Overestimating prevalence? Rethinking boundaries and confounders of moral distress.

Moral distress denotes a negative reaction to a morally challenging situation. It has been associated with adverse outcomes for healthcare professionals, patients and healthcare institutions. We argue that existing definitions, along with measures of moral distress, compromise the validity of empirical research. First, the definition and measurement of moral distress conflate moral events and psychological distress, even though they are distinct phenomena that should be assessed independently. Second, in many studies, there is a lack of clarity in distinguishing between moral and non-moral events. Finally, prior research on moral distress often overlooks the substantial body of evidence demonstrating the impact of diverse work-related factors, beyond moral events, on both distress and job retention. These challenges might undermine the effectiveness of interventions aimed at alleviating moral distress. We outline a comprehensive research agenda that encompasses conceptual clarifications, the refinement of data collection instruments, the design of studies and the application of appropriate statistical methods.

Moral failure, moral prudence, and character challenges in residential care during the Covid-19 pandemic.

In many high-income countries, an initial response to the severe impact of Covid-19 on residential care was to shield residents from outside contacts. As the pandemic progressed, these measures have been increasingly questioned, given their detrimental impact on residents' health and well-being and their dubious effectiveness. Many authorities have been hesitant in adapting visiting policies, often leaving nursing homes to act on their own safety and liability considerations. Against this backdrop, this article discusses the appropriateness of viewing the continuation of the practice of shielding as a moral failure. This is affirmed and specified in four dimensions: preventability of foreseeable harm, moral agency, moral character, and moral practice (in MacIntyre's sense). Moral character is discussed in the context of prudent versus proportionate choices. As to moral practice, it will be shown that the continued practice of shielding no longer met the requirements of an (inherently moral) practice, as external goods such as security thinking and structural deficiencies prevented the pursuit of internal goods focusing on residents' interests and welfare, which in many places has led to a loss of trust in these facilities. This specification of moral failure also allows a novel perspective on moral distress, which can be understood as the expression of the psychological impact of moral failure on moral agents. Conclusions are formulated about how pandemic events can be understood as character challenges for healthcare professionals within residential care, aimed at preserving the internal goods of residential care even under difficult circumstances, which is understood as a manifestation of moral resilience. Finally, the importance of moral and civic education of healthcare students is emphasized to facilitate students' early identification as trusted members of a profession and a caring society, in order to reduce experiences of moral failure or improve the way to deal with it effectively.

Perspectives on the role of the nurse ethicist.

This paper offers four contrasting perspectives on the role of the nurse ethicist from authors based in different areas of world, with different professional backgrounds and at different career stages. Each author raises questions about how to understand the role of the nurse ethicist. The first author reflects upon their career, the scope and purpose of their work, ultimately arguing that the distinction between 'nurse ethicist' and 'clinical ethicist' is largely irrelevant. The second author describes the impact and value that a nurse in an ethics role plays, highlighting the 'tacit knowledge' and 'lived experience' they bring to clinical ethics consultation. However, the second author also warns that the 'nurse ethicist' must be cautious in their approach to avoid being viewed as a resource only for nurses. The third author questions the introduction of additional professional distinctions such as 'nurse ethicist' on the basis that distinctions threaten the creation of egalitarian healthcare systems, while also acknowledging that clinical ethicists ought not strive for objective attachment in their work. In direct contrast, the final author suggests that the nurse ethicist can play a pivotal role in highlighting and addressing ethical challenges that are specific to nurses. These four short pieces raise questions and point to concepts that will be expanded upon and debated throughout this special issue of Nursing Ethics.

Advance Care Planning in Switzerland: Chances and challenges of delivering high-quality ACP in a small high-income, multilingual, federally organized country.

