysed using a phenomenological hermeneutic approach. In studies III and IV, eight audio- and video-recorded and two audio-recorded sessions of the CES intervention, were conducted and sorted by the data tool Transana and analysed in accordance with a qualitative content analysis (III) and a qualitative concept- and data-driven content analysis (IV).

Results: The RNs’ narratives (I) resulted in the theme ‘Calling for a deliberative dialogue’. Their narratives expressed feelings of uncertainty, solitude, abandonment, and guilt in complex and ambiguous ethically difficult situations. The narratives concerned the value conflict between preserving life by all means and preserving life with dignity. The physicians’ narratives (II) resulted in the themes ‘Feeling trapped in irresolution’ and ‘Being torn by conflicting demands’. Their narratives expressed feelings of uncertainty, solitude, abandonment and guilt related to the obligation to make crucial decisions and in situations when their ideals and the reality iii clashed. The analysis of the communication of value conflicts during the CES intervention inspired by Habermas’ theory of communicative action (study III) revealed a process of five phases: a value conflict expressed as feelings of frustration, sharing disempowerment and helplessness, revelation of the value conflict, enhancing realistic expectations of the patients and relatives, and seeing opportunities to change the situation instead of obstacles. The CES intervention (study IV) was organised as a framework with a given structure and an openness for variations to facilitate communicative action. Three courses of actions to reach a communicative agreement were identified and concerned the approach to achieve a permissive communication, opening up for extended views, and enhancing mutual understanding (IV).

Conclusion: The results show that both RNs and physicians expressed feelings of uncertainty abandonment and loneliness in similar ethically difficult situations but from different points of view. They struggled with the same value conflicts and feelings, but they did not share their struggles with each other. The lack of communication and confirmation led to distrust and increased feelings of uncertainty. The CES intervention, inspired by Habermas’ theory of communicative action, offered the possibility of dealing with experiences of ethically difficult care situations. In the permissive atmosphere, the professionals helped each other to balance their ambiguity, frustrations, and powerlessness and came to an agreement about how to handle the value conflicts and how to act. The findings from this CES intervention constitute a step towards a CES method that is clearly described so that leaders can be educated and extended intervention studies with different kinds of data can be conducted in order to further develop knowledge about how to promote an inter-professional dialogue about ethical difficulties.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2016. , 54 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1841
Keyword [en]
Care ethics, clinical ethics support, ethically difficulties, healthcare professionals, inter-professional communication, narratives
National Category
Nursing
Research subject
Caring Sciences
Identifiers
URN: urn:nbn:se:umu:diva-126973ISBN: 978-91-7601-556-8OAI: oai:DiVA.org:umu-126973DiVA: diva2:1039621
Public defence
2016-11-18, Vårdvetarhusets aula, Petrus Laestadius väg, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2016-10-28 Created: 2016-10-24 Last updated: 2016-10-28Bibliographically approved
List of papers
1. Ethically difficult situations in hemodialysis care: nurses' narratives
Open this publication in new window or tab >>Ethically difficult situations in hemodialysis care: nurses' narratives
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2014 (English)In: Nursing Ethics, ISSN 0969-7330, E-ISSN 1477-0989, Vol. 22, no 6, 711-722 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Providing nursing care for patients with end-stage renal disease entails dealing with existential issues which may sometimes lead not only to ethical problems but also conflicts within the team. A previous study shows that physicians felt irresolute, torn and unconfirmed when ethical dilemmas arose.

RESEARCH QUESTION: This study, conducted in the same dialysis care unit, aimed to illuminate registered nurses' experiences of being in ethically difficult situations that give rise to a troubled conscience.

RESEARCH DESIGN: This study has a phenomenological hermeneutic approach.

PARTICIPANTS: Narrative interviews were carried out with 10 registered nurses working in dialysis care.

ETHICAL CONSIDERATIONS: The study was approved by the Ethics Committee of the Faculty of Medicine, Umeå University.

