Two years of ethics reflection groups about coercion in psychiatry. Measuring variation within employees' normative attitudes, user involvement and the handling of disagreement.

BACKGROUND: Research on the impact of ethics reflection groups (ERG) (also called moral case deliberations (MCD)) is complex and scarce. Within a larger study, two years of ERG sessions have been used as an intervention to stimulate ethical reflection about the use of coercive measures. We studied changes in: employees' attitudes regarding the use of coercion, team competence, user involvement, team cooperation and the handling of disagreement in teams. METHODS: We used panel data in a longitudinal design study to measure variation in survey scores from multidisciplinary employees from seven departments within three Norwegian mental health care institutions at three time points (T0-T1-T2). Mixed models were used to account for dependence of data in persons who participated more than once. RESULTS: In total, 1068 surveys (from 817 employees who did and did not participate in ERG) were included in the analyses. Of these, 7.6% (N = 62) responded at three points in time, 15.5% (N = 127) at two points, and 76.8% (N = 628) once. On average, over time, respondents who participated in ERG viewed coercion more strongly as offending (p < 0.05). Those who presented a case in the ERG sessions showed lower scores on User Involvement (p < 0.001), Team Cooperation (p < 0.01) and Constructive Disagreement (p < 0.01). We observed significant differences in outcomes between individuals from different departments, as well as between different professions. Initial significant changes due to frequency of participation in ERG and case presentation in ERG did not remain statistically significant after adjustment for Departments and Professions. Differences were generally small in absolute terms, possibly due to the low amount of longitudinal data. CONCLUSIONS: This study measured specific intervention-related outcome parameters for describing the impact of clinical ethics support (CES). Structural implementation of ERGs or MCDs seems to contribute to employees reporting a more critical attitude towards coercion. Ethics support is a complex intervention and studying changes over time is complex in itself. Several recommendations for strengthening the outcomes of future CES evaluation studies are discussed. CES evaluation studies are important, since-despite the intrinsic value of participating in ERG or MCD-CES inherently aims, and should aim, at improving clinical practices.

Frequent Violations and Infringements against Users in Mental Health Care Confirmed by Both Users and Professionals - A Quantitative Study.

The main task of mental health care services is to provide good quality of care. Despite this, users are sometimes treated badly by staff. The purpose of this study was to investigate violations and infringements towards users in mental health care services, from the perspectives of both staff and users. Data were gathered through an anonymous online questionnaire sent to staff and users in Norway. Staff were recruited in collaboration with professional organisations and users in collaboration with user-organisations.

Changes in work stress among doctors in Norway from 2010 to 2019: a study based on repeated surveys.

OBJECTIVES: To explore and discuss the changes in the levels of work stress for Norwegian doctors in different job positions (hospital doctors, general practitioners (GPs), private practice specialists, doctors in academia) from 2010 to 2019. DESIGN: Repeated questionnaire surveys in 2010, 2016 and 2019, where samples were partly overlapping. SETTING: Norway. PARTICIPANTS: A representative sample of 1500-2200 doctors in different job positions. Response rates were 66.7% (1014/1520) in 2010, 73.1% (1604/2195) in 2016 and 72.5% (1511/2084) in 2019. MAIN OUTCOME MEASURE: Validated 9-item short form of the 'Effort-Reward Imbalance' questionnaire. A risky level of work stress was defined as an effort/reward ratio above 1.0. ANALYSES: Linear mixed models with estimated marginal means of job positions controlled for gender and age. Proportions with 95% CIs. RESULTS: From 2010 to 2016 and further to 2019, GPs reported a significant increase in levels on the effort scale (ES: 2.96, 3.25, 3.51) and significant decrease in levels on the reward scale (RS: 4.27, 4.05, 3.67). No significant changes were reported by hospital doctors (ES: 3.13, 3.10, 3.14; RS: 4.09, 3.98, 4.04), private practice specialists (ES: 2.58, 2.61, 2.59; RS: 4.32, 4.32, 4.30) and doctors in academia (ES: 2.63, 2.51, 2.52; RS: 4.09, 4.11, 4.14). The proportion of doctors with risky levels of work stress increased significantly for GPs (10.3%, 27.7%, 40.1%), but did not significantly change for hospital doctors (23.0%, 27.3%, 26.9%), private practice specialists (8.2%, 12.7%, 9.4%) and doctors in academia (11.9%, 19.0%, 16.4%). CONCLUSION: During a 9-year period, the proportion of risky levels of work stress increased significantly for GPs but did not significantly change for other job positions. This may be partly due to changes in expectations of younger GPs and several healthcare reforms and regulations.

