Original Manuscript
Ethics rounds: An appreciated form of ethics support
Nursing Ethics 1–11 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014560930 nej.sagepub.com
Marit Sile´n, Mia Ramklint, Mats G Hansson and Kristina Haglund Uppsala University, Sweden
Abstract Background: Ethics rounds are one way to support healthcare personnel in handling ethically difficult situations. A previous study in the present project showed that ethics rounds did not result in significant changes in perceptions of how ethical issues were handled, that is, in the ethical climate. However, there was anecdotal evidence that the ethics rounds were viewed as a positive experience and that they stimulated ethical reflection. Aim: The aim of this study was to gain a deeper understanding of how the ethics rounds were experienced and why the intervention in the form of ethics rounds did not succeed in improving the ethical climate for the staff. Research design: An exploratory and descriptive design with a qualitative approach was adopted, using individual interviews. Participants and research context: A total of 11 healthcare personnel, working in two different psychiatry outpatient clinics and with experience of participating in ethics rounds, were interviewed. Ethical considerations: The study was based on informed consent and was approved by one of the Swedish Regional Ethical Review Boards. Findings: The participants were generally positive about the ethics rounds. They had experienced changes by participating in the ethics rounds in the form of being able to see things from different perspectives as well as by gaining insight into ethical issues. However, these changes had not affected daily work. Discussion: A crucial question is whether or not increased reflection ability among the participants is a good enough outcome of ethics rounds and whether this result could have been measured in patientrelated outcomes. Ethics rounds might foster cooperation among the staff and this, in turn, could influence patient care. Conclusion: By listening to others during ethics rounds, a person can learn to see things from a new angle. Participation in ethics rounds can also lead to better insight concerning ethical issues. Keywords Ethics, healthcare professional, interviews
Corresponding author: Marit Sile´n, Centre for Research Ethics & Bioethics, Uppsala University, Box 564, SE-751 22 Uppsala, Sweden. Email: [email protected]
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Introduction One way to support healthcare staff in handling ethically difficult situations might be through ethics rounds or moral case deliberation, both of which consist of discussions based on clinical cases among healthcare staff, with the discussions being moderated by a facilitator (often an ethicist).1,2 However, few studies have evaluated the outcome of this kind of ethics support. In studies conducted in Sweden, employing a pre-test/ post-test design using questionnaires, no significant differences were found for sense of coherence, job satisfaction, burnout,3 or moral distress.4 Neither did ethics rounds, according to the participants, stimulate ethical reflection in the way they had expected.5 However, Swedish participants have been positive toward ethics rounds and have found them useful and necessary4 in that they have stimulated broader thinking, have broken them from habitual ways of thinking, and have helped the participants to see the situation from different perspectives. Ethics rounds promoted a sense of connection and helped the participants handle ethically difficult situations better as well as gave them insight into their moral responsibility. They also served as a forum for emotional relief.6 Somewhat similar findings have been reported in questionnaires by moral case deliberation participants in the Netherlands.1,7 Interviews with Dutch home-staff nurses have shown that the moral case deliberation sessions resulted in communication about moral issues. However, they did not have any direct impact on daily work.8 This study is part of a larger project that investigated whether or not ethics rounds could improve the ethical climate, that is, perceptions of how ethical issues are handled9 as well as perceived by staff working in psychiatry outpatient clinics. Previous results from this project (reported elsewhere) showed that the ethics rounds did not result in significant changes in ethical climate measured with the Hospital Ethical Climate Survey (HECS).10 There was, however, anecdotal evidence that the ethics rounds were viewed as positive and that they stimulated ethical reflection among the participants. Therefore, the aim of this study was to gain a deeper understanding of how the ethics rounds were experienced and why the intervention in the form of ethics rounds was assessed as not improving the ethical climate for the staff.
Method This study is an exploratory and descriptive study with a qualitative approach.11
Participants The participants included a convenience sample of staff (Table 1) working at one of either two psychiatric outpatient clinics in a county in Sweden. They had been part of the intervention group in a project on whether ethics rounds can improve the ethical climate and participated in monthly ethics rounds led by a philosopher/ethicist for 6 months. Each ethics round lasted for 1 h. The leader’s role was to act as a moderator, ensuring that everyone could have their say as well as helping to identify the ethical problem discussed and to clarify perspectives and arguments. The staff received information about the ethics rounds beforehand on how the ethics rounds would be carried out. They were also informed that the primary goal of the ethics rounds was not that they would find a definite answer to how the situations discussed could or should be handled, but that the ethics rounds gave opportunities to listen to others’ perspectives and that this could challenge their own impression of right and wrong in the situation. The staff chose which patient or theme to discuss at each ethics round. On three occasions (before the intervention with ethics rounds started, halfway through the intervention, and 2 months after the last ethics round), participants had completed the HECS on ethical climate10 in order to see whether the perceptions of ethical climate changed during the period of ethics rounds. Results from these are reported elsewhere, but they showed no change in perceived ethical climate. 2
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Table 1. Demographic characteristics of the participants (n ¼ 11). Variable
n
Sex Female/male Age in years Mean (SD) Professional background Occupational therapist Physician Psychologist RN Nurses’ assistant Experience in the profession Years, median (Q1; Q3) Experience at current workplace Years, mean (SD) Number of ethics rounds the participant participated in Mean (SD)
8/3 52.2 (9.1) 1 1 2 3 4 23.3 (18; 28) 10.7 (5.7) 4.7 (1.1)
SD: standard deviation; RN: registered nurse.
Procedure During the last data collection on ethical climate, all staff (30 persons) in the intervention group received an introductory letter, together with the questionnaire, about this interview study. A total of 11 of the staff sent in the written consent form, but one changed her mind about participation before the interview. One participant who had not sent in the written consent form was contacted and asked to participate in an interview since this person had had an active role during the ethics round. This person agreed to be interviewed. This means that 11 persons were interviewed. Demographic data on the participants are presented in Table 1. The Regional Ethical Review Board (dnr 2012/040) approved the project. It was also approved by the head of the division of psychiatry, the heads of the departments, and the heads of the clinics. The participation was voluntary, and the participants were assured, both in written and oral form, that data would be handled confidentially. Interviews. Individual semi-structured interviews were conducted by the first author (M.S.) in a location chosen by the participant. An interview guide was used, covering the areas presented in Table 2. These areas were formulated against the authors’ previous knowledge and experience of ethics rounds as well as what changes that might have occurred due to the ethics rounds. However, they were not covered by the questionnaire on ethical climate. The interview guide was critically reviewed by two registered nurses (RNs), one of them with previous experience of ethics rounds and the other one with research experience regarding ethics rounds. The interviews lasted between 25 and 50 min and were digitally recorded and, thereafter, transcribed verbatim. Analysis. The transcribed interviews were subjected to qualitative content analysis12 with an inductive approach. First, all interviews were read through repeatedly. Thereafter, meaning units were identified, which were then condensed. Next, the condensed meaning units were assigned codes, and the codes were compared with one another to ascertain what similarities and differences there might be. Furthermore, similar codes were combined to form a subcategory. The subcategories were then compared and grouped into categories (Table 3). 3
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Expectations of change before ethics rounds were introduced What change, if any, that occurred as a result of the ethics rounds Changes, if any, regarding how the participant thought about and handled ethical issues The usefulness of ethics rounds The role of the philosopher/ethicist during the ethics rounds Suggestions for improvements of ethics rounds in the future What might be the explanations of the result from the questionnaires on ethical climate, that is, that the perceptions of ethical climate did not change significantly during the intervention period
The analysis was performed by the first author (M.S.) with one of the co-authors (K.H.) acting as coexaminer, judging the credibility of the subcategories and categories. There was full agreement between the two authors on which subcategories should form categories, but alterations were made to their labeling. Finally, the subcategories and categories were discussed with the other authors.