We describe the development of ACP in Switzerland during the last decade in the German- and French-speaking cantons and on the national level. In 2013, a revision of the Swiss civil law came into force, declaring advance directives (ADs) as binding. Since then, ACP has been researched and implemented primarily by universities and university hospitals. Despite the foundation of the national association "ACP Swiss" in 2020, several national initiatives, and a roadmap for a national implementation, many challenges and barriers still remain. There is, however, reasonable hope to implement high-quality ACP throughout Switzerland within the next ten years.

Clinical Ethics Consultation in Chronic Illness: Challenging Epistemic Injustice Through Epistemic Modesty.

Leading paradigms of clinical ethics consultation closely follow a biomedical model of care. In this paper, we present a theoretical reflection on the underlying biomedical model of disease, how it shaped clinical practices and patterns of ethical deliberation within these practices, and the repercussions it has on clinical ethics consultations for patients with chronic illness. We contend that this model, despite its important contribution to capturing the ethical issues of day-to-day clinical ethics deliberation, might not be sufficient for patients presenting with chronic illnesses and navigating as "lay experts" of their medical condition(s) through the health care system. Not fully considering the sources of personal knowledge and expertise may lead to epistemic injustice within an ethical deliberation logic narrowly relying on a biomedical model of disease. In caring "for" and collaboratively "with" this patient population, we answer the threat of epistemic injustice with epistemic modesty and humility. We will propose ideas about how clinical ethics could contribute to an expansion of the biomedical model of care, so that important aspects of chronic illness experience would flow into clinical-ethical decision-making.

[Shared Decision-Making as a Genuine Interprofessional Endeavor]. / Shared Decision-Making als genuin interprofessionelle Aufgabe.

Shared Decision-Making as a Genuine Interprofessional Endeavor Abstract. In parallel with the growing complexity of decision-making processes, also the complexity of communication increases. This phenomenon requires adapted communication skills from all professions involved in the treatment of the patient. Consequently, the process of shared decision-making (SDM) also requires the continuous and active involvement of all the professions involved in the care process. Like the concept of interprofessional collaboration (IP), also SDM pursues the goal of creating the best possible framework conditions for the clinical context (in this case, treatment that is "tailored" to the person and agreed with him or her on the basis of his or her preferences and values). The numerous positive effects of both SDM and IP make the integration of both approaches in clinical practice not only an ethical necessity, but also a prerequisite for optimal treatment quality. The specific structure of SDM helps not only in a dyadic decision-making situation between physician and patient. It also encourages the interprofessional team to move away from an individualistic view of a single best solution to a more interprofessional team approach, which benefits both the patient and all the involved caregivers.

Who is essential in care? Reflections from the pandemic's backstage.

Since the beginning of the pandemic spread of the Coronavirus, societies have been reminded that the impact of Covid-19 and public health measures of infection containment reflect known gradients of inequality. Measures focusing only the (acknowledged) frontstage of the pandemic and neglecting its (unacknowledged) backstage-understood as those framework conditions indispensable for societies to thrive-have worsened the impact of social determinants of health on the most vulnerable, as shown by the deleterious effects of prolonged social isolation of residents of nursing homes. To reflect this phenomenon ethically, a framework is proposed which is inspired by the feminist philosopher Margret Little. At its core stands the assumption that caring for people and moral ends allows us to identify what is morally salient. This epistemological stance allows a critical look at the alleged dilemmas invoked to enforce brute, long-lasting policies of closing nursing homes in many places-especially in the light of their dubious effectiveness in preventing viral spread and the severe physical and psychological consequences for those affected. If moral salience is only fully perceived through the closeness of the caring relationship, the human suffering resulting from these policies reveals the utter inadequacy of the dilemma rhetoric used to justify them. This insight is illustrated by the personal experience of the author: He describes his role as an essential care partner of his mother living in a nursing home and forced into the role of a "visitor" who witnessed a constant deterioration of care. Based on an epistemological understanding of caring for making reliable moral judgments, potentially exclusionary effects of distinguishing essential from non-essential groups in care will be addressed together with the need to overcome strict boundaries between front- and backstage. Such efforts will strengthen the moral community of persons needing care, professional care givers and essential care partners.