RESULTS: One theme, 'Calling for a deliberative dialogue', and six sub-themes emerged: 'Dealing with patients' ambiguity', 'Responding to patients' reluctance', 'Acting against patients' will', 'Acting against one's moral convictions', 'Lacking involvement with patients and relatives' and 'Being trapped in feelings of guilt'.

DISCUSSION: In ethically difficult situations, the registered nurses tried, but failed, to open up a dialogue with the physicians about ethical concerns and their uncertainty. They felt alone, uncertain and sometimes had to act against their conscience.

CONCLUSION: In ethical dilemmas, personal and professional integrity is at stake. Mistrusting their own moral integrity may turn professionals from moral actors into victims of circumstances. To counteract such a risk, professionals and patients need to continuously deliberate on their feelings, views and experiences, in an atmosphere of togetherness and trust.

Place, publisher, year, edition, pages
Sage Publications, 2014
Keyword
Dialogue, dialysis care, ethics, narratives, nursing, troubled conscience
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-97927 (URN)10.1177/0969733014542677 (DOI)000360898200009 ()25106455 (PubMedID)
Available from: 2015-01-22 Created: 2015-01-09 Last updated: 2016-10-24Bibliographically approved
2. Feeling trapped and being torn: Physicians' narratives about ethical dilemmas in hemodialysis care that evoke a troubled conscience.
Open this publication in new window or tab >>Feeling trapped and being torn: Physicians' narratives about ethical dilemmas in hemodialysis care that evoke a troubled conscience.
2011 (English)In: BMC Medical Ethics, ISSN 1472-6939, E-ISSN 1472-6939, Vol. 12, 8Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: This study is part of a major study about difficulties in communicating ethical problems within and among professional groups working in hemodialysis care. Describing experiences of ethically difficult situations that induce a troubled conscience may raise consciousness about ethical problems and thereby open the way to further reflection. The aim of this study was to illuminate the meanings of being in ethically difficult situations that led to the burden of a troubled conscience, as narrated by physicians working in dialysis care.

METHOD: A phenomenological hermeneutic method was used to analyze the transcribed narrative interviews with five physicians who had varying lengths of experience in nephrology.

RESULTS: The analysis shows that physicians working in hemodialysis care suffered from a troubled conscience when they felt torn by conflicting demands and trapped in irresolution. They faced ethical dilemmas where they were forced to make crucial decisions about life or death, or to prioritize when squeezed between time restraints and professional and personal demands. In these ethical dilemmas the physicians avoided arousing conflicts, were afraid of using their authority, were burdened by moral responsibility and felt devalued and questioned about their way of handling the situation. The findings point to another way of encountering ethical dilemmas, being guided by their conscience. This mean sharing the agony of deciding how to act, being brave enough to bring up the crucial problem, feeling certain that better ways of acting have not been overlooked, being respected and confirmed regarding decisions made.

CONCLUSION: The meanings of being in ethically difficult situations that led to the burden of a troubled conscience in those working in hemodialysis care, indicate the importance of increasing the level of communication within and among various professional groups - to transform being burdened by a troubled conscience into using conscience as a guide - in situations where no way of solving the problem seems to be good.

Place, publisher, year, edition, pages
BioMed Central, 2011
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-44360 (URN)10.1186/1472-6939-12-8 (DOI)000291229100001 ()21569295 (PubMedID)
Available from: 2011-06-01 Created: 2011-06-01 Last updated: 2016-10-26Bibliographically approved
3. Managing Ethical Difficulties in Healthcare: Communicating in Inter-professional Clinical Ethics Support Sessions
Open this publication in new window or tab >>Managing Ethical Difficulties in Healthcare: Communicating in Inter-professional Clinical Ethics Support Sessions
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2016 (English)In: HEC Forum, ISSN 0956-2737, E-ISSN 1572-8498Article in journal (Refereed) Epub ahead of print
Abstract [en]

