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Counteracting Abuse in Health Care from a Staff Perspective: Ethical Aspects and Practical Implications
Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Health Sciences.
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.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1406
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-106234DOI: 10.3384/diss.diva-106234ISBN: 978-91-7519-329-8 (print)OAI: oai:DiVA.org:liu-106234DiVA: diva2:714836
Public defence
2014-05-16, Originalet, Qulturum, Ryhov County Hospital, Jönköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2014-04-29 Created: 2014-04-29 Last updated: 2014-05-16Bibliographically approved
List of papers
1. Ethical guidelines and the prevention of abuse in healthcare
Open this publication in new window or tab >>Ethical guidelines and the prevention of abuse in healthcare
Show others...
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, review/survey (Refereed) Published
Abstract [en]

Objective

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.

Results

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.

Conclusion

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
Keyword
Abuse in health care; Quality of care; Patient safety; Ethicalguidelines; Virtue ethics
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-81881 (URN)10.1016/j.ejogrb.2012.07.018 (DOI)000311762800003 ()
Available from: 2012-09-24 Created: 2012-09-24 Last updated: 2017-12-07
2. Ethical lapses: staff's perception of abuse in health care
Open this publication in new window or tab >>Ethical lapses: staff's perception of abuse in health care
2010 (English)In: Journal of Psychosomatic Obstetrics and Gynaecology, ISSN 0167-482X, E-ISSN 1743-8942, Vol. 31, no 3, 123-129 p.Article in journal (Refereed) Published
Abstract [en]

Objective. Studies have shown high lifetime prevalence of abuse in health care (AHC) in Nordic gynaecological patients. For patients AHC implies feeling disempowered, dehumanised and devalued. The aim of our study was to apprehend health care staffs perceptions of AHC. Study design. Qualitative interviews with staff at a Swedish gynaecological clinic analysed by Constant comparative analysis (N = 21). Results. The two categories - ethical failures against a patient and staff members avoid responsibility - gives two disparate pictures of what AHC is. The interviews showed that these pictures can exist alongside even if they contradict each other. The core category ethical lapses brings staffs contradictory reflections on AHC together in one picture. Notable is that the dualistic notion of AHC did not result in a moral conflict within staff members. Conclusion. Health care staff perceives AHC primarily as ethical lapses. Avoiding responsibility for AHC might lead to a failing recognition of AHC, implying that the problem is not properly dealt with. Our study highlights the need for a more open attitude in health care staff toward AHC. To counteract AHC, staff members need to accept that AHC occurs also in their own units, bringing in moral conflicts in the everyday work.

Keyword
Education, qualitative methods
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-58823 (URN)10.3109/0167482X.2010.491169 (DOI)
Available from: 2010-08-27 Created: 2010-08-27 Last updated: 2017-12-12
3. Counteracting Abuse in Health Care: A Quantitative Evaluation of an Intervention with Forum Play for Staff
Open this publication in new window or tab >>Counteracting Abuse in Health Care: A Quantitative Evaluation of an Intervention with Forum Play for Staff
2014 (English)Manuscript (preprint) (Other academic)
Abstract [en]

Objectives: In their lifetime, 13%–28% of female patients in the Nordic countries seeking gynecological health care have reported abuse by staff in a health care setting (AHC). Besides suffering, AHC can cause patients to avoid contacting the health care system. Thus, interventions are clearly needed. In this article, we report a drama intervention method among health care staff and study to what extent the intervention increased the staff’s awareness of AHC and their ability to take action against it.

Design: Pre-/post-test measurement by means of self-reported questionnaires with a longterm follow-up one year after the intervention. Questionnaires were distributed at four measuring times.

Setting: A women’s clinic in Sweden.

Participants: All staff at the target clinic were invited to participate in the intervention and received the questionnaires (n=137). Of those 136 had the possibility to participate in the intervention. A total of 92 staff members (67%) returned at least two questionnaires. 76 (56%) participated in the intervention, of which 61 (80%) returned at least one questionnaire.

Intervention: The drama intervention was based on Forum Play (FP), a form of improvised role-play based on the pedagogy of Augusto Boal. During one year, 2008–2009, 16 half-day FP workshops focusing on AHC were conducted at the target clinic. Participation was voluntary.

Primary outcome measures: 1) The number of reported occasions when staff heard of or were involved in AHC. 2) FP participants’ self-reported ability to act in AHC-related situations.

Results: No change could be seen in the number of occasions of AHC reported by staff between baseline and one year after the intervention. However, an increase of the participants’ ability to act in AHC-related situations was seen.

Conclusions: Health care staff’s participation in FP workshops can increase their ability to take action in AHC situations, but probably does not affect their awareness of AHC.

Keyword
Abuse in health care, interactive theater, Forum Play, Forum Theater, health care staff, professional-patient relation, moral resources
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-106232 (URN)
Available from: 2014-04-29 Created: 2014-04-29 Last updated: 2015-03-26Bibliographically approved
4. Forum Play as a method for learning ethical practice: A qualitative study among Swedish health-care staff
Open this publication in new window or tab >>Forum Play as a method for learning ethical practice: A qualitative study among Swedish health-care staff
2016 (English)In: Clinical Ethics, ISSN 1477-7509, E-ISSN 1758-101X, Vol. 11, no 1, 9-18 p.Article in journal (Refereed) Published
Abstract [en]

Background: In Scandinavia 13–28% of gynecology patients have experienced abuse in health care in their life time, which contradicts the ethical obligations not to harm the patient and to protect the patient's dignity. Concerning learning to act ethically, scholars have emphasized the importance of combining theoretical and practical dimensions. This article explores Forum Play as a way of learning to act ethically in abusive situations in health care.

Method: Ten health-care workers participating in a Forum Play course took part in this study. To explore participants' experiences of Forum Play, semi-structured interviews were conducted and processed by using the grounded theory analysis techniques of coding and constant comparison.

Results: The analysis resulted in the core category “developing response–ability.” It encompasses the processes bringing about the ability to respond adequately to situations where abuse occurs and the conditions for these processes, as well as the participants' achieved understanding of the third person's potential to act in a situation with a power imbalance. Forum Play allows participants to reflect on both verbal and body language, and gives them time to enact and think through issues of moral agency.

Conclusion: The simulated reality of Forum Play offers a platform where learning to act ethically in abusive situations in health care is facilitated by providing a safe space, suspending constricting structural conditions such as hierarchies and lack of time, fostering moral imagination, allowing creativity in developing and trying out a variety of acting alternatives, and reflecting upon the observed and experienced situation.

Place, publisher, year, edition, pages
Sage Publications, 2016
Keyword
Abuse in health care, professional-patient relation, health care, power, Forum Theater, Forum Play, constant comparative method, ethical learning
National Category
Medical Ethics
Identifiers
urn:nbn:se:liu:diva-106233 (URN)10.1177/1477750915622032 (DOI)
Note

At the time for thesis presentation publication was in status: Manuscript

At the time for thesis presentation manuscript was named: Forum Play as a Method for Ethical Learning: A Qualitative Study among Swedish Health Care Staff

Available from: 2014-04-29 Created: 2014-04-29 Last updated: 2017-12-05Bibliographically approved

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