Professional confidence, interpersonal trust, and organizational safety
Faced with ethical challenges, the moral conduct of prehospital emergency personnel requires moral perception and moral judgment to arrive at moral action. Further, the management of ethical challenges hinges on taking the requirements and demands of the prehospital emergency services and, when applicable, the external collaborators into account. When ethical challenges arise, they are often accompanied by emotions such as doubt, insecurity, inadequacy, and guilt. One participant expressed fear of losing his livelihood, reputation, and well-being in certain circumstances (text example 16). Some participants talked of individual management strategies, such as turning to religious or spiritual thought (text example 21) or sharing with a partner, close relative, or friend (text example 20). The use of dark humour is an integral part of how colleagues generally interact when outsiders are not present (text example 19). When prehospital emergency personnel involve colleagues in a dialogue on ethical challenges, confidence in their professional experience and competence is fundamental, just as interpersonal trust is a prerequisite for sharing. Professional confidence and interpersonal trust is built up over time and through regular collaboration (text examples 23 and 24).
The literature on inter-collegial trust in healthcare is limited. One example is Calnan and Rowe who, in their book “Trust Matters in Healthcare” [35], write about trust among clinicians. The authors find that medical competence is central when clinicians build trust in each other. However, being technically skilled is not sufficient. Interpersonal values like confidentiality, honesty, reliability, and good manners are equally important. In addition, the clinician must act in the patient’s best interest. Earlier trust among clinicians was achieved through hierarchical systems, but today, so the authors claim, trust is built and maintained over time. The assessment of confidentiality, honesty, reliability, and medical competence is an ongoing process. Further, the authors describe how clinicians can lose confidence in a colleague if their medical competencies are brought into serious question. Minor flaws are accepted. More importantly, confidence can be jeopardised if someone fails to show respect for a colleague. The authors find that a low level of trust causes a lack of confidence and increased criticism that in turn perpetuates the lack of trust within a team. A high level of trust leads to openness, better communication, and effective working relationships.
In our study, the prehospital emergency personnel predominantly point to informal forums as the context were ethical challenges are discussed. They report that they deliberate on ethically challenging situations in the ambulance or MECU on route back to the unit´s base. There are several reasons why prehospital emergency personnel do not discuss ethical challenges more broadly in the organisation. EMTs and PMs do not appreciate a sense of being publicly corrected (text example 17) and they do not have a forum with organisational impunity. Medical physicians are invited to present and deliberate on incidents that turned out in unwanted or unintended ways at monthly group meetings (text example 25). Although a younger physician expressed hesitation, as he did not feel confident enough to present his ethical challenges, several other physicians voiced their appreciation of this organisational opportunity to share and found it useful (text example 26).
Our study indicates that prehospital emergency personnel need to feel confident in and to trust their colleagues and managers if they are to share the ethical challenges they experience at work. French et al. [8] describe that emergency medical service professionals prefer to discuss ethical conflicts with peers, friends, family, and union delegates rather than following the formal organisational procedures (turning to a superior). This is because people who are not representatives of the organisation are viewed as more empathetic and can be consulted without fear of the legal repercussions that could follow from a formal process. Thus, a lack of trust is the primary reason for them not to engage with organisational processes or supporting committees. Calnan and Rowe [36] provide a general description of what characterises trust relations between clinicians and managers. In contrast to trust between clinicians, which is largely based on medical competence, trust in managers is driven by honesty and accessibility, but also to the extent to which they act in the interests of the clinical practice. Clinicians lose confidence in their managers if they appear to prioritise meeting government targets over clinical needs. Clinicians distrust managers “if their involvement in running service was seen as interference with clinical decision-making and indicated a lack of respect for clinicians’ professional judgement and autonomy. “Distrust was created particularly when clinicians felt managers were interfering to save money but this results in poorer patient care” [36]p137. Trust, on the other hand, is reflected in clinicians’ desire to share confidential ethical challenges related to patient care with their managers.
Professional background, moral judgement, and possibilities of action
In addition to legal requirements, medical guidelines, and demands from external collaborators, the professional background of prehospital emergency personnel influence moral perception, judgement, and action in specific incidents. Although the purpose of our study was not to investigate differences between physicians, EMTs, and PMs we found that physicians pay attention to what they can and must do medically and technically (text example 12, 13), to avoid complaints and court cases more so than EMTs and PMs. Further, physicians include theoretical perspectives to a larger extent when they reason about their actions.
