Moral distress and ethical climate in pediatric oncology care impact healthcare professionals' intentions to leave.

OBJECTIVE: To assess perceptions of ethical climate, experiences of moral distress, and intentions to leave among healthcare professionals in Nordic pediatric oncology care. METHODS: A cross-sectional survey with registered nurses, physicians, and nursing assistants at 20 Nordic pediatric cancer centers. Data were collected by using translated versions of the Swedish Hospital Ethical Climate Survey-Shortened and the Swedish Moral Distress Scale-Revised. Descriptive analyses and non-parametric tests were used to describe, summarize, and compare data. RESULTS: According to 543 healthcare professionals (response rate 58%), the ethical climate in Nordic pediatric oncology care was positive. Inadequate staffing levels, poor continuity and lack of time were the most common causes of moral distress. Registered nurses experienced significantly higher levels of moral distress compared to physicians and nursing assistants. About 6% of the respondents considered leaving due to moral distress. Typically, they assessed the ethical climate as less positive and reported higher levels of moral distress than those who had no intention to leave. CONCLUSIONS: Organizational actions that ensure safe staffing levels and improve the continuity of care are needed to prevent moral distress and high staff turnover.

Nurses' Perceptions of the Impact of a National Educational Program in Pediatric Oncology Nursing: A Cross-Sectional Evaluation.

Background: Specific knowledge is required in pediatric oncology, and specialization of nurses has been identified as a priority. In Sweden, a national program in pediatric oncology nursing has been offered since 2003. The aim of this study was to gain knowledge of nurses' perceptions of the impact of this educational program. Methods: Eighty nurses who had completed the educational program in three cohorts (2012-2019) were invited to participate in this cross-sectional survey. An electronic study-specific questionnaire containing multiple-choice questions was used. Data were analyzed using descriptive statistics and correlation tests. Results: Fifty-nine (74%) nurses completed the survey, of whom 98% responded that they would recommend the program to a large/fairly large extent. At the time of the survey, 15 (25%) participants had left pediatric oncology care. Among the remaining 44, 31 (71%) of the nurses were working bedside, and 13 (42%) of these combined this with a special position (e.g., consultant nurse). The education resulted in career advancement, as the number of nurses with special positions increased following completion of the program, from 20% to 59%. The vast majority stated that the knowledge gained from the education contributed to increased confidence in interactions with the children/families. Discussion: Continuing education of nurses in pediatric oncology has an impact on career opportunities in clinical practice and contributes to nurses' confidence and professional work. However, education is not enough to retain competent nurses. Employers need to be aware of the role of the work environment, aspects of work-life balance and career paths.

What outcomes of moral case deliberations are perceived important for healthcare professionals to handle moral challenges? A national cross-sectional study in paediatric oncology.

BACKGROUND: In paediatric oncology, healthcare professionals face moral challenges. Clinical ethics support services, such as moral case deliberation (MCD), aim to assist them in dealing with these challenges. Yet, healthcare professionals can have different expectations and goals related to clinical ethics support services. METHODS: In this study, the perceptions held by healthcare professionals (nursing assistants, registered nurses, physicians, and others) regarding the importance of possible outcomes of MCDs, prior to implementation of MCDs, were investigated. A multisite, cross-sectional, quantitative study was performed at all six Paediatric Oncology Centres in Sweden. Healthcare professionals answered the Euro-MCD instrument with 26 potential MCD outcomes using a scale from Not important (1) to Very important (4). Descriptive and comparative statistical analyses were carried out. RESULTS: All outcomes were rated high, i.e., between 3.12 and 3.78. More open communication, developing skills to analyse ethically difficult situations, better mutual understanding, and deciding on concrete actions were rated as most important. Understanding of ethical theories and critical examination of policies were rated less important. Most often nursing assistants rated higher and physicians lower than the other professions did. Women and participants without previous experience of MCDs perceived outcomes as more important. There were differences between centres as one centre had significantly higher, and one centre had significantly lower ratings compared to the others. CONCLUSION: It is clear that healthcare professionals want MCDs to improve teamwork and skills in order to analyse and manage ethically difficult situations. When comparing to previous research about important MCD outcomes, there were similarities in what healthcare professionals consider to be important when handling moral challenges regardless of country and potential differences in healthcare settings and systems, such as paediatric vs. adult care.