Findings The findings are presented in the form of seven categories with related subcategories (Table 4) and illustrative quotes.
Expecting and experiencing changes in thinking Participants expressed that ethics rounds provided an ‘‘opportunity of seeing things from a new angle’’ and that this was partly due to having a leader of the ethics rounds from outside who could contribute with new perspectives on the issues discussed: You get different angles of a problem. And that helps you to view the problem in a more nuanced way. (Person 5)
They explained that by listening to the others, they gained an understanding for the opinions held by others. They also expressed that one outcome of the ethics rounds was ‘‘being more thoughtful’’: I allow myself to be more thoughtful, to think it through one more time. Not being so quick to judge. (Person 9)
The ethics rounds made the participants ‘‘think about what benefits the patient’’; for example, how they handled the confidentiality. Besides the fact that the ethics rounds gave the opportunity of seeing things from a new angle, ‘‘changing opinions during ethics rounds’’ was something that was rarely described by the participants. However, the participants expressed that the ethics rounds had been an opportunity of ‘‘gaining better insight into ethical issues,’’ where they were now better at putting into words the ethically difficult situations they experienced and were more clear about what the ethical problem in a situation was. They expressed that they were more ready when it came to ‘‘thinking about and accepting the gray areas’’ in their work, and that there were seldom any easy answers on how they should act. 4
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Table 3. Examples from the qualitative content analysis. Meaning unit
Condensed meaning unit
Code
Subcategory
Category
When others had a different Understanding a Opportunity of Expecting and When others had different experiencing seeing things different perspective, I could perspectives I could consider changes in from a new perspective understand a different them and have some kind of thinking angle perspective of the issue. understanding for a different way of thinking and a different perspective on the issue. No, I can’t remember having any I had no explicit Had no explicit No expectations Not expecting explicit expectations. expectations. expectations of changes or experiencing changes Ethics rounds have a place in Ethics rounds are Having a need to Ethics rounds as So, I think it has a place in the forum for focus on needed in everyday work and you everyday work. Well, that is ethical issues difficult everyday need them. my summary of these ethics situations work. rounds, that you need them. Would have the Discussions Everybody It’s important to get Yes, it’s like I said, what’s with a opportunity should have everybody to express important is to make permissive to speak their say. their opinion. everybody express their climate opinion. I don’t know if it would have been Don’t know if it would have Might have been A need for more Improvement areas instructions in good with been better with some better if we had got some the form more help more help with the more, I don’t know what to call with the preparations. it, help with the preparations. preparations One thing is that we might have We might have been alright Were alright The group has a Already being a from the beginning. So, been alright from the good climate wellfrom the there wasn’t so much beginning. Perhaps there functioning beginning more room for improving wasn’t so much more room for team things. improving things.
Not expecting or experiencing changes However, participants also expressed ‘‘no experiences of changes in daily work’’ and ‘‘no experiences of changed thinking’’: If I shall be quite frank, I don’t think that there were such big differences. (Person 1)
Descriptions of ‘‘no expectations of changes’’ were also offered, with one reason being that the group already had a good work climate and shared many opinions. This was also, partly, an explanation given from those who ‘‘did not see the point with ethics rounds’’; namely, that ethical issues were already something that was discussed and handled in the group. When asked why the intervention in the form of ethics rounds did not succeed in improving the ethical climate, ‘‘organizational hindrances for changes’’ was one reason given. Other things besides the positive outcomes of the ethics rounds had been their main priority; although, this was something that the participants were dissatisfied with. The main example given of this was an organizational change within the psychiatric division, including the merging of some outpatient clinics, which had taken much energy. Another 5
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Table 4. Experiences of ethics rounds in subcategories and categories. Expecting and experiencing Not expecting or experiencing changes in changes thinking
Ethics rounds as the forum for ethical issues
Opportunity No experiences Having a need to focus on of changes in of seeing difficult daily work things situations from a new angle Being more No experiences Having ethics rounds thoughtful of changed regularly thinking instead of when the need arises Bringing up Think about No both current expectations what and closed of changes benefits cases the patient Did not see the The manager Changing should point with opinions facilitate ethics rounds during ethics ethics rounds rounds participation Questionnaire Thinking not detecting about and changes accepting the gray areas
Discussions with a permissive climate
The ethics rounds’ leader as a safe and experienced Improvement guide areas
A need for Being an Would have more experienced the instructions person opportunity in the form to speak Being listened to
Clarify the core of the discussion
Already being a well-functioning team The group has a good climate
May exaggerate A need to that it is a improve good group preparations for ethics rounds
The importance The manager’s attitude of focusing on ethical influences the issues group Someone who Making ethics Having rounds part leads the different of daily work discussion in opinions can moderate still be safe dimensions Not being judged
Summarizing the discussion
Brought the group together
reason why the ethics rounds did not succeed in improving the ethical climate was explained by the ‘‘questionnaire not detecting changes’’: It gets more nuanced . . . I think that the questionnaire is too blunt then. (Person 7)
Ethics rounds as the forum for ethical issues The participants expressed ‘‘having a need to focus on difficult situations’’ and that ethics rounds was such a forum to do so: Well, I thought it was strange that we hadn’t had ethics rounds before, because I know that there has been in the hospital. (Person 4)
The dominant opinion was ‘‘having ethics rounds regularly instead of when the need arises.’’ They were seen as a way of raising awareness for ethical issues and, in order to do that, regularity was considered important. The ethics rounds were described as a forum for ‘‘bringing up both current and closed cases.’’ 6
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When current cases were brought up, it was possible to change the course of action. However, discussing closed cases was regarded as important since lessons could be drawn that might be of use in the future when similar situations occurred. A precondition for having ethics rounds at all was that ‘‘the manager should facilitate ethics rounds participation’’ both by allocating time for them as well as by stressing the importance of participation: Our manager should say ‘‘That is our number one priority!’’ (Person 1)
Discussions with a permissive climate During the ethics rounds, it was considered important that everybody ‘‘would have the opportunity to speak’’ and that it was the leader’s responsibility to ensure this: It was obvious that the leader made sure everybody got to speak. I think that was good. (Person 10)
‘‘Being listened to’’ during the ethics rounds was considered a good experience, both by the leader as well as by the colleagues. Besides making sure that everybody was heard and listening attentively, the leader should also make sure that the participants were ‘‘not being judged’’ during the ethics rounds: Validation is important. I should never feel that I go to an ethics round to be judged. (Person 8)
One way the ethics rounds had helped the groups, as described by the participants, was by showing that ‘‘having different opinions can still be safe.’’ The leader had made it clear during the rounds that individuals had different opinions and that reaching consensus was not always the goal.
