Ethics rounds may be one way of providing training in moral reasoning and reflective practice beneficial for future ethical decision-making or it may also provide urgent support regarding patient care problems. In addition, there appears to be a social incentive, a need to gain mutual understanding among the different professions. Several studies have described disagreements nurses have with doctors over not making the decision to limit life-sustaining treatment.1^–3 Other studies have, however, shown that they do actually in theory share the same opinions as to when treatment should be limited.4 5 A lack of communication is seen as one major cause for conflicts regarding life-sustaining treatment.6 7

The term “ethics rounds” has previously been described in north American literature usually in association with the teaching of medical ethics to students and practising professionals by means of case discussions. The use of “ethics consultation” seems to be more common in north America, where one of the purposes has been described as educational8 but foremost it seems to imply short-term help to solve particular patient care problems. This help involves health personnel, patients and their families. According to the American Task Force on Standards for Bioethics Consultation, the goal is to identify, analyse and resolve value-laden issues concerning particular patients.9 10 Studies involving ethics consultation in intensive care have shown positive outcomes in terms of satisfaction with conflict resolution and ethics education, as well as a reduction of non-beneficial treatment and costs.11 There have, however, been reports of a high degree of variability in ethics consultation services.12 There is disparity over the role of the ethicist as to whether they should only clarify the circumstances or give recommendations,13 ie, to assume an authoritative or a facilitative approach.14

In European countries, some clinical ethics committees have begun giving support regarding particular patient care cases15 16 but no systematic evaluation of this support has been found. The practice of ethics rounds has been reported from one hospital in Sweden. Here an ethicist led a discussion with healthcare staff from one ward concerning a particular patient case. The ethicist’s role was to facilitate a democratic dialogue.17 Through listening to each other’s perspectives, the participants can become aware of alternative horizons and of the multiplicity of values related to clinical practice.17

In the present study, we have chosen to apply a model inspired by the previously mentioned Swedish rounds and the goal established by the American Task Force, to identify and analyse the ethical problem but excluding the solving component.10 This was in order to decrease the risk that an outside expert would remove responsibility from the person with the formal decision-making responsibility.18 Discussing known patients has two motives. First, the social context is taken into account, which brings realistic complexity into the discussion.1 Second, by using the case method, more effective learning is provided because it involves a critical situation from clinical practice.19

From a review of the literature, it seems that Europeans are beginning to develop the structure of clinical ethical discussions. Nurses and doctors are two of the main professional actors involved in ethical problems associated with inpatient care. Therefore, the main aim of this study was to evaluate one ethics rounds model, by describing nurses’ and doctors’ experiences from the rounds. An additional aim was to describe their opinions on how ethical discussion should be conducted.

METHOD

This interview study was part of a larger evaluation project concerning ethics rounds. This included interviews before the first round and after the last, as well as questionnaires before and after each round. Ethical problems surrounding the patients and the perceptions of all the professionals participating in the rounds have been explored using a questionnaire and will be presented elsewhere.

Model for ethics rounds

From 2004 to 2005, interprofessional team discussions were led by a philosopher-ethicist that dealt with the ethical problems surrounding the care of patients from the nephrology departments (one ward and one dialysis unit) of three hospitals. Dialysis patients were selected because the nature of their long-term life-sustaining treatment could provide an opportunity for the care providers to get to know them rather well (see characteristics of patients involved in table 1). Four male practical philosophers were recruited from a recently established national network that assists healthcare professionals with clinical ethical problems. One of the philosophers is a co-author (HT), the others had no relation to the authors. Three philosophers participated at each hospital. The participants were informed that the goal of the rounds was to imulate thical flection and promote mutual understanding between the professional groups. The philosophers were instructed to help to identify and analyse the ethical problems but not to make any recommendations or offer solutions. The healthcare staff were informed that they were to seek solutions on their own after the rounds.