Several studies indicate that there are differences in the ethical reasoning of different healthcare professionals. A survey based on 2129 respondents conducted by Telleus et al. [37] showed that caregivers like nurses more often assess ethical challenges in a relational position while physicians more often take a deontological position. Concurrently, Telleus et al. [37] discuss that although some empirical studies have been conducted on ethical decision-making processes among healthcare professionals most studies are theory driven. One exception is a study by Agledahl et al. [38] based on participant observation among 15 physicians from different medical specialities. The authors describe how physicians handle ethical challenges in clinical settings. Across medical specialities, physicians approach ethical challenges in a relatively uniform way. They break down the patient’s history, amplify the patient’s complaints, and categorise them according to medical symptoms. Focus is directed at the patient’s functional level and existential aspects remain unexplored.
Another exception is an interview study conducted by Hurst et al. [39] investigating physicians’ handling of ethical challenges. The authors interviewed internal medicine physicians, oncologists, and physicians in intensive care units about the ethical challenges they had experienced and how they acted. The authors found that when physicians are confronted with an ethical challenge, they seek assistance and try to avoid a conflict, protect their own integrity, conscience and reputation, and protect the group of people involved in the decision and their integrity.
In our study, we found that prehospital emergency personnel base moral judgment on the perception of morally relevant information and clues in the environment. EMTs and PMs described relying on their gut feeling (what we have termed sensory-emotional evaluation) and on physicians’ assessment of the situation. Further, physicians pointed to clinical guidelines, legislation, and bioethical concepts. To our knowledge, there is no literature analysing the process of moral judgment among EMTs and PMs. Goethals et al. [40] have described moral reasoning and behaviour among nurses in a literature review. Nurses’ ethical reasoning is a complex process based on moral theories, ethical principles, and situational aspects embedded in the specific context of the nurse-patient relationship. Ethical reasoning emerges from the patient’s need for care and is influenced by the nurse’s relationship with the patient’s relatives and the team in the clinical context. The authors conclude that the ethical behaviour of nurses is closely tied to relational and contextual aspects of care.
In our study, EMTs and PMs are legally obliged to answer to physicians’ decisions. It can prove difficult for EMTs and PMs to act against their own moral judgement when they do not agree with physicians. Some try to indirectly influence the physicians towards the desired sequence of events or comment directly on physicians’ choices (text example 10). Sometimes EMTs and PMs refrain from getting involved if overt disagreement is deemed irreconcilable with good patient care. For some EMTs and PMs, at times, the only solution can, be to leave the scene in order not to take on responsibility for actions they disagree with and to demonstrate their disapproval. Physicians, on the other hand, are aware that they are accountable to medical guidelines and legislation, as well as being responsible for the team collaboration to achieve the best possible outcome for the patient.
Our and other studies describe how the considerations of healthcare professionals are influenced by their working conditions and medical disciplines (somatic [41, 42], psychiatry [43, 44], primary health care [45, 46]), as well as their position and responsibility (nurses [14], physicians [47, 48]). However, our study clarifies an interdisciplinary perspective in moral conduct that stresses the asymmetrical power relationship between physicians, EMTs and PMs. Consequently, EMTs and PMs discreetly try to influence physicians’ decisions. If that is not possible, they may withdraw from direct engagement in patient care. EMTs and PMs convey that this is motivated by their commitment to protect patients and relatives from experiencing disagreement or conflict between the prehospital emergency personnel in a distressing situation. Further, they do not want to jeopardize their own professional reputation or risk hampering future interdisciplinary collaboration. Overall, the EMTs and PMs weigh their professional integrity against protecting patients and securing future working relations with physicians. Articulating ethical challenges that bring the asymmetric power relations into question may have major personal and professional consequences for the individual EMT or PM. Therefore, these cases are delicate, and those who articulate them are vulnerable. Paradoxically, asymmetric power relations is one key barrier to clinical ethics support [49], while at the same time offering a framework for structured dialogue on the consequences of power relations amongst prehospital emergency personnel [19].