The ethics rounds’ leader as a safe and experienced guide ‘‘Being an experienced person’’ was considered a requirement for the ethics rounds’ leader. It was considered important that the leader could ‘‘clarify the core of the discussion.’’ Getting something back, as a group, by the leader ‘‘summarizing the discussion’’ was considered valuable: And to give back the way I think they did, to summarize what we’ve talked about and maybe also what we think we’ve arrived at. That’s really important. (Person 3)
According to the participants, the leader should be ‘‘someone who leads the discussion in moderate dimensions’’; that is to say, by keeping the main thread without being authoritarian and pushing on the discussion when needed: They were very clear in their leadership without taking over. Very good at leading. I think it’s impressive, to lead without taking over. (Person 11)
The participants also explained that they had to feel confident that the leader could handle a situation if conflict arose in the group during an ethics round.
Improvement areas Although the participants expressed ‘‘being generally positive towards ethics rounds’’ and the leaders and the ethics rounds were thought to be something that ‘‘brought the group together,’’ not only physically but 7
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also mentally since the whole group discussed one and the same issue, suggestions for improvements were mentioned. ‘‘A need for more instructions in the form’’ was one of them: I don’t think we fully have got the hang of what we really could talk about. (Person 8)
Participants also expressed ‘‘a need to improve preparations for ethics rounds’’ on the part of the participants since they were not always well prepared with an issue to discuss at the ethics rounds: I don’t think we handled it that well with the ethics rounds. ‘‘Oh, is it ethics round today?’’ (Person 6)
‘‘The importance of focusing on ethical issues’’ was emphasized since there was sometimes a tendency for the ethics rounds to either turn into team meetings, where the treatment strategy for an individual patient was discussed, or into supervision. A hope of ‘‘making ethics rounds part of daily work’’ was expressed so that discussions on ethical issues were made a part of other discussions.
Already being a well-functioning team The main reason for why the ethics rounds did not succeed in improving the ethical climate, according to the participants, was because they thought ‘‘the group has a good climate,’’ even before the ethics rounds began. However, it was also explained that the group ‘‘may exaggerate that it is a good group’’: We’re very proud of having this good climate . . . We are cheering for ourselves a little extra. (Person 11)
It was explained that ‘‘the manager’s attitude influences the group’’ in a positive way: The previous manager spoke a lot about the importance of meeting both parents and children with respect, and I think the team has succeeded in that. (Person 10)
Discussion The participants were generally positive about the ethics rounds, and they had experienced changes by participating in the ethics rounds in the form of being able to see things from a different perspective and by gaining insight into ethical issues. However, it was also expressed that there had been no changes in daily work, partly because the working groups were described as already being well-functioning. Although the participants were generally positive about the ethics rounds and the leaders of them, they also identified improvement areas for future ethics rounds. The participants expressed that the ethics rounds had made them acquire new perspectives on ethical issues and made them more thoughtful. This is in line with previous research, where participants have expressed that the ethics rounds made them aware of other perspectives on the issues discussed7,8 and that new information during the ethics rounds resulted in a holistic view and made the participants break from habitual ways of thinking.6 This outcome of the ethics rounds, that is, the new insights that the participants in this study acquired, is similar to the imaginative ethics approach.2 This approach has been described as a means to envision alternative descriptions and opinions of what ethical values are at stake in the situation discussed. By listening to others’ perspectives, the participants see new risks and benefits associated with the situation and, thereby, alternative horizons of moral experience can be imagined as well as a multitude of values that might be at stake. This means that ingrained habits of moral reasoning can be challenged, which, in turn, can change the established ethical praxis of the workplace.2 To acquire a broader understanding for ethical issues, and the way different individuals can reason about these issues, is a desirable outcome 8
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of ethics rounds in that it probably means that the participants have become more skilled in reflecting on ethical issues. However, the value of this increased ability of reflection when it does not result in changes in everyday work must also be discussed. In this study, it was expressed that the ethics rounds had not meant changes in daily work and explanations for this were also offered, such as the fact that the group was already well-functioning and that there were organizational hindrances for change. Our result is in line with one previous study that showed that ethics rounds, according to the participants, had not had a direct impact on daily work8 but there are other reports, based on self-report data, that ethical reflections have resulted in increased ethical awareness and also have had consequences for practice,13,14 such as a more respectful and individualized care for the patients.13 Whether or not increased reflection ability among the participants is a good enough outcome of ethics rounds is related to the goal of ethics rounds: either as an opportunity for healthcare staff to reflect and discuss ethical issues or as an intervention that, although it is directed toward the staff, should improve patient care directly. In a Dutch study about the goals of clinical ethics support, board members as well as members of the support staff considered good care and improved quality of care as the overall goal of clinical ethics support.15 Another reason managers give for introducing ethics rounds in their team is to improve the quality of care on a daily basis.7 In this study, hope was expressed that the discussions during the ethics rounds would, in some way, lead to changes in patient work. The research on whether ethics rounds actually improve the quality of care is scant and mainly describes participants’ reflections on how lessons learnt during ethics rounds could be used in daily work.7,16 One crucial point is how good care or improved quality of care is operationalized; for example, if self-reports by staff of improved care are sufficient or if more patient-related outcomes need to be used. In a US study, where an ethics consultant gave recommendations to staff on how to handle certain patient cases that could involve value-laden conflicts, ethics consultation was shown to be associated with reductions in hospital and intensive care unit days.17 However, it must be taken into account that this kind of ethics consultation is, in many ways, different from the ethics support offered to European healthcare staff. Although the hope and goal is to improve the care by ethics rounds, it must be kept in mind that patient-related outcomes are complex measures and that it might be difficult to prove a causal relationship between the introduction of ethics rounds and improved care in the form of more positive patient-related outcomes. It might be a more realistic goal that ethics rounds can foster cooperation among the staff and that this, in turn, can influence patient care. Before the ethics rounds, the cooperation at both workplaces in this study was already considered to be satisfactory, and the groups were described as well-functioning. This was also seen as one reason for why the ethics rounds did not manage to improve the ethical climate in the groups. However, it must also be taken into account that the participants in this study had experience from a total of 6 h of ethics rounds and that this might be too little in order to be able to show any measurable changes in ethical climate in a group that at the same time is going through organizational changes. In previous studies, ethics rounds’ participants have described increased cooperation as one of the positive outcomes.6,7 If a group is already well-functioning and is experiencing good cooperation, then there might be a ceiling effect for what improvements can be achieved through ethics rounds in these areas. Therefore, it seems reasonable to introduce ethics rounds in groups that have a need of improving their cooperation regarding ethical issues. However, since ethics rounds is a kind of activity that requires an active commitment in the form of cooperation from the participants, it might not be possible to introduce ethics rounds in groups where the sense of cooperation is low, simply because it is not possible to carry out the ethics rounds. In contrast to a previous Swedish study on renal care RNs’ and physicians’ experiences of participating in ethics rounds, where the participants expressed that the ethics rounds produced a sense of equality and diminished hierarchies between the professions,6 the participants in this study did not express any such experiences. This might be due to the fact that Swedish psychiatric outpatient clinics most often have a team-based organization, wherein the team includes physicians, RNs, nurses’ assistants, psychologists, and 9
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welfare officers that work together toward the care of patients.18 This was also true for both workplaces in this study. This way of working across the professional boundaries might prevent hierarchies. Therefore, diminished hierarchies as a result of ethics rounds is not a possible outcome.
