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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.

Objectives: This study aimed to describe palliative medicine physicians' experiences performing pain assessment using the Numeric Rating Scale (NRS) - one of the most widely used pain assessment tools - for patients with cancer receiving specialised palliative care.

Study design: This qualitative study used reflexive thematic analysis.

Setting: The study was conducted in specialised palliative care settings.

Participants: Semi-structured interviews were conducted with 14 palliative medicine physicians in specialised palliative care.

Analysis: The interviews were transcribed and analysed using reflexive thematic analysis.

Results: Four themes were identified: 'Striving to create a shared understanding',  'Meeting individual needs', 'Interpreting and managing ratings' and 'Importance of organizational structures'. This can be seen as a process that moves from creating a shared foundation through individual patient meetings and handling NRS ratings to organisational-level challenges.

Conclusions: The study shows the complexity needed within palliative cancer care when using the most common pain assessment tool in Sweden, the NRS. The tool may seem simplistic, but, as shown in this study, the physicians found interpreting the assessments challenging for the whole team. This complexity should be incorporated into future healthcare education and training within the palliative care area, where patients often have chronic pain conditions in combination with cognitive impairment. Future research needs to focus on developing reliable pain assessment methods for patients who are cognitively impaired because of the cancer.

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: The ethical climate in healthcare is part of the work environment and a basis for professional nursing practice. The ethical climate is crucial as it is closely associated with staff job satisfaction, the quality-of-care provision, and nurses’ intention to stay in their current occupation and position. Even though several instruments assessing ethical climate in healthcare have been developed over the years, their psychometric properties have not been systematically reviewed.

Objectives: This study was conducted to identify and critically appraise the psychometric properties of instruments used to measure the ethical climate among healthcare professionals in care settings prior to the COVID-19 pandemic.

Methods: A systematic review was performed, covering papers published between 1994 and 2019, excluding grey literature sources. The literature search was performed in October 2019 in Cinahl, PsychINFO, PubMed, and SocIndex. Empirical studies were included describing the psychometric properties of instruments measuring the ethical climate among healthcare professionals in healthcare settings. Data on psychometric properties were extracted and a quality assessment was performed following the quality criteria for measurement properties proposed by Terwee et al. criteria 2007.

Result: Our search yielded 15,150 publications. After title and abstract screening, 611 studies were retained for full-text analysis, of which eight studies describing five instruments were included (five instrument development studies and three translation studies). Four studies concerned the Hospital Environment Climate Scale (HECS). All instruments had been assessed for content validity and internal consistency. Information concerning criterion validity, construct validity, and reproducibility was lacking or intermediate. No information concerning floor/ceiling effect or interpretability was reported in most cases. One study reported having performed a test-retest analysis. None of the included studies fulfilled all the Terwee et al. criteria.

Conclusion: Five instruments were identified as having undergone psychometric testing; however, none fulfilled all the criteria outlined by Terwee et al. Also, only one of the instruments had been subjected to the well-established test-retest analysis. This highlights a need for further well-structured validation studies of instruments assessing the ethical climate among healthcare professionals in care settings.

Objective: To explore rural general practitioners’ (GPs’) experiences of providing care in rural community hospitals (CHs) in northern Sweden.

Design: An interview study, using qualitative content analysis.

Setting: The study was conducted in Norrbotten and Västerbotten counties in Sweden and included eight rural CHs.

Participants: Semi-structured interviews were conducted in 2018 with 15 rural GPs.

Results: Two themes were identified: ‘Being the hub in the patient’s healthcare pathway’ and ‘Offering person-centred care far from hospital’. CHs are suitable for elderly, multimorbid and end-of-life patients, emphasising proximity, familiarity and discharge planning. They serve as primary care and intermediate hospital care hubs, collaborating with general hospitals and municipal caregivers. The rural GPs interviewed, as generalists, value holistic hospital patient care, and benefit from longitudinal patient knowledge. They highlighted these advantages and the cost-effectiveness of the CH model, arguing that it should be extended to urban regions. The rural GPs described their work situation as stimulating, but role conflicts in tight-knit communities, geographical distances and limited medical resources pose rural-specific ethical dilemmas.