Is there a choice when a sibling is ill? Experiences of children and adolescents who donated stem cells to a sibling.

PURPOSE: When healthy children/adolescents are potential stem cell donors to a sibling, ethical questions arise due to reduced autonomy and dependency on their family. This study aimed to explore the experiences of children/adolescents in Sweden who donated stem cells to a severely ill sibling. METHOD: Semi-structured interviews were conducted with thirteen donors, aged 6-17 years at the time of the donation, all with surviving siblings. The interviews were transcribed verbatim and analysed using qualitative content analysis. RESULT: The main category in this study was The presumed 'choice' when a sibling is ill. The experience included being Proud without an actual choice, highlights that the donors were proud to contribute, and perceptions of a request without a choice. Focusing on the ill sibling and the outcomes reveals that they were worried and protected the sibling, and downplayed the importance of their own effort. They experienced a Need ofsupport and information, which derived from receiving information without communication about what they really needed to know, but also the importance of support through play and talk. CONCLUSION: The donation involves the young donor in the care, implying an opportunity to bring the family back together. They have no real choice, when their sibling is ill and the lack of information about possible alternatives indicate that there was no option to decline. There is also a need to focus on the experiences of young donors whose siblings died after the transplantation.

A cross-sectional survey of moral distress and ethical climate - Situations in paediatric oncology care that involve children's voices.

AIM: To assess experiences of morally distressing situations and perceptions of ethical climate in paediatric oncology care, with a focus on situations that involve children's voices. DESIGN: Cross-sectional survey. METHODS: Registered Nurses at all four paediatric oncology centres in Denmark were asked to complete a web-based questionnaire with Danish translations of the Swedish Moral Distress Scale-Revised (MDS-R) and the Swedish Hospital Ethical Climate Survey-Shortened (HECS-S). Data analysis included descriptive statistics and non-parametric correlation tests. RESULTS: Nurses (n = 65) perceived morally distressing situations as rather uncommon, except for those that involved shortage of time, poor continuity of care and unsafe staffing levels. Most nurses (83%) found it disturbing to perform procedures on school-aged children against their will, and 20% reported that they do this often. Perceptions of ethical climate were positive and healthcare professionals were perceived to be attentive to children's wishes.

Does participation in ethics discussions have an impact on ethics decision-making? A cross-sectional study among healthcare professionals in paediatric oncology.

PURPOSE: The overall aim of this study was to describe perceptions of the decision-making process in relation to participation/non-participation in ethics discussions among healthcare professionals in paediatric oncology. METHODS: Healthcare professionals, working at three paediatric units where ethics discussions where performed answered a study-specific questionnaire focusing on perceptions of involvement, influence, responsibility and understanding of ethics decision-making. Statistical analyses included descriptive statistics, non-parametric paired t-tests and correlation tests. RESULTS: Participation in ethics discussions was related to perceptions of greater involvement and the possibility of influencing decisions, as well as formal/shared responsibility for the ethics decisions related to patient care. Medical doctors and registered nurses perception of involvement in decisions, possibility to influence and responsibility decreased when they were not present during the ethics discussion or when no ethics discussion was conducted at all. Healthcare professionals had a generally good understanding of the ethical issues and the ethics decisions. The whole group considered medical doctors to be the most important participants in the ethics discussions, followed by patients/family. Healthcare professionals wanted more teamwork and viewed ethics discussions as very helpful for teamwork when dealing with ethical issues in paediatric oncology. CONCLUSIONS: Ethics discussions in paediatric oncology practice increases the involvement within and the understanding of the decision-making process about ethical decisions. The understanding is not always dependent on participation, indicating a great trust in team members. Based on these findings the implementation of a structure for ethics support in paediatric oncology where patients/families are integrated is recommended.

Perceptions of important outcomes of moral case deliberations: a qualitative study among healthcare professionals in childhood cancer care.

