Anna T. Höglund

Measuring Moral Distress in Pharmacy and Clinical Practice

This article presents the development, validation and application of an instrument to measure everyday moral distress in different health care settings. The concept of moral distress has been discussed and developed over 20 years. A few instruments have been developed to measure it, predominantly in nursing. The instrument presented here consists of two factors: level of moral distress, and tolerance/openness towards moral dilemmas. It was tested in four medical departments and three pharmacies, where 259 staff members completed a questionnaire. The two factors were found to be reliable. Differences in levels of moral distress were found between pharmacies and clinical departments, and between the youngest and oldest age groups; departmental staff and the youngest group experienced higher levels of moral distress. Departments reported less tolerance/openness towards moral dilemmas than pharmacies. The instrument needs to be tested further, but its strengths are the focus on everyday ethical dilemmas and its usefulness in different health care settings.

Developing Ethical Competence in Health Care Organizations

Increased work complexity and financial strain in the health care sector have led to higher demands on staff to handle ethical issues. These demands can elicit stress reactions, that is, moral distress. One way to support professionals in handling ethical dilemmas is education and training in ethics. This article reports on a controlled prospective study evaluating a structured education and training program in ethics concerning its effects on moral distress. The results show that the participants were positive about the training program. Moral distress did not change significantly. This could be interpreted as competence development, with no effects on moral distress. Alternatively, the result could be attributed to shortcomings of the training program, or that it was too short, or it could be due to the evaluation instrument used. Organizational factors such as management involvement are also crucial. There is a need to design and evaluate ethics competence programs concerning their efficacy.

High HPV vaccine acceptance despite low awareness among Swedish upper secondary school students

Objective To investigate knowledge of human papillomavirus (HPV) and attitudes to HPV vaccination and condom use among Swedish first year upper secondary school students. Methods Classroom questionnaire filled in by 608 students from a strategic sample of seven upper secondary schools in Sweden. Results Only 13.5% (n = 82) of the students had heard about HPV and 6% (n = 35) were aware of HPV vaccination. As many as 84% (n = 508) would like to be vaccinated against HPV. The high cost of vaccination was the greatest obstacle (total group 37%, n = 227); among girls the second major hindrance was the fear of needles (19%, n = 65). Before considering an HPV vaccination 73% (n = 443) wanted more information and 36% (n = 220) would like to receive such information from the school nurse. The students considered it less likely that they would use a condom when having intercourse with a new partner if they were vaccinated than if they were not (p < 0.001). Conclusion Despite intensive marketing directed at potential vaccine consumers, knowledge of HPV and of HPV vaccines was very low among first year upper secondary school students. Their attitude towards vaccination was positive but most of them wanted more information before considering vaccination.

Knowledge of human papillomavirus and attitudes to vaccination among swedish high school students

The aim of the study was to investigate knowledge of and attitudes to sexually transmitted infection (STI) and STI prevention with special focus on human papillomavirus (HPV) and the new vaccine against HPV, among 16-year-old high school students in a Swedish context. A study-specific questionnaire was distributed to 572 first year high school students from five different high schools in a medium-sized town in Sweden. The students lacked knowledge of HPV and its association with cervical cancer. Similarly, their knowledge of the new vaccine was limited. Their attitude to condom use when having sex with a new partner was positive, but decreased if oral contraceptives were used and if they were vaccinated against an STI. The main source of information was the school, followed by youth clinics and the media. The results highlight the clinical importance for school nurses and personnel at youth clinics to inform adolescents about HPV and its association with cancer.

Taking Due Care: Moral Obligations in Dual Use Research

In the past decade, the perception of a bioterrorist threat has increased and created a demand on life scientists to consider the potential security implications of dual use research. This article examines a selection of proposed moral obligations for life scientists that have emerged to meet these concerns and the extent to which they can be considered reasonable. It also describes the underlying reasons for the concerns, how they are managed, and their implications for scientific values. Five criteria for what constitutes preventable harm are suggested and a number of proposed obligations for life scientists are considered against these criteria, namely, the obligations to prevent bioterrorism; to engage in response activities; to consider negative implications of research; not to publish or share sensitive information; to oversee and limit access to dangerous material; and to report activities of concern. Although bioterrorism might be perceived as an imminent threat, the analysis illustrates that this is beyond the responsibility of life scientists either to prevent or to respond to. Among the more reasonable obligations are duties to consider potential negative implications of ones research, protect access to sensitive material, technology and knowledge, and report activities of concern. Responsibility, therefore, includes obligations concerned with preventing foreseeable and highly probable harm. A central conclusion is that several of the proposed obligations are reasonable, although not unconditionally.