'It comes with the territory' - Staff experience with violation and humiliation in mental health care - A mixed method study.

BACKGROUND: The aim of this study was to investigate staff's experiences with violation and humiliation during work in mental health care (MHC). A total of 1160 multi-professional MHC staff in Norway responded to an online questionnaire about their experiences with different kinds of violation and humiliation in the MHC setting. In addition, a sample of professionals (eight MHC nurses) were recruited for in-depth individual interviews. METHOD: The study used an explorative mixed method with a convergent parallel design; this included a web-based questionnaire to MHC staff in combination with individual interviews. The sample is considered to be equivalent to staff groups in MHC in Norway. RESULTS: Between 70 and 80% of the staff reported experiencing rejection, being treated with disrespect, condescending behaviour or verbal harassment. Male workers were significantly more often victims of serious physical violence, and women were significantly more often targets for sexual harassment. In interviews, participants said they considered being exposed to violence and humiliation to be part of the job when working in MHC, and that experience, as well as social support from colleagues, helped MHC practitioners to cope better with violent situations and feel less humiliated at work. DISCUSSION: A high amount of MHC staff report experiences of being violated and humiliated during work. The participants' perceptions of the users and their behaviour seem to influence their experience of feeling violated and humiliated. Knowledge about the dynamics of aggression between staff and users in MHC may be used in safeguarding staff and users, prevent coercion and heighten the quality of care.

Why are doctors opting out of general practice? / Hvorfor velger leger seg bort fra allmennmedisin?

BACKGROUND: There has been a sustained focus on the lack of recruitment to general practice in Norwegian politics, media and research. We have little knowledge of the reasons that have been prominent for doctors who have actively opted out of general practice. We therefore wished to investigate what types of doctors choose not to work in general practice and why. MATERIAL AND METHOD: The data are based on a questionnaire that was sent to the 2 195 members of the Medical Panel in 2016/17. The response rate was 73.1 %. We used graphics and descriptive analyses to study inter-group differences between those who had considered general practice but made another choice, and those who had quit general practice. RESULTS: Of the 1 153 doctors who were not general practitioners, 44.1 % had not considered this as an option. 39.9 % had considered it, but chosen differently, and 16.0 % had previously worked as GPs, but quit. The administrative burden and small professional community were the main reasons for doctors to opt out of general practice. INTERPRETATION: The administrative burden and small professional community were key reasons why doctors opted out of general practice or quit the specialty. A number of other factors also played a role, and the efforts to recruit and retain GPs should therefore be seen in a wider and more overarching context.

Changes in job satisfaction among doctors in Norway from 2010 to 2017: a study based on repeated surveys.

OBJECTIVE: To assess job satisfaction for different categories of Norwegian doctors from 2010 to 2016-2017. DESIGN: Cross-sectional surveys in 2010, 2012, 2014 and 2016-2017 of partly overlapping samples. SETTING: Norway from 2010 to 2016-2017. PARTICIPANTS: Doctors working in different job positions (hospital doctors, general practitioners (GPs), private practice specialists, doctors in academia). Response rates were 67% (1014/1520) in 2010, 71% (1279/1792) in 2012, 75% (1158/1545) in 2014 and 73% (1604/2195) in 2016-2017. The same 548 doctors responded at all four points in time. MAIN OUTCOME MEASURE: Job Satisfaction Scale (JSS), a 10-item widely used instrument, with scores ranging from 1 (low satisfaction) to 7 (high satisfaction) for each item, and an unweighted mean total sum score. ANALYSIS: General Linear Modelling, controlling for gender and age, and paired t-tests. RESULTS: For all doctors, the mean scores of JSS decreased significantly from 5.52 (95% CI 5.42 to 5.61) in 2010 to 5.30 (5.22 to 5.38) in 2016-2017. The decrease was significant for GPs (5.54, 5.43 to 5.65 vs 5.17, 5.07 to 5.28) and hospital doctors (5.14, 5.07 to 5.21 vs 5.00, 4.94 to 5.06). Private practice specialists were most satisfied, followed by GPs and hospital doctors. The difference between the GPs and the private practice specialists increased over time. CONCLUSIONS: From 2010 to 2016-2017 job satisfaction for Norwegian doctors decreased, but it was still at a relatively high level. Several healthcare reforms and regulations over the last decade and changes in the professional culture may explain some of the reduced satisfaction.