The head nurse chose the patient to be the subject of the ethics rounds, in accordance with the advice of the nurses and in consultation with the doctors. It was the most moving cases that were chosen. Two major problems were experienced with regard to the 12 patients before the ethics rounds, non-compliance and end-of-life issues (see table 1). Four of the patients had died when the rounds took place. The meetings occurred in conference rooms at the hospitals. They were held regularly four times every other month at each hospital and each session lasted one and a half hours. Participation in the ethics rounds was voluntary but the doctors were urged to participate in the light of the aim to promote mutual understanding. Of the 194 participants in the 12 rounds (median 14 participants, range 7–27), 58% were nurses, 16% doctors, 17% healthcare assistants and 9% were others, such as social workers and occupational/physiotherapists.

The philosophers’ descriptions of the rounds

The philosophers were asked after each round to describe briefly how they structured the round and how they perceived their role. A manifest content analysis with the aid of the computer program N Vivo was used to sort the data. The philosophers’ descriptions showed that they structured the rounds in similar ways but perceived their roles differently in different rounds. In some rounds they perceived their role to be that of a discussion leader with a low profile, mostly listening while at the same time seeing that everyone had a chance to be heard. In other rounds they perceived their role as being more authoritarian, steering the discussion and helping to focus on ethical analysis and bringing ethical concepts into the discussion. The predominant structure was this: the philosopher started by defining what an ethical problem is, then a doctor presented background facts about the patient. A large amount of the time was then spent on identifying the ethical problems together. Some of the rounds resulted in analyses of different choices of action. Finally, the philosophers made a summary of the discussion.

Participants in the research

Of the 11 total nurses from the dialysis units and nephrology wards, six volunteered to be interviewed and five were purposely asked to participate by the head nurses as they were known for their willingness to verbalise opinions. Among the 11 doctors that participated in at least one ethics round, seven agreed to be interviewed. See characteristics in table 1.

Interview and analysis

The first author who is a nurse interviewed the nurses and the second author who is a doctor interviewed the doctors. The average duration of the audio-taped interviews was one hour. The main request was “Please, describe how you experienced the ethics rounds”. The additional question was “How would you like discussions about ethical problems at your workplace to be conducted in the future?”

Qualitative content analysis was performed using both manifest and latent interpretation in accordance with Graneheim and Lundman.20 This involved a systematic process of coding the data in several steps. The latent part involves an interpretation of the underlying meaning of the text.21 Recalled positive and negative experiences became the perspective of the analysis, which was conducted by the first author. Each interview was read several times to obtain a sense of the whole. Next, the text was divided into meaning units with condensed descriptions close to the text. The condensed descriptions were inductively interpreted and then abstracted into tentative subthemes. The latter were then compared with each other and those that shared similar meaning were collapsed, sorted and abstracted into five positive and four negative themes. The analysis thus moved from condensed descriptions to a higher level of interpretation and abstraction of the data. To achieve a high level of reliability, each step in the analysis was scrutinised and discussed by all the co-authors.20 The third author, one of the philosophers, only examined interviews from one of the hospitals, where he had not been involved in the rounds. There was on the whole a high level of agreement between the authors regarding themes and subthemes. In those cases in which there were controversies about potential overinterpretation, depth was sacrificed for credibility21 and an interpretation was made closer to the text. Finally, there was an evaluation of whether the goal of the ethics rounds had been reached.

Ethical considerations

As ethical problems would not be solved during the rounds, it was not considered unethical to exclude the patients as participants. Withdrawing life-sustaining treatment is an emotionally charged question and the ethics rounds may cause distress for the participants. The rounds could interfere with existing relationships and create new conflicts. The head nurses were therefore prepared to arrange psychological help if needed. The informed consent was based on written information regarding the study and voluntary participation.

