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Ethical guidelines and the prevention of abuse in healthcare
Linköping University, Department of Clinical and Experimental Medicine, Gender and medicine. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Clinical and Experimental Medicine, Gender and medicine. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Clinical and Experimental Medicine, Gender and medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre of Paediatrics and Gynecology and Obstetrics, Department of Gynecology and Obstetrics in Linköping.
Linköping University, Department of Medical and Health Sciences, Health and Society. Linköping University, Faculty of Arts and Sciences.
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2012 (English)In: European Journal of Obstetrics, Gynecology, and Reproductive Biology, ISSN 0301-2115, E-ISSN 1872-7654, Vol. 165, no 1, 18-28 p.Article in journal (Refereed) Published
Abstract [en]


In obstetrical and gynaecological healthcare, patients often find themselves in a vulnerable position. Sensitive issues such as sexual and reproductive health are addressed and certain procedures can be experienced as abusive. According to research a lifetime prevalence of abuse in healthcare (AHC) can be assumed for 13–28% of female patients in the Nordic countries. In the present study we analyse the content of ethical documents for healthcare professionals within obstetrics and gynaecology in Sweden, in order to find out to what extent ethicalguidelines consider issues that have shown to be related to the occurrence of AHC.

Study design

We searched the literature to find empirical data on AHC. Guidelines for nurses, midwives and physicians were selected. After developing an analytical framework based on the empirical data the content of the ethicalguidelines was analysed.


The various ethicalguidelines for staff working within obstetrics and gynaecology differ distinctively from each other regarding their content of issues that are related to AHC. Issues that were mostly disregarded were: considering the patient's perspective and the patients’ possible experience of violence, considering power imbalances within healthcare, sexual misconduct, how to deal with other professional's ethical misconduct and how professionals relate to each other. We found the ethicalguidelines of the International Federation of Gynecology and Obstetrics (FIGO) and of the International Confederation of Midwives to be those which contained most of the issues that have empirically shown to be important in regard to AHC.


While staff members from different professions may share responsibility for the same patient, their ethicalguidelines vary considerably. To become a possible resource for prevention of AHC, we suggest that ethicalguidelines in healthcare should be revised following empirical research on ethical conduct. As ethicalguidelines cannot be effective by their existence only, we would like to initiate a discussion on the function and use of ethicalguidelines in general and regarding AHC in particular. Being aware that ethicalguidelines are only a part of ethics in healthcare, however, we envision a broader approach to the aim of preventing AHC, where research is encouraged on how a virtue ethics approach could be applied.

Place, publisher, year, edition, pages
Elsevier, 2012. Vol. 165, no 1, 18-28 p.
Keyword [en]
Abuse in health care; Quality of care; Patient safety; Ethicalguidelines; Virtue ethics
National Category
Medical and Health Sciences
URN: urn:nbn:se:liu:diva-81881DOI: 10.1016/j.ejogrb.2012.07.018ISI: 000311762800003OAI: diva2:556217
Available from: 2012-09-24 Created: 2012-09-24 Last updated: 2014-04-29
In thesis
1. Counteracting Abuse in Health Care from a Staff Perspective: Ethical Aspects and Practical Implications
Open this publication in new window or tab >>Counteracting Abuse in Health Care from a Staff Perspective: Ethical Aspects and Practical Implications
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Abuse of patients by health care staff (AHC) is a cause of unnecessary suffering, which is inconsonant with the premise in medicine of not doing harm to the patient. The understanding of AHC in this thesis is considered two-dimensional: as a patient’s subjective experience and as violation of a patient’s dignity. Patients’ experiences of these events are rather well studied and are characterized by feelings of neglect and a loss of their human value. However, little is known about staff’s perspectives on AHC and what they can do to counteract it.

Aim: The overall aim of this thesis is to approach AHC from the perspective of health care staff in order to develop and test a model for enabling health care staff to recognize and take action in situations where AHC is about to happen and to handle it professionally once it has happened.

Methods: To explore professionals’ formal perspectives on AHC, five sets of ethical guidelines for staff working within gynecology and obstetrics were examined in study I, using an analytical framework based on empirical studies regarding issues related to AHC. Data for studies II and III were collected at a women’s clinic that had chosen to host an intervention model based on Forum Play (FP) as a method for counteracting AHC. In FP, an improvisational theater method, based on Boal’s Forum Theater, staff together stage problematic situations from their own experience and test different ways of acting. In study II, qualitative interviews with 21 staff members from the target clinic were conducted, to capture the staff’s perception of AHC before the intervention. Study III evaluated the impact of 16 FP workshops by means of questionnaires focusing on the occurrences of AHC and the perceived effects of FP, sent to all staff (n=137) before, during, and after the intervention. In study IV, ten participants of an FP course, consisting of a mixed group of employees working within health care, were interviewed about their experiences of the FP course.

Results: In study I, it was shown that all guidelines failed to address issues related to AHC, mainly structural issues such as power imbalances between professionals. In study II, the staff’s described perception of AHC was best categorized as ethical lapses, integrating theoretical descriptions of AHC with a defensive staff-centered position that rejected responsibility for AHC. In study III, no indication of an increased awareness of AHC was found, but an increase in the staff’s ability to act in situations with a moral dilemma was confirmed, even one year after the intervention. The findings of study IV suggest that FP has the potential to develop a response ability, enabling staff to become active in AHC situations. The power to intervene when witnessing AHC was emphasized.

Conclusions: Assuming that clinical practice is a moral activity with the good of the patient as its end, it is important for staff to be able to understand AHC from the patient’s perspective. To accomplish this, even structural aspects such as power imbalances between professionals have to be considered. By failing to address these important aspects, ethical guidelines appear to be a limited resource for helping to counteract AHC. FP enables staff participants to adopt a patient’s perspective and to develop an understanding of their power and responsibility to act when in a situation involving AHC. Furthermore FP seems to provide a useful tool for staff learning to display and overcome structural obstacles in order to intervene when witnessing AHC. If counteracting AHC is understood as a matter of acting professionally, practical training such as FP needs to be prioritized.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2014. 76 plus Appendix p.
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1406
National Category
Medical and Health Sciences
urn:nbn:se:liu:diva-106234 (URN)10.3384/diss.diva-106234 (DOI)978-91-7519-329-8 (print) (ISBN)
Public defence
2014-05-16, Originalet, Qulturum, Ryhov County Hospital, Jönköping, 09:00 (Swedish)
Available from: 2014-04-29 Created: 2014-04-29 Last updated: 2014-05-16Bibliographically approved

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Zbikowski, AnckeBrüggemann, Adrianus JelmerWijma, BarbroZeiler, KristinSwahnberg, Katarina
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Gender and medicineFaculty of Health SciencesDepartment of Gynecology and Obstetrics in LinköpingHealth and SocietyFaculty of Arts and Sciences
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European Journal of Obstetrics, Gynecology, and Reproductive Biology
Medical and Health Sciences

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