Deal with ethical problems

The role of municipalities and opportunities in involving communities in tackling ethical problems in health care (in lithuanian). Peer review is known about how health care professionals deal with ethical challenges in mental health care, especially when not making use of a formal ethics support service. We performed a systematic and open qualitative analysis focusing on the question: ‘how do health care professionals deal with ethical challenges? We deliberately did not present a fixed definition or theory of ethical categorized relevant topics into three subthemes: 1) identification and presence of ethical challenges; 2) what do the participants actually do when dealing with an ethical challenge? And 3) the significance of facing ethical s varied from dealing with ethical challenges every day and appreciating it as a positive part of working in mental health care, to experiencing ethical challenges as paralyzing burdens that cause a lot of stress and hinder constructive team cooperation. Participants struggled with what makes a challenge an ethical challenge and whether it differs from a professional challenge. When dealing with ethical challenges, a number of participants experienced difficulties handling disagreement in a constructive way. Furthermore, some participants plead for more attention for underlying intentions and justifications of treatment interviewed health care professionals dealt with ethical challenges in many different ways, often in an informal, implicit and reactive manner. This study revealed nine different categories of what health care professionals implicitly or explicitly conceive as ‘ethical challenges’. Future research should focus on how ethics support services, such as ethics reflection groups or moral case deliberation, can be of help with respect to dealing with ethical challenges and value disagreements in a constructive dsethical challengesclinical ethics support servicemental health careconstructive disagreementethics reflection groupmoral case oundworking in mental health care entails experiencing typical ethical challenges which are related to its specific characteristics [1–5]. Ethical challenges may emerge because some patients lack decisional capacity or because there is uncertainty or disagreement about that. The fact that some patients are admitted against their will, and that health care professionals are legally allowed to make use of coercive measures, also causes many different ethical challenges.

In the first place, we assume that paying attention to ethical challenges involves paying attention to defining and improving the quality of care. Furthermore, not paying attention to ethical challenges can be detrimental to patients, relatives, health care professionals, management; it might both challenge their cooperation and diminish the quality of the decision-making processes. Some studies report that not paying attention to ethical challenges might lead to increased ‘moral distress,’ which again might contribute to higher turn-over rates and sickness-rates among health care professionals [12]. Finally, recent evaluation research reports that health care professionals in mental health care highly appreciate dealing with ethical challenges using specific ethics support mechanisms such as moral case deliberation; it (in)directly improved their moral competence, the team cooperation, and the quality of care [13–16]. There is an increasing amount of literature on ethical challenges in health care [17, 18], most of the papers focus on the content of the ethical challenge itself, or present a predefined list of possible ethical issues to the respondents [19–22]. We found little information on how health care professionals actually deal with ethical challenges in health care [23–25]. There has been no systematic, empirical examination of the values or the strategies actually employed by physicians to deal with the ethically problematic situations they face without help from ethics committees or consultants. In the study of hurst and colleagues [26], american internists, oncologists, and intensive care specialists were asked (by means of short telephone interviews) what kinds of strategies and approaches they used when facing ‘a recent ethical dilemma’. In a recent study in primary health care, lillemoen and pedersen [27] found that employees often deal with ethical challenges via informal discussions among colleagues, and discussions in various types of regular meetings at the unit. Quite a few respondents also reported that ethical challenges are often not discussed, left to the individual, or that their opinion has little importance. Most of them focus mainly on dealing with ethical challenges within the pre-structured context of an ethics support service, such as moral case deliberation or ethics rounds [13–16, 28, 29]. How health care professionals deal with ethical challenges in mental health care when not making use of an ethics support service is important.

