Cultural engagement in clinical ethics: a model for ethics consultation

[Culture-sensitive training in geriatric rehabilitation: Concept and evaluation]

BACKGROUND

The number of patients with an immigration background in geriatric healthcare institutions in Germany is growing continuously. The number of medical staff with a migration background is also increasing because of the shortage of qualified employees in the healthcare sector. Therefore, the ability to act culturally sensitive is essential. A training course for employees caring for chronically ill elderly patients with a migration background was developed, tested and evaluated.

METHODS

The training was developed on the basis of interviews with experts and research literature and took place over half a day. It was then tested in a pilot study in three hospitals (geriatric, orthopaedic, cardiologic clinics) and evaluated with respect to content and implementation using both guided interviews, which were subjected to content analysis, and a questionnaire.

RESULTS

The training was feasible and well received by the participants, and a high demand for interventions on cultural sensitivity could be derived from the interviews. Improvements were achieved on the dimensions of self-reflection (recognizing one's own and others' cultural imprint), communication with patients and their relatives, and teamwork.

DISCUSSION

The participants asked for a more extensive and broader training. A multiplier training should be considered in order to implement the contents nationwide and sustainably in clinics. A randomized controlled design is necessary to verify the assumed effects.

CONCLUSION

Based on the results and the need for culture-sensitive training, the training should be carried out within a wider timeframe and in a bigger population.

Nurses’ contributions to the resolution of ethical dilemmas in practice

Background:

Complex and expensive treatment options have increased the frequency and emphasis of ethical decision-making in healthcare. In order to meet these challenges effectively, we need to identify how nurses contribute the resolution of these dilemmas.

Aims:

To identify the values, beliefs and contextual influences that inform decision-making. To identify the contribution made by nurses in achieving the resolution of ethical dilemmas in practice.

Design:

An interpretive exploratory study was undertaken, 11 registered acute care nurses working in a district general hospital in England were interviewed, using semi-structured interviews. In-depth content analysis of the data was undertaken via NVivo coding and thematic identification.

Participants and context:

Participants were interviewed about their contribution to the resolution of ethical dilemmas within the context of working in an acute hospital ward. Participants were recruited from all settings working with patients of any age and any diagnosis.

Ethical considerations:

Ethical approval was obtained from the local National Research Ethics Committee.

Findings:

Four major themes emerged: ‘best for the patient’, ‘accountability’, ‘collaboration and conflict’ and ‘concern for others’. Moral distress was also evident in the literature and findings, with moral dissonance recognised and articulated by more experienced nurses. The relatively small, single-site sample may not account for the effects of organisational culture on the results; the findings suggested that professional relationships were key to resolving ethical dilemmas.

Discussion:

Nurses use their moral reasoning based on their beliefs and values when faced with ethical dilemmas. Subsequent actions are mediated though ethical decision-making frames of reference including deontology, consequentialism, the ethics of care and virtue ethics. Nurses use these in contributing to the resolution of these dilemmas. Nurses require the skills to develop and maintain professional relationships for addressing ethical dilemmas and to engage with political and organisational macro- and micro-decision-making.

Conclusion:

Nurses’ professional relationships are central to nurses’ contributions to the resolution of ethical dilemmas.

Difficulties experienced by migrant physicians working in German hospitals: a qualitative interview study

BACKGROUND

With Germany facing a shortage of doctors, hospitals have been increasingly recruiting physicians from abroad. Studies in other countries have shown that migrant physicians experience various difficulties in their work, which might impact the quality of patient care, physician job satisfaction, and, accordingly, retention. The experiences of migrant doctors in Germany have not been systematically studied so far and will likely differ from experiences migrant physicians make in other contexts. A thorough understanding of challenges faced by this group, however, is needed to develop adequate support structures-as required by the WHO Global Code of Practice on the International Recruitment of Health Personnel.

METHODS

A qualitative study was conducted to give an overview of the multifaceted difficulties migrant physicians might face in German hospitals. Twenty semi-structured interviews with foreign-born and foreign-trained physicians were conducted in German. Participants were recruited via the State Chambers of Physicians and snowballing based on a maximum variation sampling strategy varying purposefully by source country and medical specialty. The interviews were recorded, transcribed verbatim, and analysed using qualitative content analysis.

RESULTS

Participants described difficulties relating to healthcare institutions, own competencies, and interpersonal interactions. Participants experienced certain legal norms, the regulation of licensure and application for work, and the organization of the hospital environment as inadequate. Most struggled with their lack of setting-specific (language, cultural, clinical, and system) knowledge. Furthermore, behaviour of patients and co-workers was perceived as discriminating or inadequate for other reasons.

CONCLUSIONS

This is the first study to describe the broad range of issues migrant physicians experience in Germany. Based on this information, institutional actors should devise support structures to ensure quality of care, physician wellbeing, and retention. For example, training opportunities should be offered where needed to support acquisition of setting-specific knowledge. Discrimination experienced by participants calls for better diversity management as a leadership task in healthcare institutions. Misinformation practices in recruitment could be managed by a voluntary code of ethical conduct. Further research is necessary to identify strategies that adequately address diverging normative positions between migrant health personnel and their patients and colleagues.

Cultural sensitivity in paediatrics

In a recent Journal of Medical Ethics article, 'Should Religious Beliefs Be Allowed to Stonewall a Secular Approach to Withdrawing and Withholding Treatment in Children?', Joe Brierley, Jim Linthicum and Andy Petros argue for rapid intervention in cases of futile life-sustaining treatment. In their experience, when discussions of futility are initiated with parents, parents often appeal to religion to 'stonewall' attempts to disconnect their children from life support. However, I will argue that the intervention that the authors propose is culturally insensitive.

Decision making near life's end: a prescription for change

Abstract The publication of SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) in 1995 identified major problems with decision making near the end of life. Since that time, palliative care has developed as a specialty and end-of-life communication has evolved. However, five problems in decision-making remain today: the need to discuss underlying health status with patients; the overburdening of patients and families with too many choices; lack of appreciation of the importance of symbolism in end-of-life care; confusion between cultural beliefs and scientific facts; and difficulties with making decisions because of rapid shifts by the medical team from advocating cure to comfort. Each of these issues is described.

Advance care planning: does patient gender make a difference?

BACKGROUND

Although it has received little study, gender may significantly affect patients' attitudes about advance care planning.

METHODS

We asked 26 Mexican American (14 male, 12 female), 18 European American (7 male, 11 female), and 14 African American (7 male, 7 female) inpatients for their attitudes about advance care planning and dying. Coders of different ethnicities and genders performed independent, blinded content analyses of responses.

RESULTS

The interviews identified 40 themes. Five, including "Advance directives (ADs) improve the chances a patient's wishes will be followed," characterized both genders of all 3 ethnic groups. Although no individual themes distinguished the genders across ethnic groups, 3 meta-themes--or clusters of related themes--did. Men's end-of-life wishes addressed functional outcome alone, but women's wishes addressed other factors, too. Men felt disempowered by the health system, but women felt empowered. Men feared harm from the system, but women anticipated benefit. Each ethnic group expressed these gender differences uniquely. For example, most Mexican American men preferred death to disability, believed "the health care system controls treatment," and wanted no "futile" life support. In contrast, most Mexican American women expressed wishes only about care other than life support (especially about when and where they wanted to die), believed ADs "help staff know...(such) wishes," and trusted the system to "honor (written) ADs."

CONCLUSION

Core cultural attitudes observed in both genders of 3 ethnic groups may extend to all Americans. Although core attitudes may support advance care planning for many Americans, health professionals should consider tailoring it to other, ethnic- and gender-specific attitudes.