Patient Knowledge and Trust in Health Care. A Theoretical Discussion on the Relationship Between Patients' Knowledge and Their Trust in Health Care Personnel in High Modernity.

In this paper we aim to discuss a theoretical explanation for the positive relationship between patients' knowledge and their trust in healthcare personnel. Our approach is based on John Dewey's notion of continuity. This notion entails that the individual's experiences are interpreted as interrelated to each other, and that knowledge is related to future experience, not merely a record of the past. Furthermore, we apply Niklas Luhmann's theory on trust as a way of reducing complexity and enabling action. Anthony Giddens' description and analysis of the high modern society provides a frame for discussing the preconditions for patient-healthcare personnel interaction. High modernity is dominated by expert systems and demands trust in these. We conclude that patient knowledge and trust in healthcare personnel is related because both knowledge and trust are future- and action-oriented concepts. The traits of high modernity provides opportunities and challenges as the personnel can and must perform discretion. This discretion must be made in a context where knowledge is considered uncertain and preliminary.

Trustworthy management in hospital settings: a systematic review.

BACKGROUND: Trustful relationships play a vital role in successful organisations and well-functioning hospitals. While the trust relationship between patients and providers has been widely studied, trust relations between healthcare professionals and their supervisors have not been emphasised. A systematic literature review was conducted to map and provide an overview of the characteristics of trustworthy management in a hospital setting. METHODS: We searched Web of Science, Embase, MEDLINE, APA PsycInfo, CINAHL, Scopus, EconLit, Taylor & Francis Online, SAGE Journals and Springer Link from database inception up until Aug 9, 2021. Empirical studies written in English undertaken in a hospital or similar setting and addressed trust relationships between healthcare professionals and their supervisors were included, without date restrictions. Records were independently screened for eligibility by two researchers. One researcher extracted the data and another one checked the correctness. A narrative approach, which involves textual and tabular summaries of findings, was undertaken in synthesising and analysing the data. Risk of bias was assessed independently by two researchers using two critical appraisal tools. Most of the included studies were assessed as acceptable, with some associated risk of bias. RESULTS: Of 7414 records identified, 18 were included. 12 were quantitative papers and 6 were qualitative. The findings were conceptualised in two categories that were associated with trust in management, namely leadership behaviours and organisational factors. Most studies (n = 15) explored the former, while the rest (n = 3) additionally explored the latter. Leadership behaviours most commonly associated with employee's trust in their supervisors include (a) different facets of ethical leadership, such as integrity, moral leadership and fairness; (b) caring for employee's well-being conceptualised as benevolence, supportiveness and showing concern and (c) the manager's availability measured as being accessible and approachable. Additionally, four studies found that leaders' competence were related to perceptions of trust. Empowering work environments were most commonly associated with trust in management. CONCLUSIONS: Ethical leadership, caring for employees' well-being, manager's availability, competence and an empowering work environment are characteristics associated with trustworthy management. Future research could explore the interplay between leadership behaviours and organisational factors in eliciting trust in management.

Trust in healthcare before and during the COVID-19 pandemic.

BACKGROUND: Public trust is often advantageous for health authorities during crises such as the COVID-19 pandemic. Norwegian health authorities used the public´s high trust to control the pandemic, resulting in relatively few casualties. METHODS: We wanted to describe and compare the Norwegian public trust in GPs, public healthcare, information and treatment in hospitals before and during the early phases of the COVID-19 pandemic. Further, we wanted to investigate the relationship between somatic or mental illness, and trust in GPs and public health information, and to develop a theoretical understanding of the relationship between trust in healthcare institutions, generalised trust and the societal situation caused by the COVID-19 pandemic. We performed two surveys, the first in December 2019; the second in May 2020, thus providing two snapshots of the Norwegian public's trust in healthcare and healthcare actors before and during the COVID-19 pandemic. RESULTS: There was statistically significant increased trust in public healthcare, in treatment at hospital and in information at hospital after the outbreak of the COVID-19 pandemic. There was a non-significant rise in trust in GPs. We found that trust in public health information was not related to mental health nor having a chronic, somatic disease. CONCLUSION: The findings confirm that the Norwegian public's trust in healthcare and healthcare actors is high. The trust levels are also relatively stable, and even show an increase during the early phases of the pandemic. We suggest that there is a dynamic relationship between trust in public health information, healthcare institutions, generalised trust and a societal crisis situation such as the COVID-19 pandemic. However, the GP-patient trust seems less affected by a crisis situation, than the public´s trust in healthcare institutions. This difference may be explained by the relative stability caused by mandates of trust obtained from the patient.