Methodological considerations It is described, to a limited extent, how ethical rounds are experienced by healthcare staff. Therefore, a study with a qualitative approach was used.19 Several steps were taken to increase the trustworthiness of the results. Credibility was enhanced by testing the interview questions, and the interviews were performed by a researcher who was skilled in interview methods. First two and, thereafter, all authors were involved in the analysis of data. During the analysis, all authors reflected on and discussed codes, subcategories, and categories until consensus was reached. Two of the authors were not involved in the ethics rounds, and the authors’ various perspectives enhanced the clarity of the study. Transferability of the results to other contexts should be possible, especially to other psychiatric outpatient clinics. However, transferability is a matter for the reader to decide.20 One limit of this study may be the relatively small number of interviewees. However, the interviews appeared to be rich in depth, with a variation of experiences from persons with different professions. A weakness might be that only one-third of the staff agreed to take part in an interview. It is possible that those who were not interviewed had experiences that differed from those of the staff that were interviewed. However, during the interviews, both positive and negative opinions about the ethics rounds were expressed, and the sample had a good representativeness regarding demographic characteristics.
Conclusion The results of this study revealed that by listening to others during ethics rounds, participants found that they learned to see things from a new angle and that participation in ethics rounds led to better insight into ethical issues. However, having ethics rounds in an already well-functioning team might not result in changes in perceptions of how ethical issues are handled, that is, in the ethical climate. There seems to be a preference for having ethics rounds regularly instead of only when the need arises. Conflict of interest The authors declare that there is no conflict of interest. Funding This study was funded by grants from AFA Insurance. References 1. Molewijk B, Verkerk M, Milius H, et al. Implementing moral case deliberation in a psychiatric hospital: process and outcome. Med Health Care Philos 2008; 11: 43–56. 2. Hansson MG. Imaginative ethics—bringing ethical praxis into sharper relief. Med Health Care Philos 2002; 5: 33–42. 3. Forsga¨rde M, Westman B and Nygren L. Ethical discussion groups as an intervention to improve the climate in interprofessional work with the elderly and disabled. J Interprof Care 2000; 14: 351–361. 4. Ka¨lvemark Sporrong S, Arnetz B, Hansson MG, et al. Developing ethical competence in health care organizations. Nurs Ethics 2007; 14: 825–837. 5. Svantesson M, Anderze´n-Carlsson A, Thorse´n H, et al. Interprofessional ethics rounds concerning dialysis patients: staff’s ethical reflections before and after rounds. J Med Ethics 2008; 34: 407–413. 10
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6. Svantesson M, Lo¨fmark R, Thorse´n H, et al. Learning a way through ethical problems: Swedish nurses’ and doctors’ experiences from one model of ethics rounds. J Med Ethics 2008; 34: 399–406. 7. Weidema FC, Molewijk BA, Kamsteeg F, et al. Aims and harvest of moral case deliberation. Nurs Ethics 2013; 20: 617–631. 8. Van der Dam SS, Abma TA, Molewijk AC, et al. Organizing moral case deliberation experiences in two Dutch nursing homes. Nurs Ethics 2011; 18: 327–340. 9. Olson L. Ethical climate in health care organizations. Int Nurs Rev 1995; 42: 85–90. 10. Olson LL. Hospital nurses’ perceptions of the ethical climate of their work setting. Image J Nurs Sch 1998; 30: 345–349. 11. Polit DF and Beck CT. Nursing research: generating and assessing evidence for nursing practice. 9th ed. Philiadelphia, PA: Wolters Kluwer, Lippincott Williams & Wilkins, 2012. 12. Graneheim UH and Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004; 24: 105–112. ˚ . Evaluation of ethical reflections in community healthcare: a 13. So¨derhamn U, Kjøstvedt HT and Slettebø A mixed-methods study. Nurs Ethics. Epub ahead of print 8 April 2014. DOI: 10.1177/0969733014524762. 14. Hem MH, Pedersen R, Norvoll R, et al. Evaluating clinical ethics support in mental healthcare: a systematic literature review. Nurs Ethics. Epub ahead of print 4 August 2014. DOI: 10.1177/0969733014539783. 15. Dauwerse L, Abma TA, Molewijk B, et al. Goals of clinical ethics support: perceptions of Dutch healthcare institutions. Health Care Anal 2013; 21: 323–337. 16. Van der Dam S, Schols JM, Kardol TJ, et al. The discovery of deliberation. From ambiguity to appreciation through the learning process of doing Moral Case Deliberation in Dutch elderly care. Soc Sci Med 2013; 83: 125–132. 17. Schneiderman LJ, Gilmer T, Teetzel HD, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial. JAMA 2003; 290: 1166–1172. 18. Thylefors I. Babels torn: om tva¨rprofessionellt teamsamarbete [The tower of Babel: on interprofessional teamwork]. Stockholm: Natur & Kultur, 2013. 19. Brink PJ and Wood MJ. Advanced design in nursing research. 2nd ed. London: Sage, 1998. 20. Lincoln YS and Guba EG. Naturalistic inquiry. Newbury Park, CA: Sage, 1985.