Between authoritarian and dialogical approaches: Attitudes and opinions on coercion among professionals in mental health and addiction care in Norway.

More knowledge is needed on how to reduce the prevalence of formal and informal coercion in Norwegian mental health care. To explore possible reasons for the widespread differences in coercive practice in psychiatry and drug addiction treatment in Norway, and the poor compliance to change initiatives, we performed a nationwide survey. Six vignettes from concrete and realistic clinical situations where coercive measures were among the alternative courses of action, and where the difference between authoritarian (paternalistic) and dialogical (user participation) practices was explicitly delineated, were presented in an electronic questionnaire distributed to five groups of professionals: psychiatrists, psychologists, nurses, other professionals and auxiliary treatment staff. Non-coercive dialogical resolutions were more likely than coercive authoritative. However, there is a clear professional hierarchy with regard to authoritarian approaches, with the psychiatrists on top, followed by nurses and other professionals, and with psychologists as the least authoritarian. The majority of the respondents sometimes prefer actions that are illegal, which suggests that individual opinions about coercion often overrule legislation. The variation between and within professional groups in attitudes and opinions on coercion is extensive, and may account for some of the hitherto meagre results of two ministerial action plans for coercion reduction.

Physician characteristics influence the trends in resuscitation decisions at different ages.

AIM: We examined how physicians in different medical specialties would evaluate treatment decisions for vulnerable patients in need of resuscitation. METHODS: A survey depicting six acutely ill patients from newborn infant to aged, all in need of resuscitation with similar prognoses, was distributed (in 2009) to a representative sample of 1650 members of the Norwegian Medical Association and 676 members of the Norwegian Pediatric Association. RESULTS: There were 1335 respondents (57% participation rate). The majority of respondents across all specialties thought resuscitation was in the best interest of a 24 weeks' gestation preterm infant and would resuscitate the patient, but would also accept palliative care on the family's demand. Accepting a family's refusal of resuscitation was more common for the newborn infants. Specialists were overall similar in their answers, but specialty, age and gender were associated with different answers for the patients at both ends of the age spectrum. CONCLUSION: Resuscitation decisions for the very young do not always seem to follow the best interest principle. Specialty and personal characteristics still have an impact on how we consider important ethical issues. We must be cognisant of our own valuations and how they may influence care.

Perceived bullying among Norwegian doctors in 1993, 2004 and 2014-2015: a study based on cross-sectional and repeated surveys.

OBJECTIVES: To examine 12-month prevalence of perceived bullying at work for doctors in different job categories and medical disciplines in 1993, 2004 and 2014-2015, and personality traits, work-related and health-related factors associated with perceived workplace bullying. DESIGN: Cross-sectional questionnaire surveys in 1993, 2004 and 2014-2015 where the 2004 and the 2012-2015 samples are partly overlapping. SETTING: Norway. PARTICIPANTS: Response rates were 72.8% (2628/3608) in 1993, 67% (1004/1499) in 2004 and 78.2% (1261/1612) in 2014-2015. 485 doctors responded both in 2004 and 2014-2015. OUTCOME MEASURE: Perceived bullying at work from colleagues or superiors at least a few times a month during the last year. RESULTS: Between the samples from 1993, 2004 and 2014-2015, there were no significant differences in the prevalence of perceived bullying at work. More senior hospital doctors and surgeons reported being bullied. Doctors with higher scores on the personality trait neuroticism were more likely to perceive bullying, as were female doctors, doctors with poor job satisfaction and poor self-rated health. CONCLUSIONS: The fraction of doctors who experienced bullying at work was stable over a 20-year period. Psychological, psychosocial and cultural factors are predictors of perceived bullying.

Between professional values, social regulations and patient preferences: medical doctors' perceptions of ethical dilemmas.

