Ethical challenges in home-based care: A systematic literature review.

Because of the transfer of responsibility from hospitals to community-based settings, providers in home-based care have more responsibilities and a wider range of tasks and responsibilities than before, often with limited resources. The increased responsibilities and the complexity of tasks and patient groups may lead to several ethical challenges. A systematic search in the databases MEDLINE, CINAHL, and SveMed+ was carried out in February 2019 and August 2020. The research question was translated into a modified PICO (Population, Intervention, Comparison, and Outcome) worksheet. A total of 40 articles were included. The review is conducted according to the Vancouver Protocol. The main findings from the systematic literature review show that ethical challenges experienced by healthcare and social care providers in home-based care are related to autonomy and balancing ethical principles, decisions regarding intensity of care, challenges related to priority settings, truth-telling, and balancing the professional role. Findings regarding ethical challenges within home-based care are in line with findings from institutional healthcare and social care settings. However, some significant differences from the institutional context are also highlighted.

Advance care planning in Norwegian nursing homes - limited awareness of the residents' preferences and values? A qualitative study.

BACKGROUND: 52% of all deaths in Norway occur in nursing homes. Still advance care planning (ACP) is scarce and heterogeneous. To improve the implementation and practice of ACP in nursing homes, knowledge about health care professionals' views on ACP is vital. The objective of this study is to explore nurses and physicians' aims and experiences with carrying out ACP in nursing homes. METHODS: Semi-structured group interviews were conducted with 20 health care professionals, recruited from nursing homes where ACP was performed regularly. Qualitative content analysis was used to analyse the data. RESULTS: The primary aim of the nursing home professionals when doing ACP in nursing homes were to build alliances with next of kin to avoid misunderstandings and future conflicts. Two main experiences with ACP were described: i) due to the sensitivity of ACP issues, it was important to balance directness with being sensitive, and ii) when the physicians raised questions concerning future medical treatment, the answers from residents as well as next of kin were often hesitant and unclear. CONCLUSION: Our study add insights into how ACP is practiced in nursing homes and the professionals' agenda. A focus on medical issues and achieving consensus with next of kin may result in lack of involvement of the residents and limited awareness of the residents' needs. Interdisciplinary approaches, ACP-training and tailored guidelines may improve the implementation and practice of ACP.

How to succeed with ethics reflection groups in community healthcare? Professionals' perceptions.

BACKGROUND: Healthcare personnel in the municipal healthcare systems experience many ethical challenges in their everyday work. In Norway, 243 municipalities participated in a national ethics project, aimed to increase ethical competence in municipal healthcare services. In this study, we wanted to map out what participants in ethics reflection groups experienced as promoters or as barriers to successful reflection. OBJECTIVES: To examine what the staff experience as promoters or as barriers to successful ethics reflection. RESEARCH DESIGN: The study has a qualitative design, where 56 participants in municipal healthcare participated in 10 different focus-group interviews. ETHICAL CONSIDERATIONS: The data collection was based on the participants' informed consent and approved by the Data Protection Official of the Norwegian Centre for Research Data. RESULTS: The informants had different experiences from ethics reflection group. Nevertheless, we found that there were several factors that were consistently mentioned: competence, facilitator's role, ethics reflection groups organizing, and organizational support were all experienced as promoters and as a significant effect on ethics reflection groups. The absence of such factors would constitute important barriers to successful ethics reflection. DISCUSSION: The results are coincident with other studies, and indicate some conditions that may increase the possibility to succeed with ethics reflection groups. A systematic approach seems to be important, the systematics of the actual reflections, but also in the organization of ethics reflection group at the workplace. Community healthcare is characterized by organizational instabilities as many vacancies, high workloads, and lack of predictability. This can be a hinder for ethics reflection group. CONCLUSION: Both internal and external factors seem to influence the organization of ethics reflection group. The municipalities' instabilities challenging this work, and perceived as a clear inhibitor for the development. The participants experienced that the facilitator is the most important success factor for establishing, carrying out, and to succeed with ethics reflection groups.

Implementing advance care planning in nursing homes - study protocol of a cluster-randomized clinical trial.