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Ethics rounds: An appreciated form of ethics support
Nursing Ethics 1–11 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014560930 nej.sagepub.com
Marit Sile´n, Mia Ramklint, Mats G Hansson and Kristina Haglund Uppsala University, Sweden
Abstract Background: Ethics rounds are one way to support healthcare personnel in handling ethically difficult situations. A previous study in the present project showed that ethics rounds did not result in significant changes in perceptions of how ethical issues were handled, that is, in the ethical climate. However, there was anecdotal evidence that the ethics rounds were viewed as a positive experience and that they stimulated ethical reflection. Aim: The aim of this study was to gain a deeper understanding of how the ethics rounds were experienced and why the intervention in the form of ethics rounds did not succeed in improving the ethical climate for the staff. Research design: An exploratory and descriptive design with a qualitative approach was adopted, using individual interviews. Participants and research context: A total of 11 healthcare personnel, working in two different psychiatry outpatient clinics and with experience of participating in ethics rounds, were interviewed. Ethical considerations: The study was based on informed consent and was approved by one of the Swedish Regional Ethical Review Boards. Findings: The participants were generally positive about the ethics rounds. They had experienced changes by participating in the ethics rounds in the form of being able to see things from different perspectives as well as by gaining insight into ethical issues. However, these changes had not affected daily work. Discussion: A crucial question is whether or not increased reflection ability among the participants is a good enough outcome of ethics rounds and whether this result could have been measured in patientrelated outcomes. Ethics rounds might foster cooperation among the staff and this, in turn, could influence patient care. Conclusion: By listening to others during ethics rounds, a person can learn to see things from a new angle. Participation in ethics rounds can also lead to better insight concerning ethical issues. Keywords Ethics, healthcare professional, interviews
Corresponding author: Marit Sile´n, Centre for Research Ethics & Bioethics, Uppsala University, Box 564, SE-751 22 Uppsala, Sweden. Email: [email protected]
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Introduction One way to support healthcare staff in handling ethically difficult situations might be through ethics rounds or moral case deliberation, both of which consist of discussions based on clinical cases among healthcare staff, with the discussions being moderated by a facilitator (often an ethicist).1,2 However, few studies have evaluated the outcome of this kind of ethics support. In studies conducted in Sweden, employing a pre-test/ post-test design using questionnaires, no significant differences were found for sense of coherence, job satisfaction, burnout,3 or moral distress.4 Neither did ethics rounds, according to the participants, stimulate ethical reflection in the way they had expected.5 However, Swedish participants have been positive toward ethics rounds and have found them useful and necessary4 in that they have stimulated broader thinking, have broken them from habitual ways of thinking, and have helped the participants to see the situation from different perspectives. Ethics rounds promoted a sense of connection and helped the participants handle ethically difficult situations better as well as gave them insight into their moral responsibility. They also served as a forum for emotional relief.6 Somewhat similar findings have been reported in questionnaires by moral case deliberation participants in the Netherlands.1,7 Interviews with Dutch home-staff nurses have shown that the moral case deliberation sessions resulted in communication about moral issues. However, they did not have any direct impact on daily work.8 This study is part of a larger project that investigated whether or not ethics rounds could improve the ethical climate, that is, perceptions of how ethical issues are handled9 as well as perceived by staff working in psychiatry outpatient clinics. Previous results from this project (reported elsewhere) showed that the ethics rounds did not result in significant changes in ethical climate measured with the Hospital Ethical Climate Survey (HECS).10 There was, however, anecdotal evidence that the ethics rounds were viewed as positive and that they stimulated ethical reflection among the participants. Therefore, the aim of this study was to gain a deeper understanding of how the ethics rounds were experienced and why the intervention in the form of ethics rounds was assessed as not improving the ethical climate for the staff.
Method This study is an exploratory and descriptive study with a qualitative approach.11
Participants The participants included a convenience sample of staff (Table 1) working at one of either two psychiatric outpatient clinics in a county in Sweden. They had been part of the intervention group in a project on whether ethics rounds can improve the ethical climate and participated in monthly ethics rounds led by a philosopher/ethicist for 6 months. Each ethics round lasted for 1 h. The leader’s role was to act as a moderator, ensuring that everyone could have their say as well as helping to identify the ethical problem discussed and to clarify perspectives and arguments. The staff received information about the ethics rounds beforehand on how the ethics rounds would be carried out. They were also informed that the primary goal of the ethics rounds was not that they would find a definite answer to how the situations discussed could or should be handled, but that the ethics rounds gave opportunities to listen to others’ perspectives and that this could challenge their own impression of right and wrong in the situation. The staff chose which patient or theme to discuss at each ethics round. On three occasions (before the intervention with ethics rounds started, halfway through the intervention, and 2 months after the last ethics round), participants had completed the HECS on ethical climate10 in order to see whether the perceptions of ethical climate changed during the period of ethics rounds. Results from these are reported elsewhere, but they showed no change in perceived ethical climate. 2
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Table 1. Demographic characteristics of the participants (n ¼ 11). Variable
n
Sex Female/male Age in years Mean (SD) Professional background Occupational therapist Physician Psychologist RN Nurses’ assistant Experience in the profession Years, median (Q1; Q3) Experience at current workplace Years, mean (SD) Number of ethics rounds the participant participated in Mean (SD)
8/3 52.2 (9.1) 1 1 2 3 4 23.3 (18; 28) 10.7 (5.7) 4.7 (1.1)
SD: standard deviation; RN: registered nurse.
Procedure During the last data collection on ethical climate, all staff (30 persons) in the intervention group received an introductory letter, together with the questionnaire, about this interview study. A total of 11 of the staff sent in the written consent form, but one changed her mind about participation before the interview. One participant who had not sent in the written consent form was contacted and asked to participate in an interview since this person had had an active role during the ethics round. This person agreed to be interviewed. This means that 11 persons were interviewed. Demographic data on the participants are presented in Table 1. The Regional Ethical Review Board (dnr 2012/040) approved the project. It was also approved by the head of the division of psychiatry, the heads of the departments, and the heads of the clinics. The participation was voluntary, and the participants were assured, both in written and oral form, that data would be handled confidentially. Interviews. Individual semi-structured interviews were conducted by the first author (M.S.) in a location chosen by the participant. An interview guide was used, covering the areas presented in Table 2. These areas were formulated against the authors’ previous knowledge and experience of ethics rounds as well as what changes that might have occurred due to the ethics rounds. However, they were not covered by the questionnaire on ethical climate. The interview guide was critically reviewed by two registered nurses (RNs), one of them with previous experience of ethics rounds and the other one with research experience regarding ethics rounds. The interviews lasted between 25 and 50 min and were digitally recorded and, thereafter, transcribed verbatim. Analysis. The transcribed interviews were subjected to qualitative content analysis12 with an inductive approach. First, all interviews were read through repeatedly. Thereafter, meaning units were identified, which were then condensed. Next, the condensed meaning units were assigned codes, and the codes were compared with one another to ascertain what similarities and differences there might be. Furthermore, similar codes were combined to form a subcategory. The subcategories were then compared and grouped into categories (Table 3). 3
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Nursing Ethics Table 2. Areas in the interview guide. Area
Expectations of change before ethics rounds were introduced What change, if any, that occurred as a result of the ethics rounds Changes, if any, regarding how the participant thought about and handled ethical issues The usefulness of ethics rounds The role of the philosopher/ethicist during the ethics rounds Suggestions for improvements of ethics rounds in the future What might be the explanations of the result from the questionnaires on ethical climate, that is, that the perceptions of ethical climate did not change significantly during the intervention period
The analysis was performed by the first author (M.S.) with one of the co-authors (K.H.) acting as coexaminer, judging the credibility of the subcategories and categories. There was full agreement between the two authors on which subcategories should form categories, but alterations were made to their labeling. Finally, the subcategories and categories were discussed with the other authors.