The doctor's role in the mental healthcare service ­ a qualitative study. / Legerollen i psykisk helsevern ­ en kvalitativ studie.

BACKGROUND: The role of doctors is changing, and mental health care is increasingly dominated by professional groups other than doctors. In this qualitative study, we investigated how psychiatrists perceive their role and position in mental health care. MATERIAL AND METHOD: Seven psychiatrists were given in-depth interviews based on an interview guide. The transcribed material was analysed using systematic text condensation. RESULTS: The interview material was grouped into four cross-cutting topic categories: Several informants perceived themselves as professional guarantors who step in when other interventions have failed. Many felt like guest workers in the therapeutic pathways of other professional groups, without an adequate framework for following up the patients properly. Some described the health authorities' prioritisation of mental health as a patient pathway bureaucracy, where more stringent demands for control and documentation of treatment and decisions to use coercive measures divert time and resources away from patient treatment. Several psychiatrists felt that unified management led to diffusion of responsibility, with an unclear distribution of professional responsibility between the interdisciplinary head of unit and the specialist. INTERPRETATION: The psychiatrists in the study appeared to have clear professional authority in the clinic, but their role seems to be under pressure. Interdisciplinary, unified line management, equal responsibility for treatment accorded to specialists in psychology, and the absence of psychiatrists in the management appear to have undermined the psychiatric perspective in mental health care.

Home administration of needle injections for children with rheumatic diseases: A qualitative study on nurses' perception of their educational role.

PURPOSE: To explore nurses' perceptions of their educational role, pedagogical competence, and practice in teaching children with rheumatic diseases and their parents to manage subcutaneous injections at home. DESIGN AND METHODS: In this qualitative study, we used thematic analysis to analyze data from three focus groups with 14 nurses responsible for patient education at one pediatric ward and two outpatient clinics. RESULTS: We identified three main themes capturing nurses' perceptions of their educational role: myriad expectations, awareness of own competence, and facilitation and prioritization of patient education. Nurses perceived patient education as an expected but challenging duty of their work. They described a lack of pedagogical competence, insecurity in managing parents' and children's fears and worries, and limited organizational structures guiding their educational role. Nurses who worked in outpatient clinics felt freer to individualize education compared to ward nurses. CONCLUSIONS: Nurses perceive their educational role as significant in enabling children and parents to manage subcutaneous injections at home; however, they require pedagogical competence integrated with daily practice to provide high-quality care. Short-term admissions require a different organization of patient education than before. PRACTICAL IMPLICATIONS: Nurses need increased training in communication and management of children's pain and fear during needle injections. Competence development should include opportunities for reflection and guidance in clinical practice. Pediatric specialist nurses at outpatient clinics seem to have better competence to provide individual patient education for these families. The potential advantage of web-based solutions for nurses' patient education is a promising avenue for future research.

I don't want to think about it: a qualitative study of children (6-18 years) with rheumatic diseases and parents' experiences with regular needle injections at home.