Several studies show that healthcare professionals need to communicate inter-professionally in order to manage ethical difficulties. A model of clinical ethics support (CES) inspired by Habermas' theory of discourse ethics has been developed by our research group. In this version of CES sessions healthcare professionals meet inter-professionally to communicate and reflect on ethical difficulties in a cooperative manner with the aim of reaching communicative agreement or reflective consensus. In order to understand the course of action during CES, the aim of this study was to describe the communication of value conflicts during a series of inter-professional CES sessions. Ten audio- and video-recorded CES sessions were conducted over eight months and were analyzed by using the video analysis tool Transana and qualitative content analysis. The results showed that during the CES sessions the professionals as a group moved through the following five phases: a value conflict expressed as feelings of frustration, sharing disempowerment and helplessness, the revelation of the value conflict, enhancing realistic expectations, seeing opportunities to change the situation instead of obstacles. In the course of CES, the professionals moved from an individual interpretation of the situation to a common, new understanding and then to a change in approach. An open and permissive communication climate meant that the professionals dared to expose themselves, share their feelings, face their own emotions, and eventually arrive at a mutual shared reality. The value conflict was not only revealed but also resolved.

Keyword
Work, fibromyalgia, women, interviews, qualitative methods
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-120196 (URN)10.1007/s10730-016-9303-2 (DOI)27147521 (PubMedID)
Available from: 2016-05-11 Created: 2016-05-11 Last updated: 2016-10-26
4. Towards a method for clinical ethics support to promote inter-professional communication about ethically difficult care situations: observations of an intervention
Open this publication in new window or tab >>Towards a method for clinical ethics support to promote inter-professional communication about ethically difficult care situations: observations of an intervention
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background Studies show that healthcare professionals need inter-professional clinical ethics support (CES) to communicate and reflect on ethically difficult care situations. Internationally, various CES-interventions have been performed, but the communication process and the organisation of CES are sparsely described in the literature. The CES intervention observed in this study was inspired by Habermas’ theory of communicative action and involved healthcare professionals meeting inter-professionally to discuss value conflicts to achieve a common understanding and arrive in agreement about how to act and relate. The communication of value conflicts during a series of sessions in this CES - intervention has been described in a previous study. To further develop a clearly described theory-based CES-method it is important to increase knowledge about the conditions that can promote communication of value conflicts. The aim of this study was therefore to explore the organisational and communicative conditions of a CES intervention with the intention to promote interprofessional communication about ethically difficult care situations.

Methods Eight audio- and video-recorded CES sessions were conducted over a period of eight months. The observations were transcribed and sorted by using the video analysis tool Transana and analyzed with concept and data-driven content analysis methods.

Results The findings show the CES organization as an integrated framework, providing both a given structure and openness for variation, as conditions for facilitating the communication of value conflicts. The structure consisted of both constancy and flexibility. The given structure provided constancy while the openness for variation provided flexibility. The combination of constancy and flexibility generated bot safety, and stability for a free and dynamic dialogue, and opened up for responsiveness and creativity to find proposals for actions. As courses of actions to reach communicative agreement were the approaches of a permissive communication, extended views and mutual understanding found.

Conclusion The results showed CES as an integrated framework with a given structure and openness for variations as conditions to reach a communicative agreement. The findings constitute a step towards a clearly described CES method based on Habermas theory of communicative action. Extended intervention studies with different kinds of data needs to be conducted in order to fully develop the method and get increased knowledge about how to promote a dialogue about ethically difficulties.

Keyword
Care ethics, clinical ethics support, ethical difficulties, healthcare professionals, inter-professional communication.
National Category
Nursing
Research subject
Caring Sciences
Identifiers
urn:nbn:se:umu:diva-126972 (URN)
Available from: 2016-10-24 Created: 2016-10-24 Last updated: 2016-10-26

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