How prehospital emergency personnel manage ethical challenges: the importance of confidence, trust, and safety.

BACKGROUND: Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. Ethical challenges are associated with moral distress that can lead to burnout. Clinical ethics support has proven useful to address and manage such challenges. This paper explores how prehospital emergency personnel manage ethical challenges. The study is part of a larger action research project to develop and test an approach to clinical ethics support that is sensitive to the context of emergency medicine. METHODS: We explored ethical challenges and management strategies in three focus groups, with 15 participants in total, each attended by emergency medical technicians, paramedics, and prehospital anaesthesiologists. Focus groups were audio-recorded and transcribed verbatim. The approach to data analysis was systematic text condensation approach. RESULTS: We stratified the management of ethical challenges into actions before, during, and after incidents. Before incidents, participants stressed the importance of mutual understandings, shared worldviews, and a supportive approach to managing emotions. During an incident, the participants employed moral perception, moral judgments, and moral actions. After an incident, the participants described sharing ethical challenges only to a limited extent as sharing was emotionally challenging, and not actively supported by workplace culture, or organisational procedures. The participants primarily managed ethical challenges informally, often using humour to cope. CONCLUSION: Our analysis supports and clarifies that confidence, trust, and safety in relation to colleagues, management, and the wider organisation are essential for prehospital emergency personnel to share ethical challenges and preventing moral distress turning into burnout.

Ethical challenges experienced by prehospital emergency personnel: a practice-based model of analysis.

BACKGROUND: Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. In prehospital emergency medicine, decision-making commonly takes place in everyday life, under time pressure, with limited information about a patient and with few possibilities of consultation with colleagues. This paper explores the ethical challenges experienced by prehospital emergency personnel. METHODS: The study was grounded in the tradition of action research related to interventions in health care. Ethical challenges were explored in three focus groups, each attended by emergency medical technicians, paramedics, and prehospital anaesthesiologists. The participants, 15 in total, were recruited through an internal information network of the emergency services. Focus groups were audio-recorded and transcribed verbatim. RESULTS: The participants described ethical challenges arising when clinical guidelines, legal requirements, and clinicians' professional and personal value systems conflicted and complicated decision-making processes. The challenges centred around treatment at the end of life, intoxicated and non-compliant patients, children as patients-and their guardians, and the collaboration with relatives in various capacities. Other challenges concerned guarding the safety of oneself, colleagues and bystanders, prioritising scarce resources, and staying loyal to colleagues with different value systems. Finally, challenges arose when summoned to situations where other professionals had failed to make a decision or take action when attending to patients whose legitimate needs were not met by the appropriate medical or social services, and when working alongside representatives of authorities with different roles, responsibilities and tasks. CONCLUSION: From the perspective of the prehospital emergency personnel, ethical challenges arise in three interrelated contexts: when caring for patients, in the prehospital emergency unit, and during external collaboration. Value conflicts may be identified within these contexts as well as across them. A proposed model of analysis integrating the above contexts can assist in shedding light on ethical challenges and value conflicts in other health care settings. The model emphasises that ethical challenges are experienced from a particular professional perspective, in the context of the task at hand, and in a particular, the organisational setting that includes work schedules, medical guidelines, legal requirements, as well as professional and personal value systems.

Physicians' experiences working in emergency medicine in a rural area in Northern Sweden: a qualitative study.

INTRODUCTION: Working in emergency medicine in rural areas may entail challenges due to absence of medical backup, difficulties in logistics, lack of healthcare system coordination, and, potentially, feelings of loneliness. The aim of this study was to elucidate the experiences of physicians working in an emergency medical setting in a rural area in Northern Sweden. METHODS: A qualitative study was performed based on semi-structured interviews. Six physicians were interviewed. The interviews were transcribed and analysed using the systematic text condensation method. RESULTS: Rural physicians described thriving in the rural environment. Four main themes were identified as important to their wellbeing and job satisfaction. They described close relations to the nearest referral centre, where they felt connected to the personnel in the centre. The participants described this as a crucial factor aiding their everyday work in emergency medicine. The rural physicians underlined educational and professional development individually, in teams training sessions, and through the locally created rural residency program for rural GPs as important. They expressed an adaptability to the rural environment and described having a problem-solving attitude. Additionally they found a functional transport system crucial as part of their workflow. CONCLUSION: Overall, the rural physicians thrived in the rural environment where interpersonal relations and creative initiatives along with a customised rural residency program prepared the physicians to work in rural areas. Despite the long distances between hospitals and health clinics, the physicians rarely felt alone in the field and the general well-functioning transport system with possibility for improvisations aided them in medical emergencies.