BACKGROUND: Overall outcomes of pediatric rheumatic diseases (RD) have improved due to treatment with biologic agents and methotrexate. For many children, this treatment often entails regular needle injections. Pain and fear of needle injections are common in childhood, but how children and parents handle long-term needle injections at home has not been fully explored. This study aimed to explore how regular needle injections affect children with RD and their parents in their daily living. METHODS: This explorative qualitative study used individual interviews and focus groups to ensure a comprehensive investigation of the topic. Children aged 6 to 16 years (n = 7) and their parents (n = 8) were interviewed individually 4 to 6 months after the onset of needle injection treatment. The focus groups included children aged 11 to 17 years (n = 9) and parents (n = 8) with a minimum of 6 months of experience with injection treatment. Data were analyzed using thematic analysis. RESULTS: The main themes; "challenges," "motivational factors," and "routines" captured experiences and strategies that influenced the continuation of needle injections at home. Many children feared the moment immediately before the needle stick, although they had become accustomed to the pain. Most parents felt insecure about handling needle injections and lacked follow-up from healthcare providers. The children's experience of treatment effects and self-confidence were essential to maintain motivation for further injections. A number of coping strategies helped children focus away from injection related discomfort, often discovered by chance. Facilitating firm routines and shared responsibility within families helped children develop self-confidence during the procedure. Children and parents struggled to find suitable information on the Internet. CONCLUSIONS: Children and parents experienced long-term needle injections challenging. They used their own limited resources and cooperated within the families to create routines and to introduce coping strategies necessary to manage and keep up with the procedure. Although the injection itself was not experienced very painful, the discomfort, worries and impact on daily life represented far more than a little needle stick, and thus needs more attention from healthcare providers.

Evaluating a centralised cancer support centre in the remote region of Northern Norway.

INTRODUCTION: Being diagnosed with cancer and undergoing treatment is a life-changing experience, and many cancer patients find the physical, emotional and social effects of the disease to be stressful. This study explores the experiences of cancer patients and their relatives from all parts of Northern Norway visiting the centralised cancer support centre. METHODS: In a comprehensive prospective survey, 286 visitors were invited to participate and 181 of these accepted. The characteristics of the participants, their expectations for visiting the centre, whether they wanted to meet peers or volunteers rather than clinicians and how they viewed the centre in the context of cancer care were evaluated. RESULTS: Most satisfied were visitors aged less than 50 years, women and those reporting a 'strong social network'. The majority of the visitors wanted to have better access to peers (with a similar cancer diagnosis) (89%), cancer nurses (75%) or oncologists (71%). About a third of the participants (29.8%) lived in communities with fewer than 5000 inhabitants and 59.4% in municipalities with fewer than 15 inhabitants/km2. There were no significant differences in the characteristics of the participants, or in their evaluation of the support centre, when stratified by number of inhabitants or population density in their home community. CONCLUSION: The cancer support centre was highly valued by patients and their relatives for meeting peers. The centre was most frequently visited by and most popular among women and those self-reporting strong social networks. Access to oncology doctors and nurses in this setting could be valuable. Participants living in remote areas had similar characteristics and evaluated the support centre similarly to those living in more urban areas.

Children's fear of needle injections: a qualitative study of training sessions for children with rheumatic diseases before home administration.

BACKGROUND: Treatment of rheumatic diseases in children often includes long-term needle injections, which represent a risk for refusing medication based on potential needle-fear. How nurses manage children's fear and pain during the initial educational training session of subcutaneous injections, may affect the management of the subsequent injections in the home settings. The aim of this study was to explore how children expressed fear and pain during these training sessions, and how adults' communication affected children's expressed emotions. METHODS: This qualitative explorative study used video observations and short interviews during training sessions in a rheumatic hospital ward. Participants were children between five and fifteen years (n = 8), their parents (n = 11) and nurses (n = 7) in nine training sessions in total. The analysis followed descriptions of thematic analysis and interaction analysis. RESULTS: The children expressed fears indirectly as cues and nonverbal signs more often than direct statements. Three children stated explicit being afraid or wanting to stop. The children worried about needle-pain, but experienced the stinging pain after the injection more bothersome. The technical instructions were detailed and comprehensive and each nurse shaped the structure of the sessions. Both nurses and parents frequently offered coping strategies unclearly without sufficient time for children to understand. We identified three main adult communication approaches (acknowledging, ambiguous and disregarding) that influenced children's expressed emotions during the training session. CONCLUSIONS: Children's expression of fear was likely to be indirectly, and pain was mostly related to the injection rather than the needle stick. When adults used an acknowledging communication and offered sufficient coping strategies, children seemed to become involved in the procedure and acted with confidence. The initial educational training session may have a great impact on long-term repeated injections in a home setting by providing children with confidence at the onset.

