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Clinical Ethics Support (CES) includes various forms of systematic support to deal with ethical challenges in healthcare and case-based CES (C-CES) is used for CES in particular cases. The aim was to describe and normatively discuss organizational and methodological aspects of C-CES used in Swedish healthcare. A mixed-methods approach was used. A descriptive survey was answered regarding eight organizations on hospital, regional and national level, with large variations in the number of conducted C-CES activities. Data were compiled and frequencies calculated. Based on the survey results, normative questions were formulated. Six participants, with expertise of C-CES, participated in a normative group discussion. Field notes and transcribed data were analysed qualitatively. The top ranked goal of C-CES was "Supporting decision making". Mainly prospective cases were used and C-CES was carried out as un-planned and pre-planned sessions. The normative results showed the importance of avoiding making C-CES unattractive to clinicians, for instance by keeping the time frame. The professional backgrounds of C-CES leaders varied greatly and arguments were provided for the facilitating role and that C-CES leaders ought not facilitate where they have been clinically engaged. Identified challenges included variations in uptake of C-CES activities that do not mirror the ethical challenges of the context. The unfair uptake of C-CES can be compared with the uptake in Norway where there are legal requirements for CES. In this study patients and families were not reported to request or attend C-CES. Thus, further research and interventions are needed to ensure their representation in Swedish C-CES.

Background: Studies show that healthcare professionals encounter ethically difficult situations in everyday clinical practice, and there is a need for interprofessional communication in organised forms. Ethics communication in groups (ECG), based on Habermas’s theory of communicative actions, is a form of support for interprofessional communications about ethical issues. The ‘one to five method’ is a practical tool for healthcare professionals with education in ethics to facilitate ECG in everyday clinical practice.

Research aim: To evaluate the effects of organised ECG using the ‘one to five’ method for health care professionals concerning moral distress and ethical climate at wards with round-the-clock care compared with a control group.

Research design: This was a prospective cluster randomised study with an open, non-blinded design.

Methods: Nine wards with different medical specialisations at one university hospital were purposefully and then randomly allocated to an intervention group (IG) (n = 5) and a control group (CG) (n = 4). An ECG was performed monthly for six months in the intervention group. Prospective assessments were made at 3 and 6 months using the Measure of Moral Distress-Healthcare Professionals (MMD-HP), Moral Distress Thermometer (MDT), and the Swedish Ethical Climate Questionnaire (SwECQ).

Result: Between-group analyses showed no significant differences in moral distress over time. Within-group analysis revealed that the intervention group scored lower moral distress concerning clinical causes at the patient level at the 3-month measurement point but returned to the same level as the control group at six months. The ethical climate was rated higher in the intervention group at 3 and 6 months.

Conclusion: Participation in ECG likely fosters shared values and an enhanced ethical climate, though no significant differences in moral distress were observed. Moral distress may persist despite interventions, but open dialogue and professional growth can foster moral resilience. This study found a positive relationship between an ethical climate and participation in ethics communication groups (ECG) using the ‘one to five method.’ However, the small sample size limited statistical power. Future research should include larger-scale, multicentre studies and qualitative research to explore experiences with ECG.

Trial registration: ClinicalTrials.gov: NCT05146102 (2021-11-05).

Background: Moral distress is a problem and negative experience among health-care professionals. Various instruments have been developed to measure the level and underlying reasons for experienced moral distress. The moral distress thermometer (MDT) is a single-tool instrument to capture the level of moral distress experienced in real-time.

Aim: The aim of this study was to translate the MDT and adapt it to the Swedish cultural context. R

esearch design: The first part of this study concerns the translation of MDT to the Swedish context, and the second part the psychometric testing of the Swedish version.

Participants and research context: 89 healthcare professionals working at a hospital in northern Sweden participated. Convergent validity was tested between MDT and Measure of Moral Distress-Healthcare Professionals (MMD-HP), and construct validity was tested by comparing MDT scores among healthcare professionals. MDT was compared with responses to the final questions in MMD-HP. One-way ANOVA, Welch’s ANOVA, Games–Howell post-hoc test and Pearson’s correlation analysis were done.

Ethical considerations: The study was approved by the Swedish Ethics Review Authority (dnr 2020-04120) in accordance with Helsinki Declaration.

Results: The translated Swedish version of MDT was described as relevant to capture the experience of moral distress. The mean value for MDT was 2.26, with a median of 2 and a mode value of 0. The result showed moderate correlations between the MDT and MMD-HP total scores. There was a significant difference when comparing MDT and healthcare professionals who had never considered leaving their present position with those who had left and those who had considered leaving but had not done so, with the latter assessing significantly higher moral distress.