BACKGROUND: Close to half of all deaths in Norway occur in nursing homes, which signals a need for good communication on end-of-life care. Advance care planning (ACP) is one means to that end, but in Norwegian nursing homes, ACP is not common. This paper describes the protocol of a project evaluating an ACP-intervention in Norwegian nursing homes. The aims of this research project were to promote the possibility for conversations about the end of life with patients and relatives; promote patient autonomy; create a better foundation for important decisions in the case of medical emergencies and at the end of life; and gain experiences in order to find out what characterizes good ACP and good implementation strategies. METHODS/DESIGN: This study was a mixed method study including a cluster-randomized clinical trial. Eight nursing home wards or "clusters" were pair-matched, and one ward from each pair was randomly selected for a 12-month intervention. The intervention consisted of implementing an ACP-guideline. Implementation strategies were training and supervision of project teams and staff in using the guideline, written information to patients and next of kin, and information meetings with nursing home staff. The project was evaluated using both quantitative and qualitative data, and both outcome and process evaluation. Quantitative data included patient chart reviews of ACP, diagnoses, patient preferences for decision-making and treatment, values and wishes that are more general, documented life-prolonging treatment and hospitalizations, and concordance between patient wishes and treatment. The primary outcome was documented ACP. Qualitative data included observations of conversations, interviews with patients, next of kin and health care personnel, logs from project coordinators and conversations, and transcripts from meetings with project teams in the intervention group. DISCUSSION: This project attempted to increase the quality and use of ACP in Norwegian nursing homes (NH). A mixed methods approach, inclusion of patients with dementia, attempts to involve, as many patients as possible, and a sustainable implementation plan adapted to real life in nursing homes were strengths of the project.

The significance of ethics reflection groups in mental health care: a focus group study among health care professionals.

BACKGROUND: Professionals within the mental health services face many ethical dilemmas and challenging situations regarding the use of coercion. The purpose of this study was to evaluate the significance of participating in systematic ethics reflection groups focusing on ethical challenges related to coercion. METHODS: In 2013 and 2014, 20 focus group interviews with 127 participants were conducted. The interviews were tape recorded and transcribed verbatim. The analysis is inspired by the concept of 'bricolage' which means our approach was inductive. RESULTS: Most participants report positive experiences with participating in ethics reflection groups: A systematic and well-structured approach to discuss ethical challenges, increased consciousness of formal and informal coercion, a possibility to challenge problematic concepts, attitudes and practices, improved professional competence and confidence, greater trust within the team, more constructive disagreement and room for internal critique, less judgmental reactions and more reasoned approaches, and identification of potential for improvement and alternative courses of action. On several wards, the participation of psychiatrists and psychologists in the reflection groups was missing. The impact of the perceived lack of safety in reflection groups should not be underestimated. Sometimes the method for ethics reflection was utilised in a rigid way. Direct involvement of patients and family was missing. CONCLUSION: This focus group study indicates the potential of ethics reflection groups to create a moral space in the workplace that promotes critical, reflective and collaborative moral deliberations. Future research, with other designs and methodologies, is needed to further investigate the impact of ethics reflection groups on improving health care practices.

Ethical challenges when using coercion in mental healthcare: A systematic literature review.

BACKGROUND: To better understand the kinds of ethical challenges that emerge when using coercion in mental healthcare, and the importance of these ethical challenges, this article presents a systematic review of scientific literature. METHODS: A systematic search in the databases MEDLINE, PsychInfo, Cinahl, Sociological Abstracts and Web of Knowledge was carried out. The search terms derived from the population, intervention, comparison/setting and outcome. A total of 22 studies were included. Ethical considerations: The review is conducted according to the Vancouver Protocol. RESULTS: There are few studies that study ethical challenges when using coercion in an explicit way. However, promoting the patient's best interest is the most important justification for coercion. Patient autonomy is a fundamental challenge facing any use of coercion, and some kind of autonomy infringement is a key aspect of the concept of coercion. The concepts of coercion and autonomy and the relations between them are very complex. When coercion is used, a primary ethical challenge is to assess the balance between promoting good (beneficence) and inflicting harm (maleficence). In the included studies, findings explicitly related to justice are few. Some studies focus on moral distress experienced by the healthcare professionals using coercion. CONCLUSION: There is a lack of literature explicitly addressing ethical challenges related to the use of coercion in mental healthcare. It is essential for healthcare personnel to develop a strong awareness of which ethical challenges they face in connection with the use of coercion, as well as challenges related to justice. How to address ethical challenges in ways that prevent illegitimate paternalism and strengthen beneficent treatment and care and trust in connection with the use of coercion is a 'clinical must'. By developing a more refined and rich language describing ethical challenges, clinicians may be better equipped to prevent coercion and the accompanying moral distress.

Ethics support in community care makes a difference for practice.

