Marit Helene Hem

The ethics of care: Role obligations and moderate partiality in health care

This article contends that an ethics of care has a particular moral ontology that makes it suitable to argue for the normative significance of relational responsibilities within professional health care. This ontology is relational. It means that moral choices always have to account for the web of relationships, the relational networks and responsibilities that are an essential part of particular moral circumstances. Given this ontology, the article investigates the conditions for health care professionals to be partial and to act on the basis of particular responsibilities to their patients. We will argue that priorities could be partial in three ways: first, because there may be exceptional circumstances that allow for giving priority to one patient over another; second, because the integrity of the patient and a health care worker may be connected in special ways; and, finally, even if impartiality is essential, the institutional basis of health care must always give ample space for an ethically qualified individual and personal care for patients. Even if difficult priorities may be necessary, the conditions of institutional health care should always seek to create the prerequisites for nurses and doctors to administer proper care.

Mature care and reciprocity: Two cases from acute psychiatry

In this article we elaborate on the concept of mature care, in which reciprocity is crucial. Emphasizing reciprocity challenges other comprehensions where care is understood as a one-sided activity, with either the carer or the cared for considered the main source of knowledge and sole motivation for caring. We aim to demonstrate the concept of mature care’s advantages with regard to conceptualizing the practice of care, such as in nursing. First, we present and discuss the concept of mature care, then we apply the concept to two real life cases taken from the field of acute psychiatry. In the first example we demonstrate how mature care can grasp tacit reciprocal aspects in caring. In the other, we elucidate a difficulty related to the concept, namely the lack of reciprocity and interaction that affects some relationships.

Is compassion essential to nursing practice

ABSTRACT The Norwegian Nurses’ Association recently (2001) approved a new code of ethics that included compassion as one of the basic values in nursing care. This paper examines the idea of compassion in the context of the Bible story of the Good Samaritan using an analysis of qualitative data from nurses’ clinical work with psychiatric patients. The aim is to show how the idea of compassion challenges nursing practice. Thereafter, the paper discusses the benefits of and premises for compassion in care work. The results show that nurses tend not to be guided by compassion in their work with patients. The organisation of the dayto-day work in the hospital ward, the division of labour between nurses and doctors, and the nurses’ approach to nursing were identified as influencing this tendency. The study shows that compassion is a radical concept with a potential to promote greater respect for patients’ dignity.

How to avoid and prevent coercion in nursing homes: A qualitative study

In many Western countries, studies have demonstrated extensive use of coercion in nursing homes, especially towards patients suffering from dementia. This article examines what kinds of strategies or alternative interventions nursing staff in Norway used when patients resist care and treatment and what conditions the staff considered as necessary to succeed in avoiding the use of coercion. The data are based on interdisciplinary focus group interviews with nursing home staff. The study revealed that the nursing home staff usually spent a lot of time trying a wide range of approaches to avoid the use of coercion. The most common strategies were deflecting and persuasive strategies, limiting choices by conscious use of language, different kinds of flexibility and one-to-one care. According to the staff, their opportunities to use alternative strategies effectively are greatly affected by the nursing home’s resources, by the organization of care and by the staff’s competence.

Evaluating clinical ethics support in mental healthcare: A systematic literature review

A systematic literature review on evaluation of clinical ethics support services in mental healthcare is presented and discussed. The focus was on (a) forms of clinical ethics support services, (b) evaluation of clinical ethics support services, (c) contexts and participants and (d) results. Five studies were included. The ethics support activities described were moral case deliberations and ethics rounds. Different qualitative and quantitative research methods were utilized. The results show that (a) participants felt that they gained an increased insight into moral issues through systematic reflection; (b) there was improved cooperation among multidisciplinary team members; (c) it was uncertain whether clinical ethics support services led to better patient care; (d) the issue of patient and client participation is complex; and (e) the implementation process is challenging. Clinical ethics support services have mainly been studied through the experiences of the participating facilitators and healthcare professionals. Hence, there is limited knowledge of whether and how various types of clinical ethics support services influence the quality of care and how patients and relatives may evaluate clinical ethics support services. Based on the six excluded ‘grey zone articles’, in which there was an implicit focus on ethics reflection, other ways of working with ethical reflection in practice are discussed. Implementing and evaluating clinical ethics support services as approaches to clinical ethics support that are more integrated into the development of good practice are in focus. In order to meet some of the shortcomings of the field of clinical ethics support services, a research project that aims to strengthen ethics support in the mental health services, including patients’ and caregivers’ views on ethical challenges, is presented.