Work-home balance in two cohorts of Norwegian doctors. / Jobb­hjem-balanse i to kohorter av norske leger.

BACKGROUND: Stress linked to the balance between work and home, so-called work-home interface stress, may affect the health and life situation of doctors. Reports have shown an increase in job-related stress among Norwegian doctors. We wished to investigate the development trends for this type of stress in the period 2003-14. MATERIAL AND METHOD: Work-home interface stress was measured with the aid of three questions from a validated scale, on which the respondents reported their level of stress on a scale from 1 (no stress) to 5 (very high level of stress). The measurements were made 10 and 15 years after graduation in two cohorts of doctors who had received their training within six years of each other. We used the t-test and chi-square test to compare the cohorts and to compare gender within each cohort, and linear regression analysis to adjust for any confounding factors. RESULTS: Doctors who had graduated later (later cohort, n = 248) reported significantly lower levels of work-home interface stress than doctors who had completed their studies six years earlier (early cohort, n = 197) (average score (standard deviation) 2.2 (1.0) vs. 2.6 (1.0), p = 0.001). This correlation remained significant after adjusting for other explanatory variables, such as gender (woman), number of children, weekly working hours and collegial and partner support. Fifteen years after graduation there were no differences between the cohorts in terms of perceived work-home interface stress. Within the cohorts there were no significant gender differences at any point of measurement. After adjustment for partner support and working hours, being a woman gave a significantly increased risk of experiencing work-home interface stress. INTERPRETATION: Doctors who graduated later, experienced less work-home interface stress than those who had received their training earlier. The experience of stress was buffered in women who perceived their partner as supportive and had reduced working hours.

Patient-mediated interventions to improve professional practice: A summary of a Cochrane systematic review.

OBJECTIVE: To assess the effectiveness of patient-mediated interventions on healthcare professionals' performance. METHODS: We conducted a systematic Cochrane review according to established guidelines. We searched predefined databases in 2016 and 2017. Two review authors independently assessed studies for inclusion, extracted data, assessed risk of bias, performed meta-analyses, and assessed the certainty of the evidence (GRADE). RESULTS: We included 25 randomised studies with a total of 12 268 patients. We found that patient-reported health information interventions and patient education interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate certainty evidence). We also found that patient information interventions may improve healthcare professionals' adherence to recommended clinical practice (low certainty evidence). Patient decision aids may make little or no difference to the number of healthcare professionals' adhering to recommended clinical practice (low-certainty evidence). CONCLUSION: Our findings strengthen the belief that patient-mediated interventions have the potential to improve professional practice, especially patient-reported health information interventions and patient education interventions. PRACTICE IMPLICATIONS: Our findings show that patient-reported health information interventions and patient education interventions are relevant approaches to improve professional practice. Thus, it seems reasonable to conclude that these types of patient-mediated interventions can contribute to improving the quality of healthcare services.

Patient-mediated interventions to improve professional practice.

