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Towards a method for clinical ethics support to promote inter-professional communication about ethically difficult care situations: observations of an intervention
Umeå University, Faculty of Medicine, Department of Nursing.
Umeå University, Faculty of Medicine, Department of Nursing.
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
(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 [en]
Care ethics, clinical ethics support, ethical difficulties, healthcare professionals, inter-professional communication.
National Category
Nursing
Research subject
Caring Sciences
Identifiers
URN: urn:nbn:se:umu:diva-126972OAI: oai:DiVA.org:umu-126972DiVA: diva2:1039618
Available from: 2016-10-24 Created: 2016-10-24 Last updated: 2016-10-26
In thesis
1. Experiences of being in ethically difficult care situations and an intervention with clinical ethics support
Open this publication in new window or tab >>Experiences of being in ethically difficult care situations and an intervention with clinical ethics support
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
Care ethics, clinical ethics support, ethically difficulties, healthcare professionals, inter-professional communication, narratives
National Category
Nursing
Research subject
Caring Sciences
Identifiers
urn:nbn:se:umu:diva-126973 (URN)978-91-7601-556-8 (ISBN)
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

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Fischer Grönlund, CatarinaSöderberg, AnnaSandlund, Mikael
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