BACKGROUND: In childhood cancer care, healthcare professionals must deal with several difficult moral situations in clinical practice. Previous studies show that morally difficult challenges are related to decisions on treatment limitations, infringing on the child's integrity and growing autonomy, and interprofessional conflicts. Research also shows that healthcare professionals have expressed a need for clinical ethics support to help them deal with morally difficult situations. Moral case deliberations (MCDs) are one example of ethics support. The aim of this study was to describe the MCD-related outcomes that healthcare professionals in childhood cancer care considered important, before MCDs were implemented, in order to facilitate the implementation of MCDs in childhood cancer care in Sweden. METHODS: This study is based on qualitative data. Healthcare professionals, mostly representing registered nurses, nursing assistants and physicians, working at childhood cancer care centres in Sweden, were invited to respond to the translated and content validated European MCD Outcomes Instrument, before participating in regular MCDs. Answers to the main open-ended question, included in the questionnaire, was analysed according to systematic text condensation. RESULTS: Data was collected from 161 responses from the healthcare professionals. The responses included healthcare professionals' perceptions of which MCD-related outcomes they found important for handling moral challenges. Three different themes of important outcomes from the analysis of the data are presented as follows: Interprofessional well-being in team interactions on a team level; Professional comfort when dealing with moral challenges on a personal level; and Improved quality of care for the child and the family on a care level. CONCLUSIONS: Healthcare professionals in childhood cancer care considered it important that ethics support could enhance the well-being of interprofessional teams, support healthcare professionals on an individual level and improve quality of care. The results of this study can be used in current and future training for MCD-facilitators. When knowing the context specific important MCD-outcomes, the sessions could be adapted. Managers in childhood cancer care would benefit from knowing about the specific important outcomes for their target group because they could then create relevant working conditions for clinical ethics support.

Ethical climate and moral distress in paediatric oncology nursing.

BACKGROUND: Ethical climate and moral distress have been shown to affect nurses' ethical behaviour. Despite the many ethical issues in paediatric oncology nursing, research is still lacking in the field. RESEARCH AIM: To investigate paediatric oncology nurses' perceptions of ethical climate and moral distress. RESEARCH DESIGN: In this cross-sectional study, data were collected using Finnish translations of the Swedish Hospital Ethical Climate Survey-Shortened and the Swedish Moral Distress Scale-Revised. Data analysis includes descriptive statistics and non-parametric analyses. RESPONDENTS AND RESEARCH CONTEXT: Ninety-three nurses, working at paediatric oncology centres in Finland, completed the survey. ETHICAL CONSIDERATIONS: According to Finnish legislation, no ethical review was needed for this type of questionnaire study. Formal research approvals were obtained from all five hospitals. Return of the questionnaire was interpreted as consent to participate. RESULTS: Ethical climate was perceived as positive. Although morally distressing situations were assessed as highly disturbing, in general they occurred quite rarely. The situations that did appear often reflected performing procedures on school-aged children who resist such treatment, inadequate staffing and lack of time. Perceptions of ethical climate and frequencies of morally distressing situations were inversely correlated. DISCUSSION: Although the results echo the recurrent testimonies of busy work shifts, nurses could most often practise nursing the way they perceived as right. One possible explanation could be the competent and supportive co-workers, as peer support has been described as helpful in mitigating moral distress. CONCLUSION: Nurturing good collegial relationships and developing manageable workloads could reduce moral distress among nurses.

Reasons for not using interpreters to secure patient-safe communication - A national cross-sectional study in paediatric oncology.

OBJECTIVE: To investigate the reasons for not using interpreters to secure patient-safe communication. METHODS: Healthcare personnel at six paediatric oncology centres in Sweden responded to the Communication over Language Barriers questionnaire. Descriptive and comparative analyses were performed. RESULTS: The participants (n = 267) often cared for patients with limited Swedish proficiency, although they were not trained in using interpreters. A lack of time was perceived as a barrier in emergency care situations, but also in planned care situations. Another barrier was the interpreter's ability to correctly interpret medical/care terminology. There were significant differences in evaluating the interpreters' abilities between those with/without education in using interpreters, and between Medical Doctors and Nursing Assistants. Participants were unsure whether the patient had received the correct information and thought that it was difficult to control the family/patient's understanding of the given information. The vast majority did not perceive financial constraints as a barrier for using interpreters. CONCLUSIONS: Economic resources and legislation are not enough to increase the use of interpreters. Reasons for not using interpreters are found in limitations of time, training, and interpreters' skills and knowledge. PRACTICE IMPLICATIONS: There is a need for a greater focus on training, interpreters' skills, and booking procedures in paediatric healthcare.

Important situations that capture moral distress in paediatric oncology.

