CURA—An Ethics Support Instrument for Nurses in Palliative Care. Feasibility and First Perceived Outcomes

Evaluating the feasibility and first perceived outcomes of a newly developed clinical ethics support instrument called CURA. This instrument is tailored to the needs of nurses that provide palliative care and is intended to foster both moral competences and moral resilience. This study is a descriptive cross-sectional evaluation study. Respondents consisted of nurses and nurse assistants (n = 97) following a continuing education program (course participants) and colleagues of these course participants (n = 124). Two questionnaires with five-point Likert scales were used. The feasibility questionnaire was given to all respondents, the perceived outcomes questionnaire only to the course participants. Data collection took place over a period of six months. Respondents were predominantly positive on most items of the feasibility questionnaire. The steps of CURA are clearly described (84% of course participants agreed or strongly agreed, 94% of colleagues) and easy to apply (78–87%). The perceived outcomes showed that CURA helped respondents to reflect on moral challenges (71% (strongly) agreed), in perspective taking (67%), with being aware of moral challenges (63%) and in dealing with moral distress (54%). Respondents did experience organizational barriers: only half of the respondents (strongly) agreed that they could easily find time for using CURA. CURA is a feasible instrument for nurses and nurse assistants providing palliative care. However, reported difficulties in organizing and making time for reflections with CURA indicate organizational preconditions ought to be met in order to implement CURA in daily practice. Furthermore, these results indicate that CURA helps to build moral competences and fosters moral resilience.

Ethical advice in paediatric care

The need for local ethics advice during the COVID-19 pandemic has put a spotlight on clinical ethics committees (CECs) and services. In this review, we focus on paediatric CECs that raise both generic questions and specific issues. In doing this, we acknowledge the broader roles of education, research and staff support some bioethics teams have developed but focus on the main areas of clinical ethics support to clinical teams. We raise 12 questions about the role, remit and responsibilities of CECs, provide preliminary answers to these and set out the next steps for the development of ethics support both in paediatric practice and more generally.

Preventing moral conflicts in patient care: Insights from a mixed-methods study with clinical experts

Background and aim Healthcare professionals are regularly exposed to moral challenges in patient care potentially compromising quality of care and safety of patients. Preventive clinical ethics support aims to identify and address moral problems in patient care at an early stage of their development. This study investigates the occurrence, risk factors, early indicators, decision parameters, consequences and preventive measures of moral problems. Method Semi-structured expert interviews were conducted with 20 interprofessional healthcare professionals from 2 university hospitals in Basel, Switzerland. A Likert scale questionnaire was completed by the interviewees and analysed using descriptive and inferential statistics. Results Healthcare professionals are frequently exposed to a variety of moral problems, such as end-of-life decisions, resource allocation and assessing the patient's will or decisional capacity. Thirty-four different risk factors for moral problems are identified, e.g. patient vulnerability, divergent values or world views, inadequate resources or poor ethical climate. Twenty-one early indicators are recognised such as disagreement between healthcare professionals, patients and relatives, emotional disturbances, gut feeling or conflict of conscience. A variety of preventive measures are suggested and presented in a preventive clinical ethics support process model. The most helpful measures are early ethical conversations with colleagues, early team-internal ethical case discussions and an ethics-trained contact person on the ward. Ethics training, kerbside consultations, proactive ethics consultations, ethics screening and rounds are also considered helpful. Conclusions Clinical ethics support services should not only offer reactive and complex, but also proactive and low-threshold support for healthcare professionals, patients and relatives.

Clinical ethics support services during the COVID-19 pandemic in the UK: a cross-sectional survey

BackgroundThe COVID-19 pandemic highlighted the need for clinical ethics support provision to ensure as far as possible fair decision making and to address healthcare workers’ moral distress.PurposeTo describe the availability, characteristics and role of clinical ethics support services (CESSs) in the UK during the COVID-19 pandemic.MethodA descriptive cross-sectional online survey was developed by the research team. The survey included questions on CESSs characteristics (model, types of support, guidance development, membership, parent and patient involvement) and changes in response to the pandemic. Invitations to participate were widely circulated via National Health Service institutional emails and relevant clinical ethics groups known to the research team.ResultsBetween October 2020 and June 2021, a total of 53 responses were received. In response to the pandemic, new CESSs were established, and existing provision changed. Most took the form of clinical ethics committees, groups and advisory boards, which varied in size and membership and the body of clinicians and patient populations they served. Some services provided moral distress support and educational provision for clinical staff. During the pandemic, services became more responsive to clinicians’ requests for ethics support and advice. More than half of respondents developed local guidance and around three quarters formed links with regional or other local services. Patient and/or family members’ involvement in ethics discussions is infrequent.ConclusionsThe pandemic has resulted in an expansion in the number of CESSs. Though some may disband as the pandemic eases, the reliance on CESSs during the pandemic demonstrates the need for additional research to better understand the effectiveness of their various forms, connections, guidance, services and modes of working and for better support to enhance consistency, transparency, communication with patients and availability to clinical staff.