BACKGROUND: Through the Norwegian ethics project, ethics activities have been implemented in the health and care sector in more than 200 municipalities. OBJECTIVES: To study outcomes of the ethics activities and examine which factors promote and inhibit significance and sustainability of the activities. RESEARCH DESIGN: Two online questionnaires about the municipal ethics activities. Participants and research context: A total of 137 municipal contact persons for the ethics project answered the first survey (55% response rate), whereas 217 ethics facilitators responded to the second survey (33% response rate). Ethical considerations: Based on informed consent, the study was approved by the Data Protection Official of the Norwegian Social Science Data Services. FINDINGS: Around half of the respondents found the ethics project to have been highly significant for daily professional practice. Outcomes include better handling of ethical challenges, better employee cooperation, better service quality, and better relations to patients and next of kin. Factors associated with sustainability and/or significance of the activities were sufficient support from stakeholders, sufficient available time, and ethics facilitators having sufficient knowledge and skills in ethics and access to supervision. DISCUSSION: This study shows that ethics initiatives can be both sustainable and significant for practice. There is a need to create regional or national structures for follow-up and develop more comprehensive ethics training for ethics facilitators. CONCLUSION: It is both possible and potentially important to implement clinical ethics support activities in community health and care services systematically on a large scale. Future ethics initiatives in the community sector should be designed in light of documented promoting and inhibiting factors.

Advance care planning in Norwegian nursing homes. / Forberedende samtaler i norske sykehjem.

BACKGROUND: Nursing home patients are often frail and have a number of chronic conditions. Increased risk of critical events, hospitalisations and death indicates the need for dialogue with patients and their next of kin about the future, how to agree on sound decisions and what should happen if the patient's health condition deteriorates. Previous studies have shown that only a minority of nursing homes practise this type of advance care planning. MATERIAL AND METHOD: In early summer 2014, a questionnaire was sent to all Norwegian nursing homes, containing questions about the prevalence and content of advance care planning. RESULTS: A total of 57 % (486 nursing homes) responded to the survey. Approximately two-thirds reported that they «always' or «usually' undertook advance care planning and around one-third of them had written guidelines. The conversations primarily took place when the patient's health condition deteriorated, when the patient entered the last phase of life, or in connection with the admission interview. Hospitalisation, pain relief and cardiopulmonary resuscitation (CPR) were the most frequent topics. Next of kin and the nursing home doctor participated most often in the interviews, while the patients participated more seldom. INTERPRETATION: There were large variations between the nursing homes with regard to advance care planning. This may partly be explained by the lack of national guidelines, and partly by the fact that this is a relatively recent discussion in Norway. The infrequent participation by patients in the conversations is probably associated with the fact that among them a high proportion are cognitively impaired, the availability of medical resources is low, and a culture of patient participation is insufficiently developed.

The Norwegian national project for ethics support in community health and care services.

BACKGROUND: Internationally, clinical ethics support has yet to be implemented systematically in community health and care services. A large-scale Norwegian project (2007-2015) attempted to increase ethical competence in community services through facilitating the implementation of ethics support activities in 241 Norwegian municipalities. The article describes the ethics project and the ethics activities that ensued. METHODS: The article first gives an account of the Norwegian ethics project. Then the results of two online questionnaires are reported, characterizing the scope, activities and organization of the ethics activities in the Norwegian municipalities and the ethical topics addressed. RESULTS: One hundred and thirty-seven municipal contact persons answered the first survey (55 % response rate), whereas 217 ethics facilitators from 48 municipalities responded to the second (33 % response rate). The Norwegian ethics project is vast in scope, yet has focused on some institutions and professions (e.g., nursing homes, home-based care; nurses, nurses' aides, unskilled workers) whilst seldom reaching others (e.g., child and adolescent health care; physicians). Patients and next of kin were very seldom involved. Through the ethics project employees discussed many important ethical challenges, in particular related to patient autonomy, competence to consent, and cooperation with next of kin. The "ethics reflection group" was the most common venue for ethics deliberation. CONCLUSIONS: The Norwegian project is the first of its kind and scope, and other countries may learn from the Norwegian experiences. Professionals have discussed central ethical dilemmas, the handling of which arguably makes a difference for patients/users and service quality. The study indicates that large (national) scale implementation of CES structures for the municipal health and care services is complex, yet feasible.

Coercion in nursing homes: Perspectives of patients and relatives.