It indirectly informs us about the relevance and significance of dealing with ethical challenges within the specific context of mental health care. Finally, it can stimulate reflection about what kind of ‘dealing with ethical challenges’ should get covered by ethics support services, and what kind of ‘dealing with ethical challenges’ can get supported via more implicit support mechanisms within regular clinical practice [32]. Aim of this paper is therefore to inform health care professionals, managers, and those who aim to start with ethics support services in mental health care about how health care professionals deal with ethical challenges in situations where there is no explicit use of an ethics support research question was: how do health care professionals in mental health care deal with ethical challenges related to the use of coercion? We purposely only generally described ‘ethical challenge’ by using words like ‘ethical dilemmas’, ‘ethical problems’, ‘ethical issues’, ‘situations that caused a discussion or disagreement within the team or where you were concerned or uncertain about the right use of coercion’ or ‘difficult situations’. We wanted to know how health care professionals and leaders interpreted those terms without using specific moral theories or definitions of ethical challenges as the starting point for the interviews. In order to avoid general statements or opinions, we asked them to describe concrete and detailed situations in which they dealt with ethical challenges. In this process among the authors, some of the initial topics were excluded based on the authors’ preliminary understandings of ‘ethical challenge’ and ‘dealing with. We as authors report that there is no conflict of interest in publishing these sin the following we will present a systematic analysis of how the participants deal with ethical challenges related to coercion. We categorized the results into the following themes: 1) identification and presence of ethical challenges; 2) what do the participants actually do when dealing with an ethical challenge? Identification and presence of ethical of the health care professionals seemed to have a general understanding of an ‘ethical challenge’ since they started to give descriptions of many different situations right away. They were able to present a broad variety of rich descriptions of situations in which they experienced either small or big ethical challenges [22]. The same time, some participants reported that they do not specify something as an ethical challenge in particular: ‘we do not say: now this is ethics’.

Sometimes ethical issues are just presented as regular problems that are being discussed: ‘nurses discuss this, not as an ethical problem, but just as a problem. Fact that ethical problems were not discussed as such, was not seen as problematic by some of the participants, while others explicitly wondered and struggled with how to distinguish between an ethical and a professional challenge: ‘is this ethical or is this professional? It seemed to have to do with how they understand what it means to deal with an ethical challenge. For example, some participants said they deal with ethical challenges every day: ‘yes, as a matter of fact, i think we discuss ethics every day. Others said that basically it is all ‘ethical reflections’: ‘i think all we do is ethical reflections, that is essentially what our job is. In these citations, participants seemed to perceive questioning whether you are doing the right thing as a way of dealing with ethical challenges. The burden was sometimes related to the actual enforcement of coercive measures, to the possible negative consequences of their decisions, or to the consequences of an ethical challenge within the team (for example in cases of conflicts due to disagreements in the team). We will elaborate more on these experiences in the third part of the results section (‘the significance of facing an ethical challenge’). Many participants mentioned that they do not succeed in paying explicit or enough attention to ethical challenges: ‘we debrief and talk it through in order to make sure we follow the law as much as possible, but it is less of an ethical reflection. This section we will present what the participants of the focus group interviews actually do when dealing with an ethical dual reflection or with close colleagues. Dealing with ethical challenges is then seen as something you usually do on your own, without having a dialogue with others. I think that ethical reflection…and i think that the formal, now we are sitting down to discuss, is in many ways one thing, but i think that everyone has some ethical reflection in between other tasks in the course of a day… even if we don’t sit down and think in bullet points or anything.

Mentioned that when they spoke with others about ethical challenges, quite often it was informal and with colleagues who have the same professional background (for example nurses with nurses). Some reported that there was little multidisciplinary exchange when it came to dealing with ethical challenges, especially between psychologists, psychiatrists, and doctors on the one hand, and nurses and social workers on the use of regular or ad-hoc health care professionals enumerated various types of meetings in which ethical challenges are discussed. However, ethical challenges are also discussed in informal meetings or small gatherings during the day: ‘we discuss these kinds of issues in small groups, in the back room. Often, participants mentioned that they arrange an ad-hoc meeting when experiencing an actual ethical challenge. This can be either during the process of experiencing an ethical challenge or retrospectively, when the situation that caused the ethical challenge is over. Participants did not mention prospective or structural meetings in which ethical challenges are discussed one focus group interview, they talked about four consecutive meetings with different participants. They mentioned that they need a specific kind of support in order to deal with ethical challenges. The reason why i asked how often you discuss the justifications for the possible use of coercion is because i think it’s easier to take part in situations that feel ethically challenging if you understand their background’. With ethical challenges due to l challenges emerged when health care professionals did not agree due to different viewpoints. There is quite some variety in the way health care professionals dealt with disagreement within their team. He thought it could be exciting to explore differences in ethical thinking and welcomed discussing them. I don’t really know how you think, i mean your ethical thought process, if it matches mine or not.