Implementing ethics reflection groups in hospitals: an action research study evaluating barriers and promotors.

BACKGROUND: An ethics reflection group (ERG) is one of a range of ethics support services developed to better handle ethical challenges in healthcare. The aim of this article is to evaluate the implementation process of interdisciplinary ERGs in psychiatric and general hospital departments in Denmark. To our knowledge, this is the first study of ERG implementation to include both psychiatric and general hospital departments. METHODS: The implementation and evaluation strategies are inspired by action research, using a qualitative approach and systematic text condensation of 28 individual interviews and 4 focus groups with clinicians, ethics facilitators and ward managers. RESULTS: The implementation process was influenced by both structural factors and factors related to clinicians having different values, interests and experiences. Structural barriers and promotors in the process to implement ERG included the following sub-categories: Organizational factors, recruitment and training of ethics facilitators, the deliberation model, planning and recruitment of participants to the ERGs, the support of the ward managers and the project group. Barriers and promotors found among clinicians included the following sub-categories: Expectations and pre-understandings of ERGs, understandings of a physician's job, challenges experienced by ethics facilitators. At the end of the study, when it was decided that the ERGs should be continued, the implementation strategies were remodeled by the participants to meet new challenges. CONCLUSION: The study of ERG implementation identified important structural and professional barriers and promotors that are likely to be relevant to anyone wanting to implement ethics support services across various types of healthcare services.

Professional prehospital clinicians' experiences of ethical challenges associated with the collaboration with organised voluntary first responders: a qualitative study.

BACKGROUND: Volunteer First Responders are used worldwide. In the Region of Southern Denmark, two types of programs have been established. One of these programs consists of voluntary responders without any requirements of education or training who are summoned to prehospital cardiac arrests. The other type of program is established primarily in the rural areas of the region and consists of volunteers with some mandatory education in first aid. These volunteers are summoned to all urgent cases along with the ambulances. Cooperation between professional healthcare workers and nonprofessionals summoned through official channels may be challenging. This study aimed to explore prehospital clinicians' experiences of ethical challenges in cooperation with volunteer first responders. METHODS: We conducted 16 semi-structured interviews at four different ambulance stations in the Region of Southern Denmark. Five emergency physicians and 11 emergency medical technicians/paramedics were interviewed. The interviews were transcribed, and the data were analysed using systematic text condensation. RESULTS: The study's 16 interviews resulted in the identification of some specific categories that challenged the cooperation between the two parties. We identified three main categories: 1. Beneficence, the act of doing good, 2. The risk of harming patients' autonomy 3. Non-maleficence, which is the obligation not to inflict harm on others. CONCLUSION: This study provides an in-depth insight into the ethical challenges between prehospital clinicians and voluntary first responders from the perspective of the prehospital clinicians. Both programs are considered to have value but only when treating patients with cardiac arrest. Our study highlights potential areas of improvement in the two Danish voluntary programs in their current form.

Los Naturistas-Healers Who Integrate Traditional and Biomedical Explanations in Their Treatment in the Bolivian Health Care System.

Medical pluralism is a common feature in most health care systems. In this system integration and exchanges between sectors are common, thus forming complex and hybrid systems. This paper analyses such a pluralistic system, and is based on an anthropological study involving participant observation and ethnographic interviews. The research focuses on a group of healers-Los Naturistas from urban Bolivia. They are Mestizos and serve the Indian and Indian Mestizo population. The study findings suggest they integrate explanatory models from both the traditional Andean medicine and biomedicine, but are selective in the sicknesses they treat. They predominantly use herbal medicine. As a group of healers Los Naturistas are establishing their specific place in the Bolivian health care system.