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Background: Integrating heart-failure and palliative care combines expertise from two cultures, life-saving cardiology and palliative care, and involves ethically difficult situations that have to be considered from various perspectives. We found no studies describing experiences of clinical ethical support (CES) in integrated cardiology and palliative care teams.

Objective: Our aim is to describe experiences of CES among professionals after a period of three years working in a multidisciplinary team in integrated heart-failure and palliative homecare.

Method: The study design was descriptive qualitative, comprising interviews with seven professionals from one integrated heart-failure and palliative care team who received CES over a three-year period. The interview data were subjected to qualitative content analysis.

Results: The CES was found to offer possibilities for meeting in an ethical ‘free-zone’ where the participants could relate to each other beyond their various professional roles and specialties. The trust within the team seemed to increase and the participants were confident enough to express their points of view. Together they developed an integrated understanding, and acquired more knowledge and a comprehensive view of the ethically difficult situation of concern. The CES sessions were considered a means of becoming better prepared to deal with ethical care issues and developing action strategies to apply in practice, from shared standpoints.

Conclusion: Participating in CES was experienced as meeting in an ethical ‘free-zone’ and seemed to be a means of facilitating integration of palliative and heart-failure care.

Health care often involves ethically difficult situations that may disquiet the conscience. The purpose of this study was to develop a questionnaire for identifying various perceptions of conscience within a framework based on the literature and on explorative interviews about perceptions of conscience (Perceptions of Conscience Questionnaire). The questionnaire was tested on a sample of 444 registered nurses, enrolled nurses, nurses' assistants and physicians. The data were analysed using principal component analysis to explore possible dimensions of perceptions of conscience. The results showed six dimensions, found also in theory and empirical health care studies. Conscience was perceived as authority, a warning signal, demanding sensitivity, an asset, a burden and depending on culture. We conclude that the Perceptions of Conscience Questionnaire is valid for assessing some perceptions of conscience relevant to health care providers.

Stress among healthcare students is a growing problem. As self-comfort is assumed to be a way of coping with stressful emotions, the aim of this study was to describe the patterns of self-comforting actions that healthcare students usually use in distress. One hundred and sixty-eight healthcare students volunteered to write down accounts of what they do when they comfort themselves. Their accounts were analysed using qualitative content analysis. The findings reveal two themes: Ingressing and Transcending. Ingressing comprises the sub-themes Unloading, Distracting, Nurturing oneself, Withdrawing and Reassuring. Transcending comprises the sub-themes Opening up and Finding new perspectives. These findings are in line with some stress-reducing strategies described in the literature on stress management. Winnicott’s theory about the phenomenon of transition is used to interpret the findings. In the light of Winnicott’s theory, self-comforting measures can be comprehended as the ability to transfer early childhood experiences of being nurtured and comforted into well-adapted strategies to effect relaxation and gain strength.

The aim of this study is to illuminate the meaning of encounters with a troubled conscience among psychiatric therapists. Psychiatric care involves ethical dilemmas which may affect conscience. Conscience relates to keeping or losing a sense of personal integrity when making judgments about one's actions. Ten psychiatric therapists were interviewed in June 2006. The interviews were tape-recorded, transcribed verbatim and interpreted using a phenomenological-hermeneutic method. Two themes 'Facing inadequacy' and 'Struggling to view oneself as being 'good enough'' are presented. In the therapists interviewed, awareness of their use of power, a sense of powerlessness and a sense of blame gave rise to feelings of betrayals and shameful inadequacy. By sharing their inadequacy with co-workers, they managed to endure the sense of their inadequacy which otherwise would have threatened to paralyse them. Finding consolation in sharing wearing feelings, becoming realistic and attesting their worthiness, they reached reconciliation and found confirmation of being good enough. The findings are interpreted in light of Lögstrup's ethics of trust, according to which conscience alerts us to silent but radical ethical demand and the risk of self-deception.

Background and Aim: One way to support evidence-based decisions in health care is by clinical guidelines, in particular, in highly specialized care such as intensive care units (ICUs). The aim of this study was to explore the development and dissemination of guidelines regarding mechanical ventilation (MV) in Swedish ICUs, and the use of evidence on MV in guidelines and everyday practice.

Methods: Inviting all general ICUs in Sweden (N = 65), a national survey was performed on occurrence of MV guidelines, and a review of submitted ICU guidelines by four evidence items from the AGREE instrument. In addition, ICU head nurses and senior physicians were interviewed using semistructured and open-ended questions to explore development and dissemination of MV guidelines, staff adherence or nonadherence to guidelines, and everyday practice of MV management bedside.

Findings: Fifty-five ICUs (85%) participated in the study; 51 ICUs submitted a total of 245 guidelines, including recommendations for medical or nursing MV actions. None of the documents included how evidence had been sought or assessed, while 22% included a list of references (n = 54). No guidelines included patients' experiences of MV. According to the managers, the guidelines were most often compiled by a multiprofessional team sharing the information through the ICU's website. The guidelines were mainly used as a basis for MV management bedside, but variation occurred as a result of personal preferences, lack of awareness, and adjustment to patients' needs.

Conclusions: Local MV guidelines seem to constitute a basis for healthcare practice in Swedish ICUs, even though the evidence proposed was limited with respect to how it was attained and lacked patient perspectives. In addition, the strategies used for dissemination were limited, suggesting that further initiatives are needed to support knowledge translation in advanced healthcare environments such as ICUs.

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.

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.

Background: An ethical climate has been described as a working climate embracing shared perceptions about morally correct behaviour concerning ethical issues. Various ethical climate questionnaires have been developed and validated for different contexts, but no questionnaire has been found concerning the ethical climate from an inter-professional perspective in a healthcare context. The Swedish Ethical Climate Questionnaire, based on Habermas’ four requirements for a democratic dialogue, attempts to assess and measure the ethical climate at various inter-professional workplaces. This study aimed to present the construction of and to test the psychometric properties of the Swedish Ethical Climate Questionnaire.

Method: An expert group of six researchers, skilled in ethics, evaluated the content validity. The questionnaire was tested among 355 healthcare workers at three hospitals in Sweden. A parallel analysis (PA), an exploratory factor analysis and confirmatory factor analysis were performed.

Ethical considerations: The participants included in the psychometric analysis were informed about the study, asked to participate in person and informed that they could withdraw at any time without giving any reason. They were also assured of confidentiality in the reporting of the results.

Findings: The parallel analysis (PA) recommended one factor as a solution. The initial exploratory factor analysis with a four-factor solution showed low concordance with a four-factor model. Cronbach’s alpha varied from 0.75 to 0.82; however, since two factors only consisted of one item, alpha could not be reported. Cronbach’s alpha for the entire scale showed good homogeneity (α = 0.86). A confirmatory factory analysis was carried out based on the four requirements and showed a goodness-of-fit after deleting two items. After deletion of these items, Cronbach’s alpha was 0.82.

Discussion: Based on the exploratory factor analysis, we suggest that the scale should be treated as a one-factor model. The result indicates that the instrument is unidimensional and assesses ethical climate as a whole.

Conclusion: After testing the Swedish Ethical Climate Questionnaire, we found support for the validity and reliability of the instrument. We found the 10-item version of Swedish Ethical Climate Questionnaire satisfactory. However, we found no support for measuring different dimensions and, therefore, this instrument should be seen as assessing ethical climate as of whole.

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.