BACKGROUND: Healthcare professionals are important contributors to healthcare quality and patient safety, but their performance does not always follow recommended clinical practice. There are many approaches to influencing practice among healthcare professionals. These approaches include audit and feedback, reminders, educational materials, educational outreach visits, educational meetings or conferences, use of local opinion leaders, financial incentives, and organisational interventions. In this review, we evaluated the effectiveness of patient-mediated interventions. These interventions are aimed at changing the performance of healthcare professionals through interactions with patients, or through information provided by or to patients. Examples of patient-mediated interventions include 1) patient-reported health information, 2) patient information, 3) patient education, 4) patient feedback about clinical practice, 5) patient decision aids, 6) patients, or patient representatives, being members of a committee or board, and 7) patient-led training or education of healthcare professionals. OBJECTIVES: To assess the effectiveness of patient-mediated interventions on healthcare professionals' performance (adherence to clinical practice guidelines or recommendations for clinical practice). SEARCH METHODS: We searched MEDLINE, Ovid in March 2018, Cochrane Central Register of Controlled Trials (CENTRAL) in March 2017, and ClinicalTrials.gov and the International Clinical Trials Registry (ICTRP) in September 2017, and OpenGrey, the Grey Literature Report and Google Scholar in October 2017. We also screened the reference lists of included studies and conducted cited reference searches for all included studies in October 2017. SELECTION CRITERIA: Randomised studies comparing patient-mediated interventions to either usual care or other interventions to improve professional practice. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion, extracted data and assessed risk of bias. We calculated the risk ratio (RR) for dichotomous outcomes using Mantel-Haenszel statistics and the random-effects model. For continuous outcomes, we calculated the mean difference (MD) using inverse variance statistics. Two review authors independently assessed the certainty of the evidence (GRADE). MAIN RESULTS: We included 25 studies with a total of 12,268 patients. The number of healthcare professionals included in the studies ranged from 12 to 167 where this was reported. The included studies evaluated four types of patient-mediated interventions: 1) patient-reported health information interventions (for instance information obtained from patients about patients' own health, concerns or needs before a clinical encounter), 2) patient information interventions (for instance, where patients are informed about, or reminded to attend recommended care), 3) patient education interventions (intended to increase patients' knowledge about their condition and options of care, for instance), and 4) patient decision aids (where the patient is provided with information about treatment options including risks and benefits). For each type of patient-mediated intervention a separate meta-analysis was produced.Patient-reported health information interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We found that for every 100 patients consulted or treated, 26 (95% CI 23 to 30) are in accordance with recommended clinical practice compared to 17 per 100 in the comparison group (no intervention or usual care). We are uncertain about the effect of patient-reported health information interventions on desirable patient health outcomes and patient satisfaction (very low-certainty evidence). Undesirable patient health outcomes and adverse events were not reported in the included studies and resource use was poorly reported.Patient information interventions may improve healthcare professionals' adherence to recommended clinical practice (low-certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 42) are in accordance with recommended clinical practice compared to 20 per 100 in the comparison group (no intervention or usual care). Patient information interventions may have little or no effect on desirable patient health outcomes and patient satisfaction (low-certainty evidence). We are uncertain about the effect of patient information interventions on undesirable patient health outcomes because the certainty of the evidence is very low. Adverse events and resource use were not reported in the included studies.Patient education interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We found that for every 100 patients consulted or treated, 46 (95% CI 39 to 54) are in accordance with recommended clinical practice compared to 35 per 100 in the comparison group (no intervention or usual care). Patient education interventions may slightly increase the number of patients with desirable health outcomes (low-certainty evidence). Undesirable patient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies.Patient decision aid interventions may have little or no effect on healthcare professionals' adherence to recommended clinical practice (low-certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 43) are in accordance with recommended clinical practice compared to 37 per 100 in the comparison group (usual care). Patient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies. AUTHORS' CONCLUSIONS: We found that two types of patient-mediated interventions, patient-reported health information and patient education, probably improve professional practice by increasing healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We consider the effect to be small to moderate. Other patient-mediated interventions, such as patient information may also improve professional practice (low-certainty evidence). Patient decision aids may make little or no difference to the number of healthcare professionals' adhering to recommended clinical practice (low-certainty evidence).The impact of these interventions on patient health and satisfaction, adverse events and resource use, is more uncertain mostly due to very low certainty evidence or lack of evidence.