BACKGROUND: The paediatric Moral Distress Scale-Revised (MDS-R) was previously translated and adapted to Swedish paediatric oncology. Cognitive interviews revealed five not captured situations among the 21 items, resulting in five added items: 22) Lack of time for conversations with patients/families, 23) Parents' unrealistic expectations, 24) Not to talk about death with a dying child, 25) To perform painful procedures, 26) To decide on treatment/care when uncertain. The aim was to explore experiences of moral distress in the five added situations in the Swedish paediatric MDS-R, among healthcare professionals (HCPs) in paediatric oncology. METHODS: In this national cross-sectional survey, the Swedish paediatric MDS-R, including five added items, were used. Descriptive statistics, non-parametric analysis of differences between professions and a MDS-R score for each item were calculated. Internal consistency was tested using Cronbach's alpha and inter-item correlation test. HCPs (n = 278) at all six Swedish paediatric oncology centres participated (> 89%). The Regional Ethical Review Board had no objections. Consent was assumed when the survey was returned. RESULTS: Nursing assistants (NAs) reported higher intensity and lower frequency on all added items; registered nurses (RNs) reported a higher frequency on item 22-25; medical doctors (MDs) reported higher MDS-R score on item 26. On item 22, intensity was moderate for RNs and MDs and high for NAs, and frequency was high among all. Item 22, had the second highest MDS-R score of all 26 for all professional groups. On item 23, the level of disturbance was low but it occurred often. The 26-item version showed good internal consistency for the overall sample and for all professional groups. However, item 22 and 24 could be viewed as redundant to two of the original 21. CONCLUSION: In accordance with other studies, the intensity was higher than the frequency, however, the frequency of the added items was higher than of the original items. In line with previous research, item 22 and 23 are important elements of moral distress. RNs experience the situations more often while NAs find them more disturbing. The results indicate that the added items are important in capturing moral distress in paediatric oncology.

Balancing values and obligations when obtaining informed consent: Healthcare professionals' experiences in Swedish paediatric oncology.

AIM: To explore Swedish healthcare professionals' (HCPs) clinical experiences of the informed consent process (ICP) and to compare experiences between the professions. METHODS: In this nationwide study six paediatric oncologists (POs) and eight research nurses (ReNs) from all Swedish paediatric oncology centres were interviewed. The material was analysed using Grounded theory, a qualitative constant comparative method. RESULTS: The participants' main concern was how to fulfil research obligations without putting too much strain on a family in acute crisis, which led to the core category of balancing values and obligations of both healthcare and research. To handle the challenges the participants' struggled to safeguard the families from psychological harm, tried to adjust to the families, and gradually introduced research while building trust. The conceptual model developed in the study highlights potential consequences of this balancing act with a risk of diminishing the family's autonomy through HCPs acting authoritatively (in particular POs) or with overprotection (in particular ReNs). CONCLUSION: Paediatric oncology is a research integrated healthcare environment. The HCPs need personal, professional and institutional support regarding ICP-related ethical issues, decisions and implications in this intertwined context. Furthermore, HCPs need to be aware of the potential long-term risk of developing professional moral distress.

Language barriers and the use of professional interpreters: a national multisite cross-sectional survey in pediatric oncology care.

Background: Healthcare personnel are responsible for providing patient-centered care regardless of their patients' language skills, but language barriers is identified as the main hindrances providing effective, equitable and safe care to patients with limited proficiency in a country's majority language. This study is a national multisite cross-sectional survey aiming to investigate communication over language barriers in pediatric oncology care. Material and Methods: A survey using the Communication over Language Barriers questionnaire (CoLB-q) distributed to medical doctors, registered nurses and nursing assistants at six pediatric oncology centers in Sweden (response rate 90%) using descriptive statistical analyses. Results: Professional interpreters on site were the most common solution when using an interpreter, although relatives or even children were used. The use of professional interpreters on site differed among the professions and in different clinical situations, such as medical encounter, education or procedure preparation. All professions reported that the use of professional interpreters greatly increased care relationships, patient safety and patient involvement in care. Conclusions: Healthcare personnel seem to believe that professional interpreters are crucial when caring for patients and family members who do not speak the majority language, but there is an obvious discrepancy between this belief and their use of professional interpreters.

The ethical climate in paediatric oncology-A national cross-sectional survey of health-care personnel.