BACKGROUND: We present and discuss the results of a Norwegian survey of medical doctors' views on potential ethical dilemmas in professional practice. METHODS: The study was conducted in 2015 as a postal questionnaire to a representative sample of 1612 doctors, among which 1261 responded (78%). We provided a list of 41 potential ethical dilemmas and asked whether each was considered a dilemma, and whether the doctor would perform the task, if in a position to do so. Conceptually, dilemmas arise because of tensions between two or more of four doctor roles: the patient's advocate, a steward of societal interests, a member of a profession and a private individual. RESULTS: 27 of the potential dilemmas were considered dilemmas by at least 50% of the respondents. For more than half of the dilemmas, the anticipated course of action varied substantially within the professional group, with at least 20% choosing a different course than their colleagues, indicating low consensus in the profession. CONCLUSIONS: Doctors experience a large range of ethical dilemmas, of which many have been given little attention by academic medical ethics. The less-discussed dilemmas are characterised by a low degree of consensus in the profession about how to handle them. There is a need for medical ethicists, medical education, postgraduate courses and clinical ethics support to address common dilemmas in clinical practice. Viewing dilemmas as role conflicts can be a fruitful approach to these discussions.

The HPV vaccine: knowledge and attitudes among public health nurses and general practitioners in Northern Norway after introduction of the vaccine in the school-based vaccination programme.

OBJECTIVE: To investigate knowledge of and attitudes to human papillomavirus (HPV) infection, HPV vaccination, cervical cancer, related sources of information and factors associated with willingness to vaccinate one's own daughter among primary health care (PHC) personnel. DESIGN: Cross-sectional study. SETTING: PHC. SUBJECTS: All public health nurses (PHNs) and general practitioners (GPs) in Northern Norway were invited to answer a structured electronic questionnaire; 31% participated (N = 220). MAIN OUTCOME MEASURES: Self-reported and actual knowledge, information sources, attitudes and willingness to vaccinate their (tentative) daughter. RESULTS: 47% of respondents knew that HPV infection is a necessary cause of cervical cancer. PHNs had higher self-reported and actual knowledge about HPV vaccination and cervical cancer than GPs. PHNs used the Norwegian Institute of Public Health's numerous information sources on HPV, while GPs had a low user rate. 88% of PHNs and 50% of GPs acquired information from the pharmaceutical industry. 93% PHNs and 68% of GPs would vaccinate their 12-year-old daughter. In a multivariate logistic regression analysis, willingness to vaccinate one's daughter was positively associated with younger age, being PHN (OR = 5.26, 95%CI 1.74-15.94), little concern about vaccine side effects (OR = 3.61, 95%CI 1.10-11.81) and disagreement among experts (OR = 7.31, 95%CI 2.73-19.60). CONCLUSIONS: Increased knowledge about HPV infection and vaccination is needed, particularly among GPs. Those least concerned about side effects and disagreements among experts were most likely to vaccinate their daughter. These findings are of interest for public health authorities responsible for the Norwegian vaccination and cervix cancer screening programmes, and providers of training of PHC personnel. Key points One year after introduction of HPV vaccination among 12-year-old schoolgirls in Norway, a cross-sectional study in Northern Norway among general practitioners (GPs) and public health nurses (PHNs) showed that • barely half of PHC professionals knew the causal relationship between HPV infection and cervical cancer • PHNs and GPs had higher self-reported than actual knowledge about HPV vaccination and cervical cancer nearly all PHNs and two thirds of GPs wanted to vaccinate their 12-year-old daughter. Those most concerned about side effects and disagreement among experts were less likely to vaccinate.

Changes in prevalence of workplace violence against doctors in all medical specialties in Norway between 1993 and 2014: a repeated cross-sectional survey.

OBJECTIVES: The aim of this study was to investigate whether reported prevalence of experienced threats, real acts of violence and debilitating fear of violence among Norwegian doctors have increased over the last two decades. DESIGN: Repeated cross-sectional survey. SETTING: All healthcare levels and medical specialties in Norway. PARTICIPANTS: Representative samples of Norwegian doctors in 1993 (n=2628) and 2014 (n=1158). MAIN OUTCOME MEASURES: Relative risk (RR) of self-reported prevalence of work-time experiences of threats and real acts of violence, and of being physically or psychologically unfit during the last 12 months due to fear of violence, in 2014 compared with 1993, adjusted by age, gender and medical specialty. RESULTS: There were no differences in self-reported threats (adjusted RR=1.01, 95% CI 0.95 to 1.08) or real acts (adjusted RR=0.90, 95% CI 0.80 to 1.03) of violence when comparing 2014 with 1993. The proportion of doctors who had felt unfit due to fear of violence decreased from 1993 to 2014 (adjusted RR=0.53, 95% CI 0.39 to 0.73). Although still above average, the proportion of doctors in psychiatry who reported real acts of violence decreased substantially from 1993 to 2014 (adjusted RR=0.75, 95% CI 0.60 to 0.95). CONCLUSIONS: A substantial proportion of doctors experience threats and real acts of violence during their work-time career, but there was no evidence that workplace violence has increased over the last two decades. Still, the issue needs to be addressed as part of the doctors' education and within work settings.