Findings

A few of the interviewees experienced all the ethics rounds as positive and a few found them negative or they were indifferent to the rounds. The majority, however, had mixed descriptions in which some rounds were experienced as good and others as bad. Compared with the positive statements, the negative statements were fewer in quantity. When no specific occupation is mentioned in the text below, a shared experience by the nurses and the doctors is implied. The five positive and the four negative themes of experiences are illustrated by quotations in tables 2 and 3, under the headings of subthemes.

Positive experiences

A good round was found to provide stimulation to broadened thinking, a sense of connecting, a strengthened confidence to act, insight to moral responsibility and emotional relief (table 2).

Stimulation to broadened thinking

The dominating experience was the appreciation of “getting clarifications” with help from the philosophers, which could imply the formulation of thoughts into words. The nurses especially appreciated this. Structuring the thinking into steps was perceived to make the complicated comprehensible. It was found to be a way to uncover the essence of the ethical problem as well as an educational opportunity. When the philosopher actively led the discussions in a structured manner, it was perceived that different perspectives could be envisioned easier. Different notions and other provocative questions were found with “breaking from habitual ways of thinking” and stimulated reflections regarding the nature of the problem (see quotation table 2). Besides being stimulated by the philosophers, stimulation from work mates was also experienced. New information presented about patients offered “seeing from different perspectives” and provided a more integrated and holistic view.

Sense of connecting

The discussion was experienced as having a straightforward “open climate”. Doctors described how they were positively touched by an emotionally tense discussion and experienced the critique as constructive. Nurses expressed admiration for the doctors’ openness about acknowledging errors (table 2). When the philosophers were perceived as actively leading the discussions, the speaking time was experienced to be fairly distributed between the doctors and the other participants. A “sense of equality” had been perceived and was expressed in terms of a diminished hierarchy. Nurses felt they were on more equal ground with the doctors when they experienced the doctors as lacking expertise in ethics. Nurses felt that the doctors and philosophers had listened to them and they could contribute with important information about the patient. The ethics rounds were described as being valuable for “promoting mutual understanding”. The philosophers were perceived as promoting understanding by turning accusations into ways of seeing things from a different perspective. The doctors found the rounds provided an opportunity to elucidate misunderstandings. They tried to make it clear that they had in fact reflected and spoken with the patients about their wishes and tried to explain why the decision to limit life-sustaining treatment had not been made earlier. Doctors told of an improved understanding of the nurses’ frustration over the doctors’ heterogeneous attitudes towards life-sustaining treatment. Nurses understood the doctors’ sense of powerlessness in certain decision-making situations and the difficulty of anticipating the time of death (table 2).

Strengthened confidence to act was associated with “seeing a way out” of a seemingly impossible situation. This especially emerged for nurses when the philosopher gave different alternatives for actions (table 2). They appreciated a straightforward down-to-earth guidance approach for problem solving over a solely theoretical and reflective discussion. The nurses associated “using gained insights” with a more critical attitude, which was thought to give them confidence to act in the future. Some of the patient problems discussed during the rounds were experienced as being recurrent. Being able to see a solution to a problem retrospectively was expressed as being valuable for similar situations in the future.

Insight into moral responsibility

Even though the rounds were felt to be less productive than expected by the doctors, initiating the dialogue alone was considered valuable. The doctors gained an “insight into the need for continued dialogue” with the nurses regarding problematical patients and issues concerning limiting life-sustaining treatment. They realised after the rounds that they had a responsibility to explain their motives for continued treatment better. Another insight came with the discussion of how the ethically difficult situations came about and who was responsible, shedding light on “insight into own and others’ responsibility”. The responsibility was seen as not only lying with the doctor but with everyone involved, even the patients. A discussion that began with the pointing out of a scapegoat ended up with the realisation that ethical problems can be caused by organisational shortcomings. A lack of communication and of doctor continuity in patient care was interpreted as organisational causes that can expose patients to unnecessary suffering.