Conclusion: The MDT is an easily available instrument useful as an extension to MMD-HP to measure the real-time experience of moral distress among healthcare professionals in a Swedish context.

Background: On a daily basis, healthcare professionals deal with various ethical issues and it can be difficult to determine how to act best. Clinical ethics support (CES) has been developed to provide support for healthcare professionals dealing with complex ethical issues. A long-term perspective of participating in inter-professional dialogue and reflective-based CES sessions is seemingly sparse in the literature.

Research aim: The aim was to describe experiences of impact of Inter-professional Ethics Communication in groups (IEC) based on Habermas' theory of communicative actions, after 6 months from the perspective of an inter-professional team.

Research design: A qualitative inductive approach was chosen, and individual interviews (n = 13) were conducted. Interview data were analysed using qualitative content analysis.

Participants: The participants, 10 females and two males, represented assistant nurses, registered nurses, physicians, occupational therapists, physiotherapists, welfare officers and psychologists. Each had attended at least four IEC sessions.

Ethical considerations: The study was approved by the Regional Ethical Review Board in Umeå, Sweden, and it has been undertaken in accordance with the Helsinki Declaration.

Findings: Overall, the descriptions expressed a perceived achievement of a deepened and integrated ethical awareness that increased the participants' awareness of ethically difficult situations as well as their own ethical thinking, actions and approaches in daily work. Perspectives were shared and the team become more welded. They carried the memories of the reflections within them, which was perceived as supportive when encountered new ethically situations.

Discussion: Putting words to unarticulated thoughts may stimulate repeated reflections, leading to new insights and alternative thoughts.

Conclusion: The outcome of IEC sessions 6 months following the last session can be described as an incorporated knowledge that enables actions in ethically difficult situations based on an ethical awareness both at a 'We-level' and an 'I-level'.

Background: Moral distress has been described as moral constraints and uncertainty connected with guilty feelings of being unable to give care in accordance with one's values for good care. Various instruments to measure moral distress have been developed. The instrument measure of moral distress for healthcare professionals (MMD-HP) was developed to capture the experience and frequency of moral distress among various healthcare professionals. The MMD-HP has been translated and culturally adapted into the Swedish language and context; however, the translation has not been validated. Therefore, this study aimed to evaluate the validity and reliability of the Swedish version of the measure of moral distress for healthcare professionals (MMD-HP).

Methods: Eighty-nine staff from various professions at a hospital in northern Sweden participated in the study. A confirmatory factor analysis was performed to check for consistency with the original version of the MMD-HP. To evaluate internal consistency, Cronbach's alpha was calculated for each domain and for the scale as a whole.

Results: The scale as a whole showed a Cronbach's alpha of 0.96, with a range between 0.84 and 0.90 between the different subscales. A confirmatory factor analysis based on the original four-factor structure showed good fit indices with a χ²/df of 0.67, CFI at 1.00, TLI at 1.02 and NFI at 0.97. RMSEA was at 0.00, and SRMR was at 0.08. A comparison of the total score between three equally large groups of years of experience at the present workplace showed no significant differences (F = 0.09, df = 2, p = 0.912).

Conclusions: We found that the Swedish version of the MMD-HP has shown validity and reliability for use in a Swedish context for measuring moral distress among health personnel.

Background: Ethics communication has been described as a pedagogical form, promoting development of ethical competence among nursing students. The ‘one to five method’ was developed by this research group as a tool for facilitating ethical communication in groups among healthcare professionals but has not yet been evaluated.

Aim: To explore post-graduate nursing students’ experiences of practicing ethical communication in groups.

Research design: The study design is qualitative.

Participants and research context: The study comprised 12 nursing students on a post-graduate course for Registered Nurses focusing on palliative care. After education the students engaged as participants and facilitators in ethics communication in groups, with support from the ‘one to five method’. Data were derived from the students written reflections and subjected to thematic analysis.

Ethical considerations: The study was performed in accordance with the ethical standards in the 2013 Helsinki Declaration and approved by the Ethics Committee of the Medical Faculty at Umeå University.

Results: An overall theme was identified, ‘being supported to achieve a democratic dialogue concerning ethical problems’ and five themes, related to each step of the ‘one to five method’. The themes concerned: putting the experience of an ethical dilemma into words; being confirmed by shared emotions; defining the value conflict using ethical principles; expressing virtues of empathy and raised awareness; jointly finding various action approaches.

Discussion: Regular ethics communication in groups encourages nursing students to actively seek understanding and clarification of ethically difficult situations.