Does the University of Tromsø - The Arctic University of Norway educate doctors to work in rural communities? / Utdanner Universitetet i Tromsø ­ Norges arktiske universitet leger til å arbeide i distrikter?

BACKGROUND: When Storting (the Norwegian Parliament) resolved in 1968 to build the University of Tromsø, the purpose of the study model was to promote recruitment and a stable GP density throughout North Norway. We wanted to shed light on the degree to which GPs and doctors in health trusts who were graduates of the University of Tromsø work in rural and central municipalities, and at university hospitals and other hospitals respectively. MATERIAL AND METHOD: We used de-identified data covering 406 GPs and 909 doctors in health trusts who had graduated from the University of Tromsø in the period 1979 ­ 2012. RESULTS: A larger share of GPs educated at the University of Tromsø (30 %) worked in rural municipalities compared with all GPs in Norway (19 %). GPs educated at the University of Tromsø staffed 57 % of the positions in central municipalities and 34 % of the positions in rural municipalities in North Norway. A larger share of doctors in health trusts (64 %) educated at the University of Tromsø worked at a university hospital compared with all doctors in health trusts in Norway (56 % worked at a university hospital). Over half (53 %) of the doctors at the University Hospital of North Norway were graduates of the University of Tromsø. In Nordland and Finnmark, the corresponding percentage at health trusts varied between 14 and 28 %. INTERPRETATION: Our data suggest that medical studies at the University of Tromsø make a considerable contribution to GP density in rural communities and to solid recruitment to the University Hospital of North Norway.

Staff's normative attitudes towards coercion: the role of moral doubt and professional context-a cross-sectional survey study.

BACKGROUND: The use of coercion is morally problematic and requires an ongoing critical reflection. We wondered if not knowing or being uncertain whether coercion is morally right or justified (i.e. experiencing moral doubt) is related to professionals' normative attitudes regarding the use of coercion. METHODS: This paper describes an explorative statistical analysis based on a cross-sectional survey across seven wards in three Norwegian mental health care institutions. RESULTS: Descriptive analyses showed that in general the 379 respondents a) were not so sure whether coercion should be seen as offending, b) agreed with the viewpoint that coercion is needed for care and security, and c) slightly disagreed that coercion could be seen as treatment. Staff did not report high rates of moral doubt related to the use of coercion, although most of them agreed there will never be a single answer to the question 'What is the right thing to do?'. Bivariate analyses showed that the more they experienced general moral doubt and relative doubt, the more one thought that coercion is offending. Especially psychologists were critical towards coercion. We found significant differences among ward types. Respondents with decisional responsibility for coercion and leadership responsibility saw coercion less as treatment. Frequent experience with coercion was related to seeing coercion more as care and security. CONCLUSIONS: This study showed that experiencing moral doubt is related to some one's normative attitude towards coercion. Future research could investigate whether moral case deliberation increases professionals' experience of moral doubt and whether this will evoke more critical thinking and increase staff's curiosity for alternatives to coercion.

Is imperfection becoming easier to live with for doctors?

OBJECTIVE: Being involved in serious patient injury is devastating for most doctors. During the last two decades, several efforts have been launched to improve Norwegian doctors' coping with adverse events and complaints. METHODS: The method involved survey to a representative sample of 1792 Norwegian doctors in 2012. The questions on adverse events and its effects were previously asked in 2000. RESULTS: Response rate was 71%. More doctors reported to have been involved in episodes with serious patient harm in 2012 (35%) than in 2000 (28%), and more of the episodes were reported as required by law. Doctors below age 50 report better support from colleagues, more collegial retrospective discussion on the event and less patient/family blame. In all, 27% of the doctors had been reported to the Norwegian Board of Health Supervision; 79% of these complaints were rejected; 73% of the doctors who had received a reaction from the health authorities found the reaction reasonable, but almost one out of five practiced more testing and referrals after a complaint and 25% claimed that the complaint had made them into a more fearful doctor. CONCLUSION: Our results indicate that adverse events are being met more openly in 2012 than in 2000, and that coping with imperfection and patient complaints is less devastating for new generations of doctors.