Conclusions: Rural GPs value the holistic generalist perspective of CH care and emphasise the high-quality care that the CH setting enables them to provide. Despite rural-specific ethical dilemmas, they value the CH model and are concerned about its closures.

BACKGROUND: In Europe, residential care homes (RCHs) rather than hospitals are the most common care facilities for the older adult and the place where most deaths occur in this age group. There is a lack of knowledge regarding end-of-life (EOL) discussions and how they correlate with symptoms and symptom relief.

OBJECTIVE: The aim was to examine the correlation between EOL discussions and symptom occurrence, symptom relief and prescriptions or PRN drugs against symptoms for care home residents.

METHODS: All expected deaths at RCHs from 1 October 2015 to 31 December 2016 and registered in the Swedish Register of Palliative Care were included. Univariate and multivariate logistic regression were used to compare the RCH residents, or their family members, who had received documented EOL discussions with a physician (the EOL discussion group) and the non-EOL discussion group.

RESULTS: The EOL discussion group (n=17 071) had a higher prevalence of pain, nausea, anxiety, death rattles and shortness of breath reported, compared with the non-EOL discussion group (n=4164). Those with symptoms were more often completely relieved and had more often been prescribed PRN drugs against that symptom in the EOL discussion group. All differences remained significant when adjusting for age, time living in unit and cause of death.

CONCLUSION: The results indicate that EOL discussions are correlated with higher prevalence of symptoms, but also with better symptom relief and prescription of symptom drugs PRN when symptomatic. A possible explanation for this is that the EOL discussion can work as an opportunity to discuss symptoms and treatment for symptom relief.

Background: The population is aging, leading to an increased need for palliative care and end-of-life care. There is a lack of research on the use of video consultations for knowledge transfer between specialist and general palliative care. The aim of this study was to describe healthcare professionals’ experiences of video consultations in palliative care in community homecare and nursing homes in rural areas.

Methods: Individual interviews (n = 11) were conducted with five community nurses, one occupational therapist, two specialist palliative nurses, and three specialist palliative care physicians. The data were analysed using reflexive thematic analysis.

Results: The analysis identified three themes: feeling comfortable with increased availability of specialist expertise; seeing each other facilitates communication; and being supported by physically present care professionals is essential.

Conclusion: HCPs suggest that video consultations are an effective way to increase access to specialist palliative care and provide more equal care to patients with palliative care needs in rural community care.

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.

Objectives: Symptom management and support of the family members (FMs) are consideredessential aspects of palliative care. During end of life, patients are often not able to self-reportsymptoms. There is little knowledge in the literature of how healthcare professionals(HCPs) assess symptoms compared with FMs.The objective was to compare the assessment ofsymptoms and symptom relief during the final week of life between what was reported by FMsand what was reported by HCPs.

Methods: Data from the Swedish Register of Palliative Care from 2021 and 2022 were usedto compare congruity of the assessments by the FMs and by HCPs regarding occurrence and reliefof three symptoms (pain, anxiety and confusion), using Cohen’s kappa.

Results: A total of 1131 patients were included. The agreement between FMs and HCPs was poorfor occurrence of pain and confusion (kappa 0.25 and 0.16), but fair for occurrence of anxiety(kappa 0.30). When agreeing on a symptom being present, agreement on relief of thatsymptom was poor (kappa 0.04 for pain, 0.10 for anxiety and 0.01 for confusion). The trendwas that HCPs more often rated occurrence of pain and anxiety, less often occurrence ofconfusion and more often complete symptom relief compared with the FMs.

Conclusions: The views of FMs and HCPs of the patients’ symptoms differ in the end-of-life context, but both report important information and their symptom assessments should beconsidered both together and individually. More communication between HCPs and FMs couldprobably bridge some of these differences.

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.