BACKGROUND: Studies have demonstrated the extensive use of coercion in Norwegian nursing homes, which represents ethical, professional as well as legal challenges to the staff. We have, however, limited knowledge of the experiences and views of nursing home patients and their relatives. OBJECTIVES: The aim of this study is to explore the perspectives of nursing home patients and next of kin on the use of coercion; are there situations where the use of coercion can be defended, and if so, under which circumstances? METHODS: The data are based on individual interviews with 35 patients living in six nursing homes and seven focus group interviews with 60 relatives. ETHICAL CONSIDERATIONS: Participation was based on written informed consent, and the study was approved by the Regional Committees for Medical and Health Research Ethics. RESULTS: More than half of the patients and the majority of the relatives accepted the use of coercion, trusting the staff to act in the patient's best interest. However, the acceptance of coercion is strongly related to the patients' lack of understanding, to prevent health risks and to preserve the patient's dignity. CONCLUSION: The majority of nursing home patients and relatives accepted the use of coercion in specific situations, while at the same time they emphasised the need to try alternative strategies first. There is still a need for good qualitative research on the use of coercion in nursing homes, especially with a closer focus on the perspectives and experiences of nursing home patients.

End-of-life care communications and shared decision-making in Norwegian nursing homes--experiences and perspectives of patients and relatives.

BACKGROUND: Involving nursing home patients and their relatives in end-of-life care conversations and treatment decisions has recently gained increased importance in several Western countries. However, there is little knowledge about how the patients themselves and their next-of-kin look upon involvement in end-of-life care decisions. The purpose of this paper is to explore nursing home patients' and next-of-kin's experiences with- and perspectives on end-of-life care conversations, information and shared decision-making. METHODS: The study has a qualitative and explorative design, based on a combination of individual interviews with 35 patients living in six nursing homes and seven focus group interviews with 33 relatives. The data was analysed applying a "bricolage" approach". Participation was based on informed consent, and the study was approved by the Regional Committees for Medical and Health Research Ethics. RESULTS: Few patients and relatives had participated in conversations about end-of-life care. Most relatives wanted such conversations, while the patients' opinions varied. With some exceptions, patients and relatives wanted to be informed about the patient's health condition. The majority wanted to be involved in the decision-making process, but leave the final decisions to the health professionals. Among the patients, the opinion varied; some patients wanted to leave the decisions more or less completely to the nursing home staff. Conversations about end-of-life care issues are emotionally challenging, and very few patients had discussed these questions with their family. The relatives' opinions of the patient's preferences were mainly based on assumptions; they had seldom talked about this explicitly. Both patients and relatives wanted the staff to raise these questions. CONCLUSION: Nursing home staff should initiate conversations about preferences for end-of-life care, assisting patients and relatives in talking about these issues, while at the same time being sensitive to the diversity in opinions and the timing for such conversations. As the popularity of advance care planning increases in many Western countries, discussions of patients' and relatives' perspectives will be of great interest to a broader audience.

How to avoid and prevent coercion in nursing homes: a qualitative study.

In many Western countries, studies have demonstrated extensive use of coercion in nursing homes, especially towards patients suffering from dementia. This article examines what kinds of strategies or alternative interventions nursing staff in Norway used when patients resist care and treatment and what conditions the staff considered as necessary to succeed in avoiding the use of coercion. The data are based on interdisciplinary focus group interviews with nursing home staff. The study revealed that the nursing home staff usually spent a lot of time trying a wide range of approaches to avoid the use of coercion. The most common strategies were deflecting and persuasive strategies, limiting choices by conscious use of language, different kinds of flexibility and one-to-one care. According to the staff, their opportunities to use alternative strategies effectively are greatly affected by the nursing home's resources, by the organization of care and by the staff's competence.

[Use of coercion in nursing homes after new legislation]. / Bruk av tvang i sykehjem etter ny lovgivning.

BACKGROUND: The use of coercion in nursing homes is common as well as challenging, but was not regulated by law until 2009. Two key conditions are that the patient must be without mental competence and that the coercive measures are in the patient's best interest. Inspection reports have revealed insufficient application of the law, and this is of concern to patients as well as healthcare staff. With the aid of a qualitative study, we wished to identify the challenges encountered and the experiences gained by doctors and other nursing-home personnel from the new provisions regarding the use of coercion. MATERIAL AND METHOD: A total of 65 nursing-home employees were interviewed in focus groups. The interview guide included questions on, for example, when coercion is being used and how the new chapter of the Act is being applied. In the qualitative analysis, the content of the statements was categorised and condensed. RESULTS: All focus-group interviews described coercion as frequently occurring, but also that few formal decisions are being made. Involvement of the doctors and inter-disciplinary cooperation were assessed as crucial for ensuring appropriate application of the new regulations, in addition to time, staffing and competence. The participants were uncertain as to how the new regulations should be applied, and regarded the requirements for a formal decision as unrealistic. Some of the coercive measures described are illegal. The absence of legal authority in cases where coercion is regarded as the lesser evil was described as challenging. INTERPRETATION: The new legal basis for the use of coercion is likely to raise awareness of the issue, but has a large potential for erroneous interpretation and causing reluctance to make formal decisions. In some areas, the law is out of step with the realities in nursing homes and the employees' values.