Findings The findings are presented in the form of seven categories with related subcategories (Table 4) and illustrative quotes.
Expecting and experiencing changes in thinking Participants expressed that ethics rounds provided an ‘‘opportunity of seeing things from a new angle’’ and that this was partly due to having a leader of the ethics rounds from outside who could contribute with new perspectives on the issues discussed: You get different angles of a problem. And that helps you to view the problem in a more nuanced way. (Person 5)
They explained that by listening to the others, they gained an understanding for the opinions held by others. They also expressed that one outcome of the ethics rounds was ‘‘being more thoughtful’’: I allow myself to be more thoughtful, to think it through one more time. Not being so quick to judge. (Person 9)
The ethics rounds made the participants ‘‘think about what benefits the patient’’; for example, how they handled the confidentiality. Besides the fact that the ethics rounds gave the opportunity of seeing things from a new angle, ‘‘changing opinions during ethics rounds’’ was something that was rarely described by the participants. However, the participants expressed that the ethics rounds had been an opportunity of ‘‘gaining better insight into ethical issues,’’ where they were now better at putting into words the ethically difficult situations they experienced and were more clear about what the ethical problem in a situation was. They expressed that they were more ready when it came to ‘‘thinking about and accepting the gray areas’’ in their work, and that there were seldom any easy answers on how they should act. 4
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Table 3. Examples from the qualitative content analysis. Meaning unit
Condensed meaning unit
Code
Subcategory
Category
When others had a different Understanding a Opportunity of Expecting and When others had different experiencing seeing things different perspective, I could perspectives I could consider changes in from a new perspective understand a different them and have some kind of thinking angle perspective of the issue. understanding for a different way of thinking and a different perspective on the issue. No, I can’t remember having any I had no explicit Had no explicit No expectations Not expecting explicit expectations. expectations. expectations of changes or experiencing changes Ethics rounds have a place in Ethics rounds are Having a need to Ethics rounds as So, I think it has a place in the forum for focus on needed in everyday work and you everyday work. Well, that is ethical issues difficult everyday need them. my summary of these ethics situations work. rounds, that you need them. Would have the Discussions Everybody It’s important to get Yes, it’s like I said, what’s with a opportunity should have everybody to express important is to make permissive to speak their say. their opinion. everybody express their climate opinion. I don’t know if it would have been Don’t know if it would have Might have been A need for more Improvement areas instructions in good with been better with some better if we had got some the form more help more help with the more, I don’t know what to call with the preparations. it, help with the preparations. preparations One thing is that we might have We might have been alright Were alright The group has a Already being a from the beginning. So, been alright from the good climate wellfrom the there wasn’t so much beginning. Perhaps there functioning beginning more room for improving wasn’t so much more room for team things. improving things.
Not expecting or experiencing changes However, participants also expressed ‘‘no experiences of changes in daily work’’ and ‘‘no experiences of changed thinking’’: If I shall be quite frank, I don’t think that there were such big differences. (Person 1)
Descriptions of ‘‘no expectations of changes’’ were also offered, with one reason being that the group already had a good work climate and shared many opinions. This was also, partly, an explanation given from those who ‘‘did not see the point with ethics rounds’’; namely, that ethical issues were already something that was discussed and handled in the group. When asked why the intervention in the form of ethics rounds did not succeed in improving the ethical climate, ‘‘organizational hindrances for changes’’ was one reason given. Other things besides the positive outcomes of the ethics rounds had been their main priority; although, this was something that the participants were dissatisfied with. The main example given of this was an organizational change within the psychiatric division, including the merging of some outpatient clinics, which had taken much energy. Another 5
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Table 4. Experiences of ethics rounds in subcategories and categories. Expecting and experiencing Not expecting or experiencing changes in changes thinking
Ethics rounds as the forum for ethical issues
Opportunity No experiences Having a need to focus on of changes in of seeing difficult daily work things situations from a new angle Being more No experiences Having ethics rounds thoughtful of changed regularly thinking instead of when the need arises Bringing up Think about No both current expectations what and closed of changes benefits cases the patient Did not see the The manager Changing should point with opinions facilitate ethics rounds during ethics ethics rounds rounds participation Questionnaire Thinking not detecting about and changes accepting the gray areas
Discussions with a permissive climate
The ethics rounds’ leader as a safe and experienced Improvement guide areas
A need for Being an Would have more experienced the instructions person opportunity in the form to speak Being listened to
Clarify the core of the discussion
Already being a well-functioning team The group has a good climate
May exaggerate A need to that it is a improve good group preparations for ethics rounds
The importance The manager’s attitude of focusing on ethical influences the issues group Someone who Making ethics Having rounds part leads the different of daily work discussion in opinions can moderate still be safe dimensions Not being judged
Summarizing the discussion
Brought the group together
reason why the ethics rounds did not succeed in improving the ethical climate was explained by the ‘‘questionnaire not detecting changes’’: It gets more nuanced . . . I think that the questionnaire is too blunt then. (Person 7)
Ethics rounds as the forum for ethical issues The participants expressed ‘‘having a need to focus on difficult situations’’ and that ethics rounds was such a forum to do so: Well, I thought it was strange that we hadn’t had ethics rounds before, because I know that there has been in the hospital. (Person 4)
The dominant opinion was ‘‘having ethics rounds regularly instead of when the need arises.’’ They were seen as a way of raising awareness for ethical issues and, in order to do that, regularity was considered important. The ethics rounds were described as a forum for ‘‘bringing up both current and closed cases.’’ 6
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When current cases were brought up, it was possible to change the course of action. However, discussing closed cases was regarded as important since lessons could be drawn that might be of use in the future when similar situations occurred. A precondition for having ethics rounds at all was that ‘‘the manager should facilitate ethics rounds participation’’ both by allocating time for them as well as by stressing the importance of participation: Our manager should say ‘‘That is our number one priority!’’ (Person 1)
Discussions with a permissive climate During the ethics rounds, it was considered important that everybody ‘‘would have the opportunity to speak’’ and that it was the leader’s responsibility to ensure this: It was obvious that the leader made sure everybody got to speak. I think that was good. (Person 10)
‘‘Being listened to’’ during the ethics rounds was considered a good experience, both by the leader as well as by the colleagues. Besides making sure that everybody was heard and listening attentively, the leader should also make sure that the participants were ‘‘not being judged’’ during the ethics rounds: Validation is important. I should never feel that I go to an ethics round to be judged. (Person 8)
One way the ethics rounds had helped the groups, as described by the participants, was by showing that ‘‘having different opinions can still be safe.’’ The leader had made it clear during the rounds that individuals had different opinions and that reaching consensus was not always the goal.