How to Train and Assess the Quality of Facilitators for Moral Case Deliberation? Experiences with and Evaluation of Self-Reflection and Observation Forms for Facilitators of Moral Case Deliberation

"In Europe, Moral Case Deliberation (MCD) has been well-known and established as a form of Clinical Ethics Support (CES) and implemented in many international (health care) institutions. Since 2007 Amsterdam UMC organizes training for professionals to become a facilitator of MCD. To support and asses the development of those future facilitators MCD, an instrument has been developed which can be used by both trainees and trainers. The instrument consists of a self-reflection form and an observation form. Both forms are almost identical and contain a part of open questions reflecting upon the personal learning goals of the trainee and a part of 56 closed questions. The part of closed questions contains concrete descriptions of preferred skills and attitude of the MCD facilitator trainee, related to MCD in general and the specific steps of the Dilemma method and the Socratic Dialogue in particular. Special attention is being paid to concrete actions for fostering a dialogue and deepening the moral inquiry. The instrument can also be used by trained and more experienced facilitators of MCD to reflect upon their acquired skills and attitude, and indirectly on the quality of CES they provide. In this presentation we will present the instrument and share our experiences in using the two forms in order to train and assess (the quality of) facilitators of MCD. Furthermore, we will present preliminary results of the analysis of more than 1200 forms collected in the past decade from trainings on national and international level. "

Moral Competence, Moral Teamwork, Moral Action – Outcomes of Moral Case Deliberation in the Euro-MCD 2.0 For Evaluating Clinical Ethics Support

"Background: For Moral Case Deliberation (MCD), like any form of Clinical ethics support (CES), it is important to know whether it reaches its presumed goal of supporting healthcare professionals in their ethical challenges. Evaluation is needed to gain insight in the value of MCD. Therefore, the Euro-MCD instrument was developed to assess outcomes of MCD, and has now been revised. The aim of this presentation is to present the revised Instrument: the Euro-MCD 2.0. Methods: The revision process was an iterative dialogue in which field study findings were integrated with theoretical reflections and expert-input. Results: The Euro-MCD 2.0 has three domains: 1) Moral Competence, 2) Moral Teamwork and 3) Moral Action. Moral Competence includes items on moral sensitivity, analytical skills and a virtuous attitude, like ‘I speak up in ethically difficult situations’. Moral Teamwork refers to open dialogue and supportive relationships, for example ‘We feel secure to share emotions in ethically difficult situations’. Moral Action includes items about moral decision-making and responsible care, like ‘We are able to explain and justify our care towards patients and their families’. Discussion: The Euro-MCD 2.0 is shorter and more strongly substantiated by empirical data and theoretical reflections. At the conference, we will reflect on the revision process and the underlying foundations of the domains. The revised instrument helps to get insight in the MCD related outcomes for healthcare professionals in their daily practice. Our research can further improve implementation of MCD and contribute to the research field of evaluation of CES in general. "

Moral Challenges of Ethics Support Staff. Developing a Moral Compass for Facilitators of Moral Case Deliberation

"Ethics support staff often help others to deal with moral challenges. However, they themselves can also experience moral challenges when practicing ethics support. Facilitators of Moral Case Deliberation (MCD) sometimes for example experience ethical questions when it comes to (breaking) confidentiality. Facilitators might find themselves compelled to intervene or act upon things they hear or see whilst facilitating a MCD. For example, a MCD facilitator finds out that a participant does something illegal. Or, what to do if a MCD facilitator is asked to inform the Inspectorate about details of a MCD? When is a facilitator allowed or obligated to break confidentiality and share information with others? How to make such a decision? And, if allowed to break confidentiality, how to do this in a morally sound way? Currently there are no moral guidelines on how to act upon these questions. We conducted empirical research that explores moral challenges of MCD facilitators related to confidentiality and develops a moral compass which provides directions to approach these challenges. Data collection consists of three complementary methods: * analyses of 3 a 4 audiotaped and transcribed MCD sessions about how and when to break confidentiality; * in-depth interviews about the topic; * focus group to validate the findings and co-create a moral compass. In our presentation, we will reflect upon both the theoretical and normative considerations concerning confidentiality in ethics support and the empirical results of this study. Furthermore, we will present a preliminary version of a moral compass in order to strengthen the moral competency of MCD facilitators. "

Everyday Ethical Challenges and Informal Ethics Support Structures of Migrant Caregivers in Older Adult Care in England

"This paper builds on anthropological fieldwork I conducted in 2019 while living for over two months with migrant caregivers of older adults in Epsom, England. Caregivers’ experiences resonated with existing literature on everyday ethical challenges in caregiving: navigating divergent perspectives on good care, negotiating professional disagreements on treatments, dealing with older adults’ verbal and physical abuse appropriately, and telling older adults ‘white lies’ to avoid mental distress. Caregivers also faced unique ethical challenges because of their migrant identities: dealing with racism, conscientious objecting of certain requests made by older adults, struggling with language when following training and defending themselves against exploitative managers, and carrying the burden of being a translator to fellow migrant colleagues. Based on insight into ethical challenges unique to migrant caregivers, this paper focuses on informal ethics support systems on which migrants relied ‒ an unexplored area in the literature on ethics support within social care ‒ and explores formal ethics support systems that could support migrant caregivers in the future. Existing literature shows that the UK in general lacks ethics support systems to help caregivers recognize and appropriately address ethical challenges. The literature goes on to explore kinds of formal ethics support systems that could address ethical challenges. However, the literature completely overlooks needs and challenges unique to migrant caregivers who increasingly constitute the older adult care workforce in the UK. Understanding everyday ethical challenges and informal support systems of migrant caregivers are important steps in ensuring wellbeing of caregivers, and thus, quality of care. "