Prioritising patient care: The different views of clinicians and managers.

BACKGROUND: There is little research comparing clinicians' and managers' views on priority settings in the healthcare services. During research on two different qualitative research projects on healthcare prioritisations, we found a striking difference on how hospital executive managers and clinical healthcare professionals talked about and understood prioritisations. AIM: The purpose of this study is to explore how healthcare professionals in mental healthcare and somatic medicine prioritise their care, to compare different ways of setting priorities among managers and clinicians and to explore how moral dilemmas are balanced and reconciled. Research design and participants: We conducted qualitative observations, interviews and focus groups with medical doctors, nurses and other clinical members of the interdisciplinary team in both somatic medical and mental health wards in hospitals in Norway. The interviews were recorded and transcribed verbatim. Ethical considerations: Basic ethical principles for research ethics were followed. The respondents signed an informed consent for participation. They were assured anonymity and confidentiality. The studies were approved by relevant ethics committees in line with the Helsinki Convention. FINDINGS: Our findings showed a widening gap between the views of clinicians on one hand and managers on the other. Clinicians experienced a threat to their autonomy, to their professional ideals and to their desire to perform their job in a professional way. Prioritisations were a cause of constant concern and problematic decisions. Even though several managers understood and empathised with the clinicians, the ideals of patient flow and keeping budgets balanced were perceived as more important. DISCUSSION: We discuss our findings in light of the moral challenges of patient-centred individual healthcare versus demands of distributive justice from healthcare management. CONCLUSION: The clinicians' ideals of autonomy and good medical and nursing care for the individual patients were perceived as endangered.

To support and to be supported. A qualitative study of peer support centres in cancer care in Norway.

OBJECTIVE: To explore what peer supporters, patients and their relatives want and gain from peer support in cancer care. METHODS: Focus group interviews with peer supporters, and in-depth interviews with peer supporters, patients and relatives (N=38) and observations of daily activities in a Vardesenter ("Cairn Centre"). RESULTS: Peer supporters helped cancer patients and relatives with coping in and outside the hospital in several ways: (1) conveying hope and providing ways to cope in situations where despair would often be prevalent, thus protecting against unhealthy stress; (2) being someone who had the same experiences of disease and treatment, and thus providing a framework for positive social comparisons; and (3) to be an important supplement to family and health care providers. To be working as a peer supporter was also found to be positive and important for the peer supporters themselves. CONCLUSION: The peer support program represented a valuable supplement to informal support from family and friends and healthcare providers, and gave the peer supporters a new role as "professionally unprofessional". PRACTICE IMPLICATIONS: Organised peer support represents a feasible intervention to promote coping for cancer survivors.

The good doctor - strong and persevering. / Den gode legen ­ sterk og utholdende.

BACKGROUND: In today's society, doctors are confronted with a number of opposing interests, from other colleagues, patients and employers. The development and regulation of the medical profession have been widely studied. However, less research has been devoted to the doctors' own perception of what it means to be a good doctor. MATERIAL AND METHOD: We conducted eight focus-group interviews and three individual interviews among senior consultants and specialty registrars in the areas of surgery, psychiatry and internal medicine in two different hospitals. Total N = 48, of which 56 % were women. The interviews were analysed with the aid of systematic text condensation. RESULTS: «Professional dedication¼ demonstrated through «a high degree of attendance in the workplace¼ and «a high work capacity¼ were key topics for good doctors. Having a «high work capacity¼ was defined as being willing to go to great lengths, work overtime and work effectively. The senior consultants perceived their job as doctors more as a «lifestyle¼, while the specialty registrars more frequently regarded their work as a «job¼. INTERPRETATION: Norwegian hospital doctors wish to appear dedicated to their profession. They can demonstrate this by showing great willingness to work intensively and effectively with patients, while also going to great lengths to be available beyond normal working hours.

The hospital doctor of today - still continuously on duty. / Dagens sykehuslege ­ fremdeles alltid på vakt.