Participant also stressed that dealing with ethical challenges based on disagreements can be useful in itself, as long as they are professional discussions, and as long as they focus on the patients. It seemed that the biggest ethical challenge was not the fact that they disagreed, but the way in which they communicated or did not communicate their disagreement with each other. If that is the case, then destructively dealing with disagreement might not be the problem, but disagreement in itself is perceived as being to deal with loyalty dilemmas? That all team members should do the same can be both a strategy that tries to avoid ethical challenges and at the same time creates ethical ding to the message or to the messenger? Fragment seems to refer to an important aspect of how team members interpret the question, the questioner and the process of questioning when dealing with ethical challenges due to disagreement. In this way ethical issues can be reframed as or reduced to a personal or psychological . A daily routine to a paralyzing mentioned in the first section (‘identification and prevalence of dealing with ethical challenges’), some participants said they deal with ethical challenges every day; it is a regular thing that is inherently attached to working as a professional in mental health care. This kind of ‘dealing with’ seems to refer to the act of ‘wondering whether we do the right thing’ or ‘asking questions about what is right’. However, most citations refer to situations in which the participants, both individually and as a team, become paralyzed due to the heaviness of dealing with ethical challenges. We will describe some of these burdens in more detail risks with serious participants described facing ethical challenges as a dramatic and exhausting experience when the decision that has to be made involves a certain risk. For example, one participant described the ethical challenge of whether to give a suicidal patient permission to leave the ward or cooperation is l participants talked about poor team cooperation due to disagreement within the team about what is morally right. He describes a situation in which he dealt with a patient in a different way than most of the team thought was right.

With ethical challenges is a far we have reported most on the participants’ burden when facing ethical challenges. However, some participants stressed that struggling with ethical challenges is a necessity in order to make sure that the patients receive good treatment. This participant thought that struggling is also a positive and appropriate response when facing ethical challenges related to this type of coercion (i. Need to understand when executing tanding and lack of understanding plays a significant role in what it means to face an ethical challenge. Participants stressed the need to understand why coercion is being used, and the subsequent need to accept the reasons for the use of coercion when facing an ethical challenge. Of the participants of the focus group interviews in mental health care seem to have had a general and implicit understanding of an ‘ethical challenge. They presented many different ethical challenges; the content of these ethical challenges are described elsewhere [22]. Some participants of the focus group interviews mentioned that they deal with ethical challenges related to coercion all day, as an ongoing activity, such as wondering whether they are doing the right thing. Others mentioned stressful ethical challenges due to for example the high risks that are connected to their behaviour and decisions (e. A small number of the participants stated that struggling with ethical challenges is a good thing, or even a necessity, in order to ensure that health care professionals do the right thing. Struggling, they described, is also a sign of being a dedicated professional, of not treating ethical challenges as routine ipants mentioned lack of time, knowledge and a specific methodology for dealing with ethical challenges in a multidisciplinary context. It seems that dealing with ethical challenges often took place in a rather implicit way.

With implicit we mean two things: a) they did not frame the issues explicitly as being an ethical or moral issue, and b) they do not use specific meetings or methods with an explicit focus on ethics. This raises the question whether discussing an ethical challenge just once but in an explicit way, for example within an ethics committee or during a moral case deliberation, can be more time efficient than discussing that ethical challenge informally and implicitly on several occasions. Another question is whether there should be a kind of ‘stepped care’ plan for dealing with ethical challenges: the more serious and structural a certain ethical challenge, the more explicit ways of dealing with ethical challenges might be useful. Two participants spoke generally about how they actually discuss or reflect upon the ethical challenges by weighing conflicting situations that were described by the participants when talking about ‘dealing with ethical challenges,’ appeared to be reactions to concrete ‘problems’, directly after the problem had occurred. In other words, most ‘dealing with’ activities seem to be reactive, retrospective and within a short time-span. Patients and relatives are often key stakeholders in the situations that are described as ethical challenges, yet they rarely seem to be involved in the actual dealing with those ethical ipants stressed the need for understanding the use of coercion. Interestingly, participants themselves gave three possible reasons for how ethical challenges emerged or became more difficult to deal with. And third, those who have to deal with ethical challenges concerning coercion on a daily basis were often not participants of treatment meetings where views and decisions related to coercion are discussed and explained. We think that better organized and more timely communication about situations which might cause ethical challenges or upcoming disagreement and confusion within the team can decrease both the prevalence and the severity of the ethical l challenges caused by moral doubt or uncertainty, that is, not knowing what is right to do, were not mentioned that often in the interviews. Interestingly, this study showed that disagreement as such does not automatically lead to experiencing an ethical challenge or having problems with team cooperation. Other teams experienced less constructive ways of dealing with disagreement, for example by means of privatizing existing disagreements, or criticizing persons or teams instead of opinions or viewpoints. Our findings urge for future research on how teams can develop constructive disagreement styles, and in which way ethics support services, such as ethics reflection groups or moral case deliberation, can be open approach in the analyses also stimulated reflections among us as researchers about what we mean with ‘dealing with.