Conclusions: The results indicate that ethics communication in groups could be a way of developing virtues during education. Interventions using the ‘one to five method’ need to be further studied among student groups from other healthcare contexts.

Healthcare professionals have expressed a wish for facilitated inter-professional communications about ethical difficulties experienced in clinical practice. The introduction of an easily accessible method for facilitating ethical communication in groups may promote its implementation in everyday clinical practice. The aim of this paper was to draw on previous studies and available knowledge in order to develop and describe a method that enables systematic implementation of inter-professional ethical communication in groups. The ‘one-to-five method’ for facilitated ethical communication in groups is theoretically inspired by Habermas's theory of communicative actions and base on previous studies that accords with the Helsinki Declaration (2013). The ‘one to five method’ supports guidance of ethical communication in five steps: telling the story about the situation; reflections and dialogue concerning the emotions involved; formulation of the problem/dilemma; analysis of the situation and the dilemma; and searching for a choice of action or approach. It offers an easily accessible method for teaching healthcare professionals how to facilitate ethics communication groups. Educating facilitators closely connected to clinical work may lead to ethical dialogue becoming a natural part of clinical practice for healthcare professionals.

Healthcare professionals have expressed a wish for facilitated inter-professional communications about ethical difficulties experienced in clinical practice. The introduction of an easily accessible method for facilitating ethical communication in groups may promote its implementation in everyday clinical practice. The aim of this paper was to draw on previous studies and available knowledge in order to develop and describe a method that enables systematic implementation of inter-professional ethical communication in groups. The 'one-to-five method' for facilitated ethical communication in groups is theoretically inspired by Habermas's theory of communicative actions and base on previous studies that accords with the Helsinki Declaration (2013). The 'one to five method' supports guidance of ethical communication in five steps: telling the story about the situation; reflections and dialogue concerning the emotions involved; formulation of the problem/dilemma; analysis of the situation and the dilemma; and searching for a choice of action or approach. It offers an easily accessible method for teaching healthcare professionals how to facilitate ethics communication groups. Educating facilitators closely connected to clinical work may lead to ethical dialogue becoming a natural part of clinical practice for healthcare professionals.

BACKGROUND: Moral distress has been described as an emotionally draining condition caused by being prevented from providing care according to one's convictions. Studies have described the impact of moral distress on healthcare professionals, their situations and experiences. The Measure of Moral Distress for Healthcare Professionals (MMD-HP) is a questionnaire that measures moral distress experienced by healthcare professionals at three levels: patient, system and team. The aim of this project was to translate and make a cultural adaption of the MMD -HP to the Swedish context.

METHODS: The questionnaire comprises 27 items, rated according to frequency and intensity on a five-point Likert scale (0-4). The procedure for translating MMD-HP followed WHO guidelines (2020). These entailed a forward translation from English to Swedish, a back translation, expert panel validation, pretesting and cognitive face-to-face interviews with 10 healthcare professionals from various professions and healthcare contexts.

RESULTS: The Swedish version of MMD-HP corresponds essentially to the concept of the original version. Parts of some items' had to be adjusted or removed in order to make the item relevant and comprehensible in a Swedish context. Overall, the cognitive interviewees recognized the content of the items which generally seemed relevant and comprehensible.

CONCLUSION: The Swedish version of MMD-HP could be a useful tool for measuring moral distress among healthcare professionals in a Swedish healthcare context.

Studies show that healthcare professionals need inter-professional clinical ethics support (CES) in order to communicate and reflect on ethically difficult care situations that they experience in their clinical practice. Internationally, various CES interventions have been performed, but the communication processes and organisation of these interventions are rarely described in detail. The aim of this study was to explore communicative and organisational conditions of a CES intervention with the intention of promoting inter-professional communication about ethically difficult care situations. Eight audio- and video-recorded inter-professional CES sessions, inspired by Habermas' theory of communicative actions, were conducted. The observations were transcribed, sorted, and analysed using concept- and data-driven content analysis methods. The findings show three approaches to promoting communicative agreement, which include the CES facilitators' and participants' approaches to promoting a permissive communication, extended views, and mutual understanding. The CES sessions had organizational aspects for facilitating communicative agreement with both a given structure and openness for variation. The dynamic structure of the organization, promoted both safety and stability as well as a creativity and responsiveness, which in turn opened up for a free and dynamic inter-professional dialogue concerning ethically difficult care situations. The findings constitute a step towards a theory-based CES method inspired by Habermas' theory of communicative action. Further research is needed in order to fully develop the method and obtain increased knowledge about how to promote an inter-professional dialogue about ethically difficulties.