Ethical challenges in connection with the use of coercion: a focus group study of health care personnel in mental health care

BackgroundIn recent years, the attention on the use of coercion in mental health care has increased. The use of coercion is common and controversial, and involves many complex ethical challenges. The research question in this study was: What kind of ethical challenges related to the use of coercion do health care practitioners face in their daily clinical work?MethodsWe conducted seven focus group interviews in three mental health care institutions involving 65 multidisciplinary participants from different clinical fields. The interviews were recorded and transcribed verbatim. We analysed the material applying a ‘bricolage’ approach. Basic ethical principles for research ethics were followed. We received permission from the hospitals’ administrations and all health care professionals who participated in the focus group interviews.ResultsHealth care practitioners describe ethical dilemmas they face concerning formal, informal and perceived coercion. They provide a complex picture. They have to handle various ethical challenges, not seldom concerning questions of life and death. In every situation, the dignity of the patient is at stake when coercion is considered as morally right, as well as when coercion is not the preferred intervention. The work of the mental health professional is a complicated “moral enterprise”.The ethical challenges deserve to be identified and handled in a systematic way. This is important for developing the quality of health care, and it is relevant to the current focus on reducing the use of coercion and increasing patient participation. Precise knowledge about ethical challenges is necessary for those who want to develop ethics support in mental health care. Better communication skills among health care professionals and improved therapeutic relationships seem to be vital.ConclusionsA systematic focus on ethical challenges when dealing with coercion is an important step forward in order to improve health care in the mental health field.

Questionable Requirement for Consent in Observational Research in Psychiatry

Informed consent represents a cornerstone of the endeavours to make health care research ethically acceptable. Based on experience of qualitative research on power dynamics in nursing care in acute psychiatry, we show that the requirement for informed consent may be practised in formalistic ways that legitimize the researchers activities without taking the patients changing perception of the situation sufficiently into account. The presentation of three patient case studies illustrates a diversity of issues that the researcher must consider in each situation. We argue for the necessity of researchers to base their judgement on a complex set of competencies. Consciousness of research ethics must be combined with knowledge of the challenges involved in research methodology in qualitative research and familiarity with the therapeutic arena in which the research is being conducted. The article shows that the alternative solution is not simple but must emphasize the researchers ability to doubt and be based on an awareness of the researchers fallibility.

HIV and infant feeding in Malawi: public health simplicity in complex social and cultural contexts

BackgroundThe question of when and how to best wean infants born to mothers with HIV requires complex answers. There are clinical guidelines on best approaches but limitations persist when applying them in diverse low-income settings. In such settings, infant-feeding practices are not only dependent on individual women’s choices but are also subject to social and cultural pressures. However, when developing infant-feeding policies little attention has been paid to these pressures, even though they may yield useful empirical knowledge on the various forces that shape the infant-feeding dilemmas confronting women with HIV. This study aimed to a) identify the infant-feeding challenges that women with HIV faced when they were advised to wean their children at an early age of six months and b) explore how the women adhered to their infant-feeding options while facing and managing these challenges.MethodsThis study was conducted between February 2008 and April 2009 at two public health facilities where services to prevent mother-to-child transmission of HIV were implemented. Repeated in-depth interviews were conducted with 20 HIV-positive women. Two of the 20 women were also chosen for case studies which included home visits.ResultsSeveral interdependent factors including the conflicting pressures of sexual morality and the demands of nurturing and motherhood, in conditions of abject poverty, impeded the participating women from following medical advice on infant feeding. If they adhered to the medical advice, the women would encounter difficulty maintaining their ascribed roles as respected wives, mothers and members of the society at large. The necessity of upholding their moral standing through continued breastfeeding, which signified HIV-negative status, put pressure on them to ignore the medical advice.ConclusionsThe infant-feeding dilemmas for women with HIV are complex. The integration of public health efforts with context-specific socio-cultural understanding is essential. The recent 2010 WHO guidelines offer a possible way of resolving these challenges. They recommend breastfeeding for one year with an adaptation to two years for Malawi. Efforts in the PMTCT programmes to supplement existing support systems, e.g. through the mothers-to-mothers (M2M) programme or consultation with expert mothers may also help women overcome these challenges.

Mature Care and Nursing in Psychiatry: Notions Regarding Reciprocity in Asymmetric Professional Relationships

The idea behind this article is to discuss the importance and to develop the concept of reciprocity in asymmetric professional relationships. As an empirical starting point for an examination of the possible forms of reciprocity between patients and nurses in psychiatry, we chose two qualitative in-depth interviews with two different patients. The manners in which these two patients relate to medical personnel—one is dependent, the other is independent—show that this presents challenges to nurses. The theoretical context is provided by the notion of mature care as it has been developed by feminist-oriented ethics of care, in contrast to the notion of altruistic care. In relation to the concept of mature care, we discuss how nursing can be perceived in demanding relationships with patients in psychiatry. Reciprocity implies that, in principle, the interests of the nurses also matter in a nurse-patient relationship. We show that reciprocity—in practice—is complicated and challenging in a number of different ways. Mature care—with its systematic inclusion of relationships and reciprocity—provides an alternative understanding of what takes place between patients and nurses compared with an altruistic notion of care. As such, mature care can be regarded as an useful paradigm for nurse-patient relationships in psychiatry.

Dealing with ethical challenges: a focus group study with professionals in mental health care

BackgroundLittle 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. Understanding this is important in order to be able to support the professionals, to improve the quality of care, and to know in which way future ethics support services might be helpful.MethodsWithin a project on ethics, coercion and psychiatry, we executed a focus group interview study at seven departments with 65 health care professionals and managers. 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 challenge.ResultsWe 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 challenges.Results 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. Some participants reported that they do not have the time and that they lack a specific methodology. Quite often, informal and retrospective ad-hoc meetings in small teams were organized. 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 decisions.ConclusionsThe 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 way.