For example, we asked ourselves whether just being aware of an ethical challenge should be understood as dealing with an ethical challenge. Should ‘dealing with’ at least consist of identifying some value uncertainties or value conflicts, and some basic reasoning about it? There is obviously a wide and nuanced range of what health care professionals actually do, feel and mean when they say they are dealing with ethical challenges. We can envision a dealing-with continuum with on the one hand ‘recognizing’ or ‘mentioning’ an ethical challenge, and on the other, a structured moral case deliberation in which the participants step by step go through the processes of systematically analysing and reasoning together with a trained ethics facilitator. Future research on dealing with ethical challenges could explore more specifically the different ways in which one can deal with ethical challenges, and the needs of the health care r point for discussion relates to the basic question of what health care professionals consider to be an ethical challenge. As authors we distinguished the following nine categories of ethical challenges as used by the participants in the focus group interviews: a) unidentified or implicit ethical challenges described as ‘a problem’ or ‘a discussion’ about what is right or good; b) ‘professional’ challenges; c) situations with implicit or explicit value-issues that are emotionally challenging for the employees; d) having reflections or explicitly asking questions about what is right or good; e) dilemmas where principles such as safety versus patient autonomy are identified and weighed; f) finding a balance between the legal and the ethical; g) disagree about what is morally right; h) disrespectful handling of disagreements between persons or (sub) teams; and i) feeling stuck between staying loyal to a decision from the team or your supervisor, versus your own convictions about what is morally right. Sometimes an ethical challenge started with experiencing different viewpoints on what good patient care should be and ended up with an additional ethical challenge with respect to how to deal with those different viewpoints in a respectful explicitly mentioned that they never used the word ‘ethical. Quite a few health care professionals struggled with the difference between a professional challenge and an ethical challenge. 51 reported after having analyzed ethics diaries from health care professionals in mental health care “… staff members have an extremely wide interpretation of the concept of ‘ethical considerations’. While analyzing the focus group interview transcripts, we, as authors, discussed an example of how to distinguish an ‘ethical’ challenge from a ‘non-ethical’ challenge. 50, use another distinction when stating that “a large part of all statements can rather be interpreted as an expression of ‘moral stress’ than as genuine ethical reflections. Donaldson and colleagues [40] asked medical students to write down a case which according to the students had an ethical interest.

In their analysis, donaldson and colleagues distinguished between ethical-philosophical, legal-regulatory and practical-operational aspects of the students’ cases. The nature of a doctor’s duty to be honest or whether a good outcome would justify a decision), or mid-level ethical principles. A more pragmatic description comes from a recent paper from lillemoen and pedersen on ethical challenges in primary health care: ‘ethical challenges may arise when we cannot do what we think ought to be done, or when there is doubt or disagreement about what is right or wrong’ [27], p. This moment, we distinguish the following six categories of ethical challenges as experienced by health care professionals: a) sincerely asking oneself whether one does the right or good thing; b) not knowing what is the right thing to do; c) being uncertain or in doubt about what is the right or good thing to do; d) disagree about what is morally right or good to do; e) knowing what is right or good to do but not being able or allowed to do that; and f) feeling obligated or forced to do something which you think is morally wrong or bad. In another paper based on these focus group interviews, in which we describe the content of the actual ethical challenges related to the use of coercion, we elaborate more on the values that were at stake within these ethical challenges [22]. Empirical and conceptual research with respect to what is and should be conceived as an ethical challenge, is still needed. This might not only increase the clarity and consistent use of the term ‘ethical challenge’, it might also help to strengthen the moral awareness and sensitivity of health care professionals in general. Furthermore, empirical and conceptual research might clarify what kind of challenges clinical ethics support services (such as moral case deliberation, ethics reflection groups or ethics committees) should deal with. For example, would a ‘stepped care’ plan, which informs us what kind of implicit and explicit support fits with what kind of ethical challenge, be of help? Finally, the empirical and conceptual understanding of what is and should being conceived as an ethical challenges will be helpful in developing more targeted training and tools for both health care professionals and staff members of clinical ethics support ths and limitations of this a limitation and strength of this study is that we, purposely, did not define beforehand what we meant by ‘an ethical challenge’ and ‘dealing with. We just asked and looked at what kind of stories came up in order to see how health care professionals, through their stories, implicitly or explicitly define what they consider to be ‘an ethical challenge’ and ‘dealing with. This resulted in a rich and varied harvest on what participants understood as ‘ethical challenges’ and ‘dealing with.