OBJECTIVE: To describe health-care personnel's (HCP's) perceptions of the ethical climate at their workplace in paediatric oncology. METHODS: A cross-sectional survey was conducted using the Swedish version of the shortened Hospital Ethical Climate Survey (HECS-S). HCP at all six paediatric oncology centres (POCs) in Sweden were invited to participate. Analysis included descriptive statistics, the Mann-Whitney U test (differences between groups) and Spearman's rank correlation. Informed consent was assumed when the respondents returned the survey. RESULTS: A high response rate was achieved as 278 HCP answered the questionnaire. Medical doctors perceived the ethical climate to be more positive than registered nurses and nursing assistants. At the POC with the significantly lowest values concerning immediate manager, no significant correlation with the other items was found. At the POC with the poorest ethical climate, HCP also had the lowest perception of the possibility of practicing ethically good care. CONCLUSIONS: Differences between centres and professional groups have been demonstrated. A negative perception of the immediate manager does not necessarily mean that the ethical climate is poor, but the manager's ability to provide the conditions for an open dialogue within the health-care team is key to achieving an ethical climate.

Moral distress in paediatric oncology: Contributing factors and group differences.

BACKGROUND: Providing oncological care to children is demanding and ethical issues concerning what is best for the child can contribute to moral distress. OBJECTIVES: To explore healthcare professionals' experiences of situations that generate moral distress in Swedish paediatric oncology. RESEARCH DESIGN: In this national study, data collection was conducted using the Swedish Moral Distress Scale-Revised. The data analysis included descriptive statistics and non-parametric analysis of differences between groups. PARTICIPANTS AND RESEARCH CONTEXT: Healthcare professionals at all paediatric oncology centres in Sweden were invited to participate. A total of 278 healthcare professionals participated. The response rate was 89%. ETHICAL CONSIDERATIONS: In its advisory statement, the Regional Ethical Review Board decided that the study was of such a nature that the legislation concerning ethical reviews was not applicable. All participants received written information about the aim of the study and confidentiality. Participants demonstrated their consent by returning the survey. FINDINGS: The two situations with the highest moral distress scores concerned lack of competence and continuity of personnel. All professional groups reported high levels of disturbance. Nurses rated significantly higher frequencies and higher total Moral Distress Scale scores compared to medical doctors and nursing assistants. DISCUSSION: Lack of competence and continuity, as the two most morally distressing situations, confirms the findings of studies from other countries, where inadequate staffing was reported as being among the top five morally distressing situations. The levels of total Moral Distress Scale scores were more similar to those reported in intensive care units than in other paediatric care settings. CONCLUSION: The two most morally distressing situations, lack of competence and continuity, are both organisational in nature. Thus, clinical ethics support services need to be combined with organisational improvements in order to reduce moral distress, thereby maintaining job satisfaction, preventing a high turnover of staff and ensuring the quality of care.

The interpreter's voice: Carrying the bilingual conversation in interpreter-mediated consultations in pediatric oncology care.

OBJECTIVES: The objective of this study was to explore interpreters' perceived strategies in the interaction in interpreter-mediated consultations between healthcare personnel and patients/families with limited Swedish proficiency in pediatric oncology care. METHODS: This study had an inductive approach using an exploratory qualitative design. A total of eleven semi-structured interviews were performed with interpreters who had experience interpreting in pediatric oncology care. RESULTS: The interpreters' perceived strategies were divided into four generic categories; strategies for maintaining a professional role, strategies for facilitating communication, strategies for promoting collaboration, and strategies for improving the framework of interpreting provision. These four generic categories were then merged into the single main category of carrying the bilingual conversation. CONCLUSIONS: The interpreters stretch their discretionary power in order to carry the bilingual conversation by using strategies clearly outside of their assignment. PRACTICAL IMPLICATIONS: The study contributes to the understanding of the interpreter-mediated consultation in pediatric oncology care, and this can be used to improve the care of patients and families in pediatric oncology care with limited knowledge of a country's majority language.

Translating and culturally adapting the shortened version of the Hospital Ethical Climate Survey (HECS-S) - retaining or modifying validated instruments.