Effect of interventions to reduce potentially inappropriate use of drugs in nursing homes: a systematic review of randomised controlled trials.

BACKGROUND: Studies have shown that residents in nursing homes often are exposed to inappropriate medication. Particular concern has been raised about the consumption of psychoactive drugs, which are commonly prescribed for nursing home residents suffering from dementia. This review is an update of a Norwegian systematic review commissioned by the Norwegian Directorate of Health. The purpose of the review was to identify and summarise the effect of interventions aimed at reducing potentially inappropriate use or prescribing of drugs in nursing homes. METHODS: We searched for systematic reviews and randomised controlled trials in the Cochrane Library, MEDLINE, EMBASE, ISI Web of Knowledge, DARE and HTA, with the last update in April 2010. Two of the authors independently screened titles and abstracts for inclusion or exclusion. Data on interventions, participants, comparison intervention, and outcomes were extracted from the included studies. Risk of bias and quality of evidence were assessed using the Cochrane Risk of Bias Table and GRADE, respectively. Outcomes assessed were use of or prescribing of drugs (primary) and the health-related outcomes falls, physical limitation, hospitalisation and mortality (secondary). RESULTS: Due to heterogeneity in interventions and outcomes, we employed a narrative approach. Twenty randomised controlled trials were included from 1631 evaluated references. Ten studies tested different kinds of educational interventions while seven studies tested medication reviews by pharmacists. Only one study was found for each of the interventions geriatric care teams, early psychiatric intervening or activities for the residents combined with education of health care personnel. Several reviews were identified, but these either concerned elderly in general or did not satisfy all the requirements for systematic reviews. CONCLUSIONS: Interventions using educational outreach, on-site education given alone or as part of an intervention package and pharmacist medication review may under certain circumstances reduce inappropriate drug use, but the evidence is of low quality. Due to poor quality of the evidence, no conclusions may be drawn about the effect of the other three interventions on drug use, or of either intervention on health-related outcomes.

Staff and family relationships in end-of-life nursing home care.

This article examines the involvement of residents and their relatives in end-of-life decisions and care in Norwegian nursing homes. It also explores challenges in these staff-family relationships. The article is based on a nationwide survey examining Norwegian nursing homes' end-of-life care at ward level. Only a minority of the participant Norwegian nursing home wards 'usually' explore residents' preferences for care and treatment at the end of their life, and few have written procedures on the involvement of family caregivers when their relative is in the terminal phase. According to the respondents, most staff seem to comfort relatives well. However, several challenges were described. The study revealed a need for better procedures in the involvement of residents and relatives in nursing home end-of-life care. The findings emphasize a need to strengthen both the involvement of nursing home physicians and staff communication skills.

Unitary management, multiple practices?

PURPOSE: The purpose of this paper is to explore whether unitary managers with different professional backgrounds carry out and reflect differently upon their roles as unitary managers. DESIGN/METHODOLOGY/APPROACH: This paper presents findings from two different studies, comprising both data from qualitative interviews and a nationwide survey. FINDINGS: Doctors and nurses in many respects perform their roles as unitary managers differently. They hold the same position but carry out their roles differently. Doctors are very committed to clinical tasks and stress to a great extent that clinical tasks should be integrated in management at the department level. The opposite is true for the nurses, where leadership first and foremost should be understood as management. PRACTICAL IMPLICATIONS: Even though doctors and nurses are in the same position they manage differently, being committed to different tasks within the unit. This is not the intention of the reform. However, the question is thus, will this have (severe) consequences for the organization? Or does it represent a healthy diversity in the health organisation? ORIGINALITY/VALUE: This paper explores whether different professions carry out their managerial tasks differently and what practical implications this could have. It brings to the fore substantial empirical data on how one of the major reforms in Norwegian (and international) health care has been adopted and carried out by major professional groups.

Improved patient participation through advance care planning in nursing homes-A cluster randomized clinical trial.