Although the results are clearly related to the use of coercion in mental health care, we think the underlying mechanisms of dealing with ethical challenges can have a wider relevance. A clear limitation is that we only talked to them about (dealing with) ethical challenges. If we had had more time, and had used participatory observation at the wards, we could clearly have gained more differentiated sionsan open analysis of how health care professionals in mental health care actually experience and deal with ethical challenges related to coercion resulted in a rich harvest, both theoretically and practically. Dealing with ethical challenges within the team in a constructive way can particularly be a challenge, certainly when it involves or leads to disagreement. Interestingly, disagreement was sometimes seen as a positive necessity in order to cooperate well together and to find out how to reach a view on good care, while within some teams the disagreement lead to an additional ethical challenge with threatened the quality of trust and cooperation within the team. The findings of this focus group study seem to indicate that dealing with ethical challenges is an important and quite often a burdensome part of working in mental health care which requires more, and a more appropriate, study also revealed nine different categories of what health care professionals implicitly or explicitly conceive as ‘ethical challenges’. Future empirical and conceptual research is needed in order to further clarify the concept and practice of ‘ethical challenge. Furthermore, future empirical research could enlighten if, and in which way, specific ethics arenas such as ethics reflection groups or moral case deliberation, can actually be of additional help when dealing with ethical challenges and value s’ informationbm, mhh & rp work respectively as associate professor of clinical ethics, postdoc-researcher and professor-researcher at the centre for medical ethics, institute of health and society, faculty of medicine, university of oslo, p. This means that they must abide by certain moral principles and rules of britain ethical guidelines for research are published by the british psychological society and in america by the american psychological association. If you are ever in doubt as to whether research is ethical or not it is worthwhile remembering that if there is a conflict of interest between the participants and the researcher it is the interests of the subjects that should take s must now undergo an extensive review by an institutional review board (us) or ethics committee (uk) before they are implemented. All uk research requires ethical approval by one or more of the following:(a) department ethics committee (dec): for most. Some of the more important ethical issues are as follows:Whenever possible investigators should obtain the consent of participants.

American psychologist, 39(5), raduate ethics and psychology l issues planning psychology ethics lecture ogs, foxes, and the evolving social contract in psychological science: ethical challenges and methodological practice guidelines for the conduct of psychological research within the ines for psychologists working with ines for ethical practice in psychological research ethical principles of psychologists and code of tion of , while you are here please could you kindly share this website:Home | about | a-z index | privacy policy follow workis licensed under a creative commons attribution-noncommercial-no derivative works 3. There was a gradually developing consensus about the key ethical principles underlie the research endeavor. Allowing anyone who is willing to be are a number of key phrases that describe the system of ethical protections contemporary social and medical research establishment have created to try to the rights of their research participants. Ethical standards also require that researchers not put participants in ion where they might be at risk of harm as a result of ipation. Increasingly, researchers have had to deal with the ethical issue of 's right to service. But when that treatment or program may cial effects, persons assigned to the no-treatment control may feel their rights access to services are being when clear ethical standards and principles exist, there will be times when to do accurate research runs up against the rights of potential participants. Furthermore, there be a procedure that assures that researchers will consider all relevant ethical formulating research plans. To address such needs most institutions and formulated an institutional review board (irb), a panel of persons s grant proposals with respect to ethical implications and decides onal actions need to be taken to assure the safety and rights of participants.