BACKGROUND: Norwegian hospital doctors emphasise the value of working hard and efficiently and of a high degree of attendance in the workplace. This helps establish social norms that guide behaviour within the professional culture. It is important to examine what consequences these values may entail when the doctor also needs to cater to his or her own needs. MATERIAL AND METHOD: We conducted eight focus-group interviews and three individual interviews among a total of 48 senior consultants and specialty registrars working in the areas of surgery, psychiatry and internal medicine. Total N = 48; 56 % women. The interviews were analysed with the aid of systematic text condensation. RESULTS: When Norwegian hospital doctors wish to appear as good doctors, they see that this entails consequences for the interrelationships with colleagues, the management and the work-life balance. Conflicts of interest arose between senior consultants and specialty registrars. Management initiatives to deal with absence, adaptation of the job to the life stage of each individual doctor and increased management involvement among doctors were among the measures proposed. INTERPRETATION: Better mutual knowledge between doctors and management with regard to each other's values and responsibilities could constitute key premises for structural changes, for example in terms of better planning of leaves of absence and opportunities for adaptation of work schedules to the life stage of the persons concerned.

Conscientious objection to referrals for abortion: pragmatic solution or threat to women's rights?

BACKGROUND: Conscientious objection has spurred impassioned debate in many Western countries. Some Norwegian general practitioners (GPs) refuse to refer for abortion. Little is know about how the GPs carry out their refusals in practice, how they perceive their refusal to fit with their role as professionals, and how refusals impact patients. Empirical data can inform subsequent normative analysis. METHODS: Qualitative research interviews were conducted with seven GPs, all Christians. Transcripts were analysed using systematic text condensation. RESULTS: Informants displayed a marked ambivalence towards their own refusal practices. Five main topics emerged in the interviews: 1) carrying out conscientious objection in practice, 2) justification for conscientious objection, 3) challenges when relating to colleagues, 4) ambivalence and consistency, 5) effects on the doctor-patient relationship. CONCLUSIONS: Norwegian GP conscientious objectors were given to consider both pros and cons when evaluating their refusal practices. They had settled on a practical compromise, the precise form of which would vary, and which was deemed an acceptable middle way between competing interests.

Inadequate treatment for elderly patients: professional norms and tight budgets could cause "ageism" in hospitals.

We have studied ethical considerations of care among health professionals when treating and setting priorities for elderly patients in Norway. The views of medical doctors and nurses were analysed using qualitative methods. We conducted 21 in depth interviews and 3 focus group interviews in hospitals and general practices. Both doctors and nurses said they treated elderly patients different from younger patients, and often they were given lower priorities. Too little or too much treatment, in the sense of too many interventions and too much drugs, combined with too little care and comfort, was admitted as a relatively frequent yet unwanted consequence of the way clinical priorities were set for elderly patients. This was explained in terms of elderly patients not tolerating the same treatment as younger patients, and questions were raised about the quality of life of many elderly patients after treatment. These explanations were frequently referred to as medically sound decision making. Other explanations had little to do with medically sound decisions. These often included deep frustration with executive guidelines and budget constraints.

Mandates of trust in the doctor-patient relationship.

We examine the conditions for trust relationships between patients and physicians. A trust relationship is not normally negotiated explicitly, but we wanted to discuss it with both patients and physicians. We therefore relied on a combination of interviews and observations. Sixteen patients and 8 family physicians in Norway participated in the study. We found that trust relationships were negotiated implicitly. Physicians were authorized by patients to exercise their judgment as medical doctors to varying degrees. We called this phenomenon the patient's mandate of trust to the physician. A mandate of trust limited to specific complaints was adequate for many medical procedures, but more open mandates of trust seemed necessary to ensure effective and humane treatment for patients with more complex and diffuse illnesses. More open mandates of trust were given if the physician showed an early interest in the patient, was sensitive, gave time, built alliances, or bracketed normal behavior.