OBJECTIVE: To improve patient participation in advance care planning in nursing homes where most patients have some degree of cognitive impairment. METHODS: This was a pair-matched cluster randomized clinical trial with eight wards in eight Norwegian nursing homes. We randomized one ward from each of the matched pairs to the intervention group. We included all patients above 70. The primary outcome was prevalence of documented patient participation in end-of-life treatment conversations. The intervention included implementation support using a whole-ward approach where regular staff perform advance care planning and invite all patients and next of kin to participate. RESULTS: In intervention group wards the patients participated more often in end-of-life treatment conversations (p < 0.001). Moreover, the patient's preferences, hopes AND worries (p = 0,006) were more often documented, and concordance between provided TREATMENT and patient preferences (p = 0,037) and next of kin participation in advance care planning with the patient (p = 0,056) increased. CONCLUSION: Improved patient participation - also when cognitively impaired - is achievable through advance care planning in nursing homes using a whole-ward approach. PRACTICE IMPLICATIONS: Patients with cognitive impairment should be included in advance care planning supported by next of kin. A whole-ward approach may be used to implement advance care planning. TRIAL REGISTRATION: ISRCTN registry (ID ISRCTN69571462) - retrospectively registered.

[Unified management in Norwegian hospitals--still controversial?]. / Enhetlig ledelse--fortsatt en varm potet?

BACKGROUND: The Norwegian parliament's decision to establish unified management on all hospitals units was accompanied by strong public debate. The arguments focused especially on the decision that other than doctors could fill the top managerial position at the department level. We have studied the selection of managers, the prevalence and content of disagreements and conflicts, and how the departments handled the conflicts. MATERIAL AND METHODS: We have used three data sets: a survey of the top managements at all hospitals, interviews with 28 managers, and a survey of a sample of managers at the department level. RESULTS AND INTERPRETATIONS: In 2004, about 67% of the managers were doctors, 28% were nurses and 5% had other professional backgrounds. Managers educated as nurses were most prevalent in psychiatric wards and in emergency medicine. About half of the hospitals and departments had experienced conflicts when implementing the reform. Confusion about medical responsibility and resistance towards the manager not being a doctor seemed to be most common. With some exception, the conflicts have calmed down, probably because of some clarification from the Ministry of Health about the managers' medical responsibility; also, departments with managers who not are doctors have established a division of labour that satisfy the doctors in the department.

Women doctors in Norway: the challenging balance between career and family life.

In most Western countries, women doctors are still underrepresented in the higher positions in the medical hierarchy and in the most prestigious specialities. A crucial question is whether family responsibilities affect female and male career differently. The article examines how Norwegian physicians balance their work and family responsibilities and demonstrates differences in the way doctors combine work and family obligations, between women and compared with men. Among women doctors, the probability of becoming a specialist decreased with an increasing number of children. Moreover, postponing the birth of the first child increased the probability of completing hospital specialities. Although more women than men work part-time, this was the case only for a small proportion of women doctors. Transition from full-time to part-time work is primarily an accommodating strategy to family responsibilities, however strongly influenced by variations in the opportunity structure of different specialities. The findings further demonstrate that being married to another doctor had a positive impact on the career, especially for women doctors.

Gender similarities in doctors' preferences--and gender differences in final specialisation.

This article is based on a career history study of gender differences and similarities in recruitment to and transitions between specialities among Norwegian doctors. A questionnaire on career and family history was sent to all Norwegian doctors authorised in 1980-1983. Descriptive statistics and logistic regression were used to describe and analyse completion of specialisation in the specialty in which they started their career. Survival analysis was used to analyse transitions between medical specialities. The findings clearly contradict the idea that the low proportion of women in male dominated areas of medicine reflects women's lack of interest in specialities like surgery and internal medicine. Women were as likely as men to start their career in these fields. The problem is their not completing specialist training. A far higher proportion of men than women completed their specialist training in surgery. The reasons for this are complex. Heavy work loads with duties and "nights on call" make it difficult for women to combine childcare and work and make them change to other specialities. Also, female specialists in surgery and internal medicine postpone having their first child compared to women in other medical specialities. However, the fact that some women change from surgery to gynaecology and obstetrics, a specialty which to a considerable extent are comparable with surgery with regard to duty and work loads, indicate that structural barriers in combining childcare and a hospital career do not fully explain the flux of women. The possible existence of other closure mechanisms in surgery, as indicated by some doctors in this and in other studies, have to be further explored.