Patient participation during hospitalization for myocardial infarction: Perceptions among patients and personnel

BACKGROUND Patient participation in healthcare decision-making and illness management has been associated with high patient satisfaction ratings and improved treatment outcomes in chronic diseases. Less is known about patient participation in acute illness, such as myocardial infarction (MI). AIM To explore and describe patient and personnel perceptions of patient participation in care processes and decision-making during hospitalization for MI. METHOD A descriptive qualitative design was used. Five thematic focus group interviews were carried out (n = 25), two with patients and three with personnel, at three Swedish hospitals in 2005. Two researchers were present during the interviews; one as facilitator and one responsible for documentation. The interviews were recorded, transcribed verbatim and analysed through a thematic stepwise method. RESULTS Five themes emerged from the interviews: the meaning of patient participation, positive outcomes, difficult situations, hindrances and facilitating factors. A shared basic assumption in all groups was that patient participation is valuable and desirable in the patient-doctor/nurse encounter in MI care. However, both staff and patients viewed patient participation primarily as information. Active involvement in medical decision-making was less emphasized. Participation was judged as especially difficult to achieve during the initial, emergency phase of MI, although the informants also stressed the need for information in this phase. Positive outcomes of patient participation mentioned were that the patient may feel more secure if involved and that he/she might be more committed to the recovery process. Hindrances were lack of time, staff and, in patients, medical knowledge. Patient characteristics could also influence the level of participation. CONCLUSION If patient participation is to be achieved in all phases of MI care, patients need to be made aware of their right to participate. Health care professionals need to develop appropriate communication skills for each phase of the MI patients hospitalization.

We are white coats whirling round - moral distress in Swedish pharmacies

AstractObjective: The extended role of pharmacists has made pharmacy practice more complex and increased the moral responsibility of pharmacy staff. Consequently, ethics has become an important part of their daily work. In health care, ethical dilemmas have been shown to cause distress, usually referred to as “moral distress”. Moral distress among hospital personnel has been well described and discussed in numerous studies. There are very few similar studies in pharmacy settings. This article reports on the results of an investigation concerning whether and in what situations moral distress is present in pharmacy practice.Method: A questionnaire derived from focus group data, covering ethically troubling situations in pharmacy settings, was distributed to all staff of three pharmacies in Sweden.Results: The results show that moral distress is experienced in the day-to-day pharmacy practice, and that it is in many ways connected to care providing. For example, prioritizing between customers was reported as very stressful. Younger personnel reported higher moral distress than their older colleagues did. However, there were no differences between pharmacies. A lack of support structures, such as meetings where ethical issues can be discussed, was reported by all the participating pharmacies.Conclusion: It is reasonable to assume that moral distress is even more present in pharmacy practice than in other health care areas as it is, in general, much more sensitive and exposed to the modern, demanding customer. The meeting with the customer is on a more neutral ground than in, for example, a hospital setting. Allthough there are ethical codes for pharmacists, they are not enough. Moral distress is experienced anyway; general codes and personal coping strategies must be supplemented with support from the management and work organization. There is a need to look more closely at specific factors related to the degree and extension of moral distress, going beyond individual coping strategies.

A Precautionary Principle for Dual Use Research in the Life Sciences

Most life science research entails dual-use complexity and may be misused for harmful purposes, e.g. biological weapons. The Precautionary Principle applies to special problems characterized by complexity in the relationship between human activities and their consequences. This article examines whether the principle, so far mainly used in environmental and public health issues, is applicable and suitable to the field of dual-use life science research. Four central elements of the principle are examined: threat, uncertainty, prescription and action. Although charges against the principle exist - for example that it stifles scientific development, lacks practical applicability and is poorly defined and vague - the analysis concludes that a Precautionary Principle is applicable to the field. Certain factors such as credibility of the threat, availability of information, clear prescriptive demands on responsibility and directives on how to act, determine the suitability and success of a Precautionary Principle. Moreover, policy-makers and researchers share a responsibility for providing and seeking information about potential sources of harm. A central conclusion is that the principle is meaningful and useful if applied as a context-dependent moral principle and allowed flexibility in its practical use. The principle may then inspire awareness-raising and the establishment of practical routines which appropriately reflect the fact that life science research may be misused for harmful purposes.

Is patient involvement during hospitalization for acute myocardial infarction associated with post-discharge treatment outcome? An exploratory study

Objective  To investigate whether patient involvement during hospitalization for acute myocardial infarction (MI) was associated with health and behavioural outcomes 6–10 weeks after hospital discharge.

Paediatric health calls to Swedish telenurses: a descriptive study of content and outcome

We collected data about telephone triage calls concerning children in Sweden. A sample of 110 paediatric calls were recorded. The transcribed data were analysed regarding word count, reasons for calling, results of calls, ages and gender of children, and gender of parents. The median call length was 4.4 min and the median childs age was 3.5 years. Mothers made 73% of calls, but mothers and fathers called to the same extent about daughters and sons, and regardless of age. The most common reasons for calls were ear problems, rash/wound or fever. In nearly half the calls, the telenurses provided self-care advice. Call length, word count or callers part of word count did not differ according to gender of parents or children. However, mothers were more likely to receive self-care advice while fathers were more often referred to other health services by the telenurses. Telenurses might need to improve their gender competence, and more male telenurses in the service would potentially be beneficial to callers.