The ethics rounds’ leader as a safe and experienced guide ‘‘Being an experienced person’’ was considered a requirement for the ethics rounds’ leader. It was considered important that the leader could ‘‘clarify the core of the discussion.’’ Getting something back, as a group, by the leader ‘‘summarizing the discussion’’ was considered valuable: And to give back the way I think they did, to summarize what we’ve talked about and maybe also what we think we’ve arrived at. That’s really important. (Person 3)
According to the participants, the leader should be ‘‘someone who leads the discussion in moderate dimensions’’; that is to say, by keeping the main thread without being authoritarian and pushing on the discussion when needed: They were very clear in their leadership without taking over. Very good at leading. I think it’s impressive, to lead without taking over. (Person 11)
The participants also explained that they had to feel confident that the leader could handle a situation if conflict arose in the group during an ethics round.
Improvement areas Although the participants expressed ‘‘being generally positive towards ethics rounds’’ and the leaders and the ethics rounds were thought to be something that ‘‘brought the group together,’’ not only physically but 7
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also mentally since the whole group discussed one and the same issue, suggestions for improvements were mentioned. ‘‘A need for more instructions in the form’’ was one of them: I don’t think we fully have got the hang of what we really could talk about. (Person 8)
Participants also expressed ‘‘a need to improve preparations for ethics rounds’’ on the part of the participants since they were not always well prepared with an issue to discuss at the ethics rounds: I don’t think we handled it that well with the ethics rounds. ‘‘Oh, is it ethics round today?’’ (Person 6)
‘‘The importance of focusing on ethical issues’’ was emphasized since there was sometimes a tendency for the ethics rounds to either turn into team meetings, where the treatment strategy for an individual patient was discussed, or into supervision. A hope of ‘‘making ethics rounds part of daily work’’ was expressed so that discussions on ethical issues were made a part of other discussions.
Already being a well-functioning team The main reason for why the ethics rounds did not succeed in improving the ethical climate, according to the participants, was because they thought ‘‘the group has a good climate,’’ even before the ethics rounds began. However, it was also explained that the group ‘‘may exaggerate that it is a good group’’: We’re very proud of having this good climate . . . We are cheering for ourselves a little extra. (Person 11)
It was explained that ‘‘the manager’s attitude influences the group’’ in a positive way: The previous manager spoke a lot about the importance of meeting both parents and children with respect, and I think the team has succeeded in that. (Person 10)
Discussion The participants were generally positive about the ethics rounds, and they had experienced changes by participating in the ethics rounds in the form of being able to see things from a different perspective and by gaining insight into ethical issues. However, it was also expressed that there had been no changes in daily work, partly because the working groups were described as already being well-functioning. Although the participants were generally positive about the ethics rounds and the leaders of them, they also identified improvement areas for future ethics rounds. The participants expressed that the ethics rounds had made them acquire new perspectives on ethical issues and made them more thoughtful. This is in line with previous research, where participants have expressed that the ethics rounds made them aware of other perspectives on the issues discussed7,8 and that new information during the ethics rounds resulted in a holistic view and made the participants break from habitual ways of thinking.6 This outcome of the ethics rounds, that is, the new insights that the participants in this study acquired, is similar to the imaginative ethics approach.2 This approach has been described as a means to envision alternative descriptions and opinions of what ethical values are at stake in the situation discussed. By listening to others’ perspectives, the participants see new risks and benefits associated with the situation and, thereby, alternative horizons of moral experience can be imagined as well as a multitude of values that might be at stake. This means that ingrained habits of moral reasoning can be challenged, which, in turn, can change the established ethical praxis of the workplace.2 To acquire a broader understanding for ethical issues, and the way different individuals can reason about these issues, is a desirable outcome 8
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of ethics rounds in that it probably means that the participants have become more skilled in reflecting on ethical issues. However, the value of this increased ability of reflection when it does not result in changes in everyday work must also be discussed. In this study, it was expressed that the ethics rounds had not meant changes in daily work and explanations for this were also offered, such as the fact that the group was already well-functioning and that there were organizational hindrances for change. Our result is in line with one previous study that showed that ethics rounds, according to the participants, had not had a direct impact on daily work8 but there are other reports, based on self-report data, that ethical reflections have resulted in increased ethical awareness and also have had consequences for practice,13,14 such as a more respectful and individualized care for the patients.13 Whether or not increased reflection ability among the participants is a good enough outcome of ethics rounds is related to the goal of ethics rounds: either as an opportunity for healthcare staff to reflect and discuss ethical issues or as an intervention that, although it is directed toward the staff, should improve patient care directly. In a Dutch study about the goals of clinical ethics support, board members as well as members of the support staff considered good care and improved quality of care as the overall goal of clinical ethics support.15 Another reason managers give for introducing ethics rounds in their team is to improve the quality of care on a daily basis.7 In this study, hope was expressed that the discussions during the ethics rounds would, in some way, lead to changes in patient work. The research on whether ethics rounds actually improve the quality of care is scant and mainly describes participants’ reflections on how lessons learnt during ethics rounds could be used in daily work.7,16 One crucial point is how good care or improved quality of care is operationalized; for example, if self-reports by staff of improved care are sufficient or if more patient-related outcomes need to be used. In a US study, where an ethics consultant gave recommendations to staff on how to handle certain patient cases that could involve value-laden conflicts, ethics consultation was shown to be associated with reductions in hospital and intensive care unit days.17 However, it must be taken into account that this kind of ethics consultation is, in many ways, different from the ethics support offered to European healthcare staff. Although the hope and goal is to improve the care by ethics rounds, it must be kept in mind that patient-related outcomes are complex measures and that it might be difficult to prove a causal relationship between the introduction of ethics rounds and improved care in the form of more positive patient-related outcomes. It might be a more realistic goal that ethics rounds can foster cooperation among the staff and that this, in turn, can influence patient care. Before the ethics rounds, the cooperation at both workplaces in this study was already considered to be satisfactory, and the groups were described as well-functioning. This was also seen as one reason for why the ethics rounds did not manage to improve the ethical climate in the groups. However, it must also be taken into account that the participants in this study had experience from a total of 6 h of ethics rounds and that this might be too little in order to be able to show any measurable changes in ethical climate in a group that at the same time is going through organizational changes. In previous studies, ethics rounds’ participants have described increased cooperation as one of the positive outcomes.6,7 If a group is already well-functioning and is experiencing good cooperation, then there might be a ceiling effect for what improvements can be achieved through ethics rounds in these areas. Therefore, it seems reasonable to introduce ethics rounds in groups that have a need of improving their cooperation regarding ethical issues. However, since ethics rounds is a kind of activity that requires an active commitment in the form of cooperation from the participants, it might not be possible to introduce ethics rounds in groups where the sense of cooperation is low, simply because it is not possible to carry out the ethics rounds. In contrast to a previous Swedish study on renal care RNs’ and physicians’ experiences of participating in ethics rounds, where the participants expressed that the ethics rounds produced a sense of equality and diminished hierarchies between the professions,6 the participants in this study did not express any such experiences. This might be due to the fact that Swedish psychiatric outpatient clinics most often have a team-based organization, wherein the team includes physicians, RNs, nurses’ assistants, psychologists, and 9
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welfare officers that work together toward the care of patients.18 This was also true for both workplaces in this study. This way of working across the professional boundaries might prevent hierarchies. Therefore, diminished hierarchies as a result of ethics rounds is not a possible outcome.