BACKGROUND: The Hospital Ethical Climate Survey (HECS) was developed in the USA and later shortened (HECS-S). HECS has previously been translated into Swedish and the aim of this study was to describe a process of translating and culturally adapting HECS-S and to develop a Swedish multi-professional version, relevant for paediatrics. Another aim was to describe decisions about retaining versus modifying the questionnaire in order to keep the Swedish version as close as possible to the original while achieving a good functional level and trustworthiness. METHODS: In HECS-S, the respondents are asked to indicate the veracity of statements. In HECS and HECS-S the labels of the scale range from 'almost never true' to 'almost always true'; while the Swedish HECS labels range from 'never' to 'always'. The procedure of translating and culturally adapting the Swedish version followed the scientific structure of guidelines. Three focus group interviews and three cognitive interviews were conducted with healthcare professionals. Furthermore, descriptive data were used from a previous study with healthcare professionals (n = 89), employing a modified Swedish HECS. Decisions on retaining or modifying items were made in a review group. RESULTS: The Swedish HECS-S consists of 21 items including all 14 items from HECS-S and items added to develop a multi-professional version, relevant for paediatrics. The descriptive data showed that few respondents selected 'never' and 'always'. To obtain a more even distribution of responses and keep Swedish HECS-S close to HECS-S, the original labels were retained. Linguistic adjustments were made to retain the intended meaning of the original items. The word 'respect' was used in HECS-S with two different meanings and was replaced in one of these because participants were concerned that respecting patients' wishes implied always complying with them. CONCLUSIONS: The process of developing a Swedish HECS-S included decisions on whether to retain or modify. Only minor adjustments were needed to achieve a good functional level and trustworthiness although some items needed to be added. Adjustments made could be used to also improve the English HECS-S. The results shed further light on the need to continuously evaluate even validated instruments and adapt them before use.

Development and evaluation of the Communication over Language Barriers questionnaire (CoLB-q) in paediatric healthcare.

OBJECTIVE: To develop a valid and reliable questionnaire addressing the experiences of healthcare personnel of communicating over language barriers and using interpreters in paediatric healthcare. METHODS: A multiple- methods approach to develop and evaluate the questionnaire, including focus groups, cognitive interviews, a pilot test and test-retest. The methods were chosen in accordance with questionnaire development methodology to ensure validity and reliability. RESULTS: The development procedure showed that the issues identified were highly relevant to paediatric healthcare personnel and resulted in a valid and reliable Communication over Language Barriers questionnaire (CoLB-q) with 27 questions. CONCLUSION: The CoLB-q is perceived as relevant, important and easy to respond to by respondents and has satisfactory validity and reliability. PRACTICE IMPLICATIONS: The CoLB-q can be used to map how healthcare personnel overcome language barriers through communication tools and to identify problems encountered in paediatric healthcare. Furthermore, the transparently described process could be used as a guide for developing similar questionnaires.

Ethics case reflection sessions: Enablers and barriers.

BACKGROUND: In previous research on ethics case reflection (ECR) sessions about specific cases, healthcare professionals in childhood cancer care were clarifying their perspectives on the ethical issue to resolve their main concern of consolidating care. When perspectives were clarified, consequences in the team included 'increased understanding', 'group strengthening' and 'decision grounding'. Additional analysis of the data was needed on conditions that could contribute to the quality of ECR sessions. OBJECTIVE: The aim of this study was to explore conditions for clarifying perspectives during ECR sessions. RESEARCH DESIGN: Data were collected from observations and interviews and the results emerged from an inductive analysis using grounded theory. Participants and research context: Six observations during ECR sessions and 10 interviews were performed with healthcare professionals working in childhood cancer care and advanced paediatric homecare. Ethical considerations: The study was approved by a regional ethical review board. Participants were informed about their voluntary involvement and that they could withdraw their participation without explaining why. FINDINGS: Two categories emerged: organizational enablers and barriers and team-related enablers and barriers. Organizational enablers and barriers included the following sub-categories: the timing of the ECR session, the structure during the ECR session and the climate during the ECR session. Sub-categories to team-related enablers and barriers were identified as space for inter-professional perspectives, varying levels of ethical skills and space for the patient's and the family's perspectives. DISCUSSION: Space for inter-professional perspectives included the dominance of a particular perspective that can result from hierarchical positions. The medical perspective is relevant for understanding the child's situation but should not dominate the ethical reflection. CONCLUSION: Conditions for ECR sessions have been explored and the new knowledge can be used when training facilitators as well as for those who organize/implement ECR sessions. Awareness of space for different perspectives, including the possible medical advantage over the nursing perspective, could reduce the somewhat unilateral attention and contribute to an inter-professionally shared reflection.