'We felt like part of a production system': A qualitative study on women's experiences of mistreatment during childbirth in Switzerland.

INTRODUCTION: Mistreatment during childbirth is an issue of global magnitude that not only violates fundamental human rights but also seriously impacts women's well-being. The purpose of this study was to gain a better understanding of the phenomenon by exploring the individual experiences of women who reported mistreatment during childbirth in Switzerland. MATERIALS AND METHODS: This project used a mixed methods approach to investigate women's experiences of mistreatment during childbirth in general and informal coercion specifically: The present qualitative study expands on the findings from a nationwide online survey on childbirth experience. It combines inductive with theoretical thematic analysis to study the 7,753 comments women wrote in the survey and the subsequent interviews with 11 women who reported being mistreated during childbirth. RESULTS: The women described a wide range of experiences of mistreatment during childbirth in both the survey comments and the interviews. Out of all survey participants who wrote at least one comment (n = 3,547), 28% described one or more experiences of mistreatment. Six of the seven types of mistreatment listed in Bohren and colleagues' typology of mistreatment during childbirth were found, the most frequent of which were ineffective communication and lack of informed consent. Five additional themes were identified in the interviews: Informal coercion, risk factors for mistreatment, consequences of mistreatment, examples of good care, and what's needed to improve maternity care. CONCLUSION: The findings from this study show that experiences of mistreatment are a reality in Swiss maternity care and give insight into women's individual experiences as well as how these affect them during and after childbirth. This study emphasises the need to respect women's autonomy in order to prevent mistreatment and empower women to actively participate in decisions. Both individual and systemic efforts are required to prevent mistreatment and guarantee respectful, dignified, and high-quality maternity care for all.

Informal coercion during childbirth: risk factors and prevalence estimates from a nationwide survey of women in Switzerland.

BACKGROUND: In many countries, the increase in facility births is accompanied by a high rate of obstetric interventions. Lower birthrates or elevated risk factors such as women's higher age at childbirth and an increased need for control and security cannot entirely explain this rise in obstetric interventions. Another possible factor is that women are coerced to agree to interventions, but the prevalence of coercive interventions in Switzerland is unknown. METHODS: In a nationwide cross-sectional online survey, we assessed the prevalence of informal coercion during childbirth, women's satisfaction with childbirth, and the prevalence of women at risk of postpartum depression. Women aged 18 years or older who had given birth in Switzerland within the previous 12 months were recruited online through Facebook ads or through various offline channels. We used multivariable logistic regression to estimate the risk ratios associated with multiple individual and contextual factors. RESULTS: In total, 6054 women completed the questionnaire (a dropout rate of 16.2%). An estimated 26.7% of women experienced some form of informal coercion during childbirth. As compared to vaginal delivery, cesarean section (CS) and instrumental vaginal birth were associated with an increased risk of informal coercion (planned CS risk ratio [RR]: 1.52, 95% confidence interval [1.18,1.96]; unplanned CS RR: 1.92 [1.61,2.28]; emergency CS RR: 2.10 [1.71,2.58]; instrumental vaginal birth RR: 2.17 [1.85,2.55]). Additionally, migrant women (RR: 1.45 [1.26,1.66]) and women for whom a self-determined vaginal birth was more important (RR: 1.15 [1.06,1.24]) more often reported informal coercion. Emergency cesarean section (RR: 1.32 [1.08,1.62]), being transferred to hospital (RR: 1.33 [1.11,1.60]), and experiencing informal coercion (RR: 1.35 [1.19,1.54]) were all associated with a higher risk of postpartum depression. Finally, women who had a non-instrumental vaginal birth reported higher satisfaction with childbirth while women who experienced informal coercion reported lower satisfaction. CONCLUSIONS: One in four women experience informal coercion during childbirth, and this experience is associated with a higher risk of postpartum depression and lower satisfaction with childbirth. To prevent traumatic after-effects, health care professionals should make every effort to prevent informal coercion and to ensure sensitive aftercare for all new mothers.