Personal capacity for empathy as essential for moral conduct
According to Vetlesen and Nordvedt [30], moral conduct is a result of the emotional-cognitive process of moral perception and judgement resulting in action. Fundamental to any moral conduct is the ability to be receptive to the moral significance of a specific situation, and how the situation affects the well-being of the people involved. “Emotions are active and indeed indispensable in disclosing to us that others’ weal and woe is somehow at stake in a given situation” [31]. The individual’s emotional life resonates with his or her ability to empathise with others. The ability to empathise is developed exactly through growing up with others. Moral conduct in emergency services, as elsewhere, is based on the perception of what is morally significant, which is ultimately a result of the entire personal biography, including experiences at work. The personally developed capacity for empathy is a foundation for doing the job and is challenged, developed, or hampered on the job. The growing acceptance of psychological treatment (text example 18) may come with the risk that challenges associated with moral behaviour are privatised and individualised. The relevant and natural psychological reactions prehospital emergency personnel experience because ethical challenges may even be seen as pathological. Even if individual psychological treatment can provide an opportunity to reflect on work-related ethical challenges, it does not support organisationally grounded and collective ways of developing strategies for managing ethical challenges. This contrasts with generalising and normalising the emotional ability that forms the basis of moral perception, which is fundamental for prehospital emergency personnel to make decisions based on a moral assessment of a specific situation. Privatisation hinders an important dialogue about the psychological protection and well-being of personnel who are expected – and consider it an important part of the job – to empathise with their patients.
Establishing clinical ethics support
Moral case deliberation [50]is one of several different ways of organising clinical ethics support. In a literature review, Haan et al. [19] describe the impact of moral case deliberation in healthcare settings. The authors identify four thematic clusters: (a) changes that are brought about on a personal and inter-professional level, concerning the healthcare professional’s feelings of relief, relatedness and confidence; understanding of the perspectives of colleagues, one’s own perspective and the moral issue at stake; and awareness of the moral dimension of one’s work and of the importance of reflection; (b) changes that are brought about in caring for patients and families; and (c) changes that are brought about on an organizational level. Moreover, the authors identify a cluster of themes concerning (d) facilitators and barriers in the preparation and context of MCD, i.e., a safe and open atmosphere created by a facilitator, a concrete case, commitment of participants, a focus on the moral dimension, and a supportive organisation.
Traditionally, professionals embedded in a medical culture are reluctant to share ethical challenges with outsiders, as they can be seen as being disloyal to colleagues [51]. The inclination to share ethical challenges differs between various healthcare professionals. While nurses find it very important to share their ethical dilemmas and decisions with other nurses and to receive support [40], physicians are more reluctant to do so [49]. Yet our analysis supports other studies [14] showing that moral conduct – involving moral perception, judgement, and action – is rarely understood or acted on by health professionals as a simple matter of right or wrong. By contrast, ethical challenges are commonly staged as complex situations involving decisions and actions dependent on legal, medical, and organisational demands [3, 8]. For these reasons, individual coping strategies are not enough to address moral distress. The development and testing of context sensitive forms of clinical ethics support in the prehospital emergency services of the region of Southern Denmark will be discussed elsewhere.
Strength and limitations
The results of the study are based on data generated using mixed focus groups with the participation of both MECU physicians, EMTs and PMs. Focus groups may offer a safe place for participants to reflect on topics that are difficult to talk about, e.g. because of stigmatization or taboo. By including MECU physicians, EMTs and PMs we have ensured sufficient dynamics in the focus group for different experiences, perspectives and coping strategies to be articulated. However, the presence of MECU physicians in the focus group could have had the consequence that not all EMTs and PMs experienced the focus group as a safe place, which is why they may have withheld important and relevant perspectives. Nevertheless, a rich and diverse data material was collected and it became clear that there were different areas of responsibility and opportunities for moral action depending on whether it was MECU physicians or EMTs and PMs who experienced ethical challenges.
A limitation concerning external validation to other healthcare branches is that generally, in healthcare services, female employees are overrepresented. In Denmark, however, in the prehospital emergency system, the personnel traditionally consists mostly of male employees. Although this trend is slowly changing, the gender distribution in the focus groups reflects the gender distribution at present.
Moreover, the participants were recruited through information about the purpose of the study. This may have resulted in an overrepresentation of prehospital emergency personal who were particularly interested in ethical challenges. By not necessarily forming a representative sample of prehospital personnel, this study cannot quantify the overall incidence of ethical challenges among prehospital emergency personnel.
Despite the limitations described above, our comprehensive descriptions of the context of the research project may enable readers from other parts of the healthcare system to assess differences and apply our findings with relation to their clinical practice. We thus have sought to enhance the transferability of the study´s results through a reader-based analytical validity.
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