Methodological considerations It is described, to a limited extent, how ethical rounds are experienced by healthcare staff. Therefore, a study with a qualitative approach was used.19 Several steps were taken to increase the trustworthiness of the results. Credibility was enhanced by testing the interview questions, and the interviews were performed by a researcher who was skilled in interview methods. First two and, thereafter, all authors were involved in the analysis of data. During the analysis, all authors reflected on and discussed codes, subcategories, and categories until consensus was reached. Two of the authors were not involved in the ethics rounds, and the authors’ various perspectives enhanced the clarity of the study. Transferability of the results to other contexts should be possible, especially to other psychiatric outpatient clinics. However, transferability is a matter for the reader to decide.20 One limit of this study may be the relatively small number of interviewees. However, the interviews appeared to be rich in depth, with a variation of experiences from persons with different professions. A weakness might be that only one-third of the staff agreed to take part in an interview. It is possible that those who were not interviewed had experiences that differed from those of the staff that were interviewed. However, during the interviews, both positive and negative opinions about the ethics rounds were expressed, and the sample had a good representativeness regarding demographic characteristics.
Conclusion The results of this study revealed that by listening to others during ethics rounds, participants found that they learned to see things from a new angle and that participation in ethics rounds led to better insight into ethical issues. However, having ethics rounds in an already well-functioning team might not result in changes in perceptions of how ethical issues are handled, that is, in the ethical climate. There seems to be a preference for having ethics rounds regularly instead of only when the need arises. Conflict of interest The authors declare that there is no conflict of interest. Funding This study was funded by grants from AFA Insurance. References 1. Molewijk B, Verkerk M, Milius H, et al. Implementing moral case deliberation in a psychiatric hospital: process and outcome. Med Health Care Philos 2008; 11: 43–56. 2. Hansson MG. Imaginative ethics—bringing ethical praxis into sharper relief. Med Health Care Philos 2002; 5: 33–42. 3. Forsga¨rde M, Westman B and Nygren L. Ethical discussion groups as an intervention to improve the climate in interprofessional work with the elderly and disabled. J Interprof Care 2000; 14: 351–361. 4. Ka¨lvemark Sporrong S, Arnetz B, Hansson MG, et al. Developing ethical competence in health care organizations. Nurs Ethics 2007; 14: 825–837. 5. Svantesson M, Anderze´n-Carlsson A, Thorse´n H, et al. Interprofessional ethics rounds concerning dialysis patients: staff’s ethical reflections before and after rounds. J Med Ethics 2008; 34: 407–413. 10
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6. Svantesson M, Lo¨fmark R, Thorse´n H, et al. Learning a way through ethical problems: Swedish nurses’ and doctors’ experiences from one model of ethics rounds. J Med Ethics 2008; 34: 399–406. 7. Weidema FC, Molewijk BA, Kamsteeg F, et al. Aims and harvest of moral case deliberation. Nurs Ethics 2013; 20: 617–631. 8. Van der Dam SS, Abma TA, Molewijk AC, et al. Organizing moral case deliberation experiences in two Dutch nursing homes. Nurs Ethics 2011; 18: 327–340. 9. Olson L. Ethical climate in health care organizations. Int Nurs Rev 1995; 42: 85–90. 10. Olson LL. Hospital nurses’ perceptions of the ethical climate of their work setting. Image J Nurs Sch 1998; 30: 345–349. 11. Polit DF and Beck CT. Nursing research: generating and assessing evidence for nursing practice. 9th ed. Philiadelphia, PA: Wolters Kluwer, Lippincott Williams & Wilkins, 2012. 12. Graneheim UH and Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004; 24: 105–112. ˚ . Evaluation of ethical reflections in community healthcare: a 13. So¨derhamn U, Kjøstvedt HT and Slettebø A mixed-methods study. Nurs Ethics. Epub ahead of print 8 April 2014. DOI: 10.1177/0969733014524762. 14. Hem MH, Pedersen R, Norvoll R, et al. Evaluating clinical ethics support in mental healthcare: a systematic literature review. Nurs Ethics. Epub ahead of print 4 August 2014. DOI: 10.1177/0969733014539783. 15. Dauwerse L, Abma TA, Molewijk B, et al. Goals of clinical ethics support: perceptions of Dutch healthcare institutions. Health Care Anal 2013; 21: 323–337. 16. Van der Dam S, Schols JM, Kardol TJ, et al. The discovery of deliberation. From ambiguity to appreciation through the learning process of doing Moral Case Deliberation in Dutch elderly care. Soc Sci Med 2013; 83: 125–132. 17. Schneiderman LJ, Gilmer T, Teetzel HD, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial. JAMA 2003; 290: 1166–1172. 18. Thylefors I. Babels torn: om tva¨rprofessionellt teamsamarbete [The tower of Babel: on interprofessional teamwork]. Stockholm: Natur & Kultur, 2013. 19. Brink PJ and Wood MJ. Advanced design in nursing research. 2nd ed. London: Sage, 1998. 20. Lincoln YS and Guba EG. Naturalistic inquiry. Newbury Park, CA: Sage, 1985.
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