COVID-19 era healthcare ethics education: Cultivating educational and moral resilience.

The COVID-19 pandemic crisis has had profound effects on global health, healthcare, and public health policy. It has also impacted education. Within undergraduate healthcare education of doctors, nurses, and allied professions, rapid shifts to distance learning and pedagogic content creation within new realities, demands of healthcare practice settings, shortened curricula, and/or earlier graduation have also challenged ethics teaching in terms of curriculum allotments or content specification. We propose expanding the notion of resilience to the field of ethics education under the conditions of remote learning. Educational resilience starts in the virtual classroom of ethics teaching, initially constituted as an "unpurposed space" of exchange about the pandemic's challenging impact on students and educators. This continuously transforms into "purposed space" of reflection, discovering ethics as a repertory of orientative knowledge for addressing the pandemic's challenges on personal, professional, societal, and global levels and for discovering (and then addressing) that the health of individuals and populations also has moral determinants. As such, an educational resilience framework with inherent adaptability rises to the challenge of supporting the moral agency of students acting both as professionals and as global citizens. Educational resilience is key in supporting and sustaining professional identify formation and facilitating the development of students' moral resilience and leadership amid moral complexity and potential moral transgression-not only but especially in times of pandemic.

[Integrated Complex Treatment for Extreme Anorexia Nervosa; An Interdisciplinary Treatment Concept of the University Hospital Zurich]. / Integrierte Komplexbehandlung bei extremer Anorexia nervosa.

Integrated Complex Treatment for Extreme Anorexia Nervosa; An Interdisciplinary Treatment Concept of the University Hospital Zurich Abstract. The serious physical mental and psychosocial morbidity due to anorexia nervosa is often perceived by sufferers as less serious than from their environment. Doctors and other healthcare professionals are therefore confronted with the difficulty that urgent medical treatment is considered as unnecessary or even threatening by those affected. Although patients with anorexia nervosa usually wish to improve their condition, they are usually only able to tolerate treatment aimed at normalizing eating behavior and gaining weight in response to high external pressure. In view of this situation, an interdisciplinary team with experience in these treatments is required to treat these patients. Close cooperation is necessary to ensure a supporting treatment framework.

Exploring moral problems and moral competences in midwifery: A qualitative study.

BACKGROUND: Most undergraduate midwifery curricula comprise ethics courses to strengthen the moral competences of future midwives. By contrast, surprisingly little is known about the specific moral competences considered to be relevant for midwifery practice. Describing these competences not only depends on generic assumptions about the moral nature of midwifery practice but also reflects which issues practitioners themselves classify as moral. OBJECTIVE: The goal of this study was to gain insight into the ethical issues midwives encounter in their daily work, the key competences and resources they consider indispensable to understand and deal with them, and to assess phenomena linked to moral distress. METHODS: We conducted individual semi-structured interviews with eight midwives and two other health professionals, varying in terms of years of experience and work setting. Interview transcripts were analyzed in an interdisciplinary research group, following thematic analysis. ETHICAL CONSIDERATIONS: This study was not subject to approval according to the Swiss Law on Research with Humans. Participants were informed about the study goals and gave written informed consent prior to participation. RESULTS: External constraints limiting the midwife's and the patient's autonomy and resulting interpersonal conflicts were found to be the most relevant ethical issues encountered in clinical practice and were most often associated with moral distress. These conflicts often arise in the context of medical interventions midwives consider as not appropriate and situations in which less experienced midwives in particular observe a lack of both interprofessional communication and trust in their professional competence. Ethical issues related to late abortions or prenatal diagnostics and selective abortions were also frequently addressed, but many midwives involved had learned to cope with them. DISCUSSION: In the light of the ethical issues and factors contributing to phenomena of moral distress, an empirically grounded profile of moral competences is drafted. Curricular implications in the light of possible adaptations within undergraduate midwifery education are critically discussed.