Emotional relief

Relief was experienced just by having time for reflection, without value judgements and the demand for results. A few interviewees valued “sharing heavy thoughts”, which they felt they usually had to bear alone (table 2). The philosophers were perceived as being sensitive and helpful in sorting out and dealing with feelings. “Feeling of support” could include dealing with patient aggressiveness by interpreting it as a form of ambivalence towards living. The nurses believed the doctors needed these discussions as support to make the decision to limit life-sustaining treatment.

Negative experiences

The negative and indifferent experiences were associated with a sense of unconcern and alienation, as well as frustration with the lack of solutions and a sense of resignation to non-change (table 3).

Sense of unconcern

The rounds themselves were experienced as being worthless or just a “worthless philosopher input” was described. They did not leave an impression beyond that of a discussion leader. A desire for more ethics theory was expressed because some of the reasoning was found to be too complicated. The philosopher was perceived as being unable to make his knowledge applicable to the real world (table 3). There were also experiences that ethical analysis was overshadowed by relational conflicts. “Unmoving patient cases” was experienced as negatively affecting the overall feeling. This could occur when the patient was unknown or the problem was perceived as being neither emotionally moving nor ethically relevant. Feelings of being “already morally secure” about values and possible actions and the solving of the problem also gave feelings of indifference.

Sense of alienation

When the philosopher did not take command over a round, interviewees perceived it as polemical and filled with unleashed emotions. A “deadlock” between nurses and doctors was experienced. Nurses believed that the doctors felt their positions were threatened during such rounds. They felt the doctors took a united front against them, used only medical arguments and did not listen to them. Nurses felt rejected when the doctors did not understand how they felt when the patients were perceived as being exposed to suffering. Doctors had the impression that the nurses used the rounds as an opportunity to criticise them. “Inflicted value judgements” were experienced when the philosopher was felt to influence the round too much with his own opinions and this was found to be coercive and inhibited the discussion (table 3).

Frustration with lack of solutions

The rounds were experienced as isolated happenings that had little reference to daily practice. Finding “no direct impact on daily practice” left nurses with a feeling of disappointment. Nurses had expected the rounds to lead to positive changes. They found they became impatient when theoretical reflections instead of practical solutions were discussed. There was a “wish for the answer book” and a feeling that the questions only produced more questions. “No consensus for action” signifies that they missed a formal decision that would direct future actions or compel doctors to be decisive about life-sustaining treatment. They and their non-participating co-workers shared the sentiment that discussions that did not aim to produce solutions were a waste of time (table 3).

Resignation to non-change

“Lack of time for further reflection” at work was felt to hinder the use of knowledge acquired from the rounds. Nurses felt “discouraged by others’ lack of commitment” by remaining silent or not attending the rounds as a result of their resistance to reflection. Co-workers who lacked emotional presence and were only interested in getting the job done also discouraged them. There was a feeling among the interviewees that there were “insoluble classic problems” related to doctors’ and nurses’ differing attitudes towards limiting life-sustaining treatment. Doctors had resigned themselves to believing that nurses would never understand the difficulties associated with having the responsibility for making life and death decisions. Nurses on the other hand had determined it impossible to influence doctors. Another classic problem felt to be unsolvable was getting non-compliant patients to cooperate.

Evaluation of the ethics rounds’ goal

The goal established for the rounds seemed to be reached in some of the rounds. The theme “stimulation to broadened thinking” corresponds with stimulate ethical reflection. The theme “sense of connecting” describes a broader experience under which promoting mutual understanding constitutes a subtheme. Some interviewees did not explicitly speak of having gained understanding but nevertheless described the ethics rounds as a forum that promoted understanding. In other rounds associated with negative experiences, the goal did not appear to be reached. This was reflected by the view of “worthless philosopher input” and the “sense of alienation”. Nurses expressed an expectation that solutions would be reached but that was not part of the original goal. Appreciation was expressed when “seeing a way out” of an ethical problem and “frustration with lack of solutions” from other rounds were noted.

Opinions as to how to conduct ethics discussions in the future

In the light of their experience of ethics rounds, the interviewees were asked how ethics discussions should be performed in the future. No differences of opinion between the nurses and the doctors emerged. The majority were of the opinion that interdisciplinary team conferences were bound to be continued in some way. Some wished for team conferences without a leader but the predominant view was that a leader is necessary. Whether a leader was needed could depend upon the severity of the problem. It was preferred that the leader should be a person from outside, in a position to see a problem in a new light. There was no clear opinion as to which profession a leader should be drawn from, it could depend on the type of problem. Philosopher, chaplain and social worker were mentioned but the competence of the person seemed more important (box 1). Groups with six to 10 participants from different professions were preferred, so that no one would be afraid to speak out. Rounds on a regular basis two to four times a year were desired but also emergency meetings in the case of urgent problems. There was a difference of opinion as to whether the aim should be simply to reflect on problems or also to solve them. The predominant view was that the rounds should lead to some kind of action or decision-making.

DISCUSSION

The ethics rounds in this study seemed to provide training in moral reasoning but, above all, the rounds seemed to meet the needs of a forum for crossing over professional boundaries. Conspicuous was the nurses’ expectation that solutions to the ethical problems would be sought despite explicit instructions to the contrary.

As reported previously from north America, there is a lack of clarity as to whether the ethicist should simply elucidate the issue or should also make recommendations;13 our study would seem to confirm this finding. Discussing patients currently in treatment probably led to the expectation of solutions. Nurses’ “frustration with lack of solutions” may be caused by unfamiliarity with reflection. On the other hand, it may be a question of pent-up feelings derived from a perceived lack of end-of-life decision-making, which has been reported both in this and in previous studies.1^–3 This suggests that practice in reflection cannot on its own diminish frustrations. In some rounds, however, the philosopher-ethicists offered different alternatives for action, which was experienced by nurses as instilling a “strengthened confidence to act”. The approach these philosophers used seems similar to the facilitation approach used in American ethics consultations, in which attempts are made to facilitate consensus building among healthcare professionals. In our study design the philosophers were not involved in the clinical practice and did not, for example, speak to patients or their families or access medical records.14 15 This design was chosen so that the outside expert would not have too much influence.

The kind of leadership practised by the philosophers in our study seemed to be crucial. When the discussion was perceived to be controlled by the philosopher it was experienced as being democratic and beneficial to the ethical analysis. The philosophers seemed to have different abilities in group process skills, such as handling the power balance between the nurses and the doctors and the individual ability also seemed to fluctuate between rounds. This suggests differences in the climate of collaboration at the work places and a different level of value-laden cases. One philosopher put it this way: “It was a very good discussion today. I felt I had a hold on the conversation and could direct it. It was a drastic contrast to the way it was last time (at another hospital), where I completely lost control.” This was well illustrated in the interviews, in which the interviewees described positive experiences of the later discussion and negative of the earlier. In view of the qualitative design of this study, however, we must be cautious about causal explanations.

The interviewees had little to say regarding which profession the leaders of future rounds should be drawn from, being more concerned with the leaders’ character and competence. This is in accordance with the American Task Force on Standards for Bioethics Consultation, which assigns importance not only to such things as interpersonal and process skills and the capacity to make ethical assessments but also to character. The interpersonal and process skills include an ability to facilitate and structure meetings in such a way that the participants feel free to express their concerns.9 14 Nothing is said, however, about the ability to maintain control over the discussions.

One of the most salient findings was the nurses’ and doctors’ polarised descriptions of each other, even with regard to the positively described experiences. It seems that a major portion of the rounds was spent trying to connect with each other, which may suggest that some of the ethical problems were in fact relational conflicts. This is supported by the results found in an ethnographic study of the practice of ethics consultation.22 According to the sociologist Chambliss,23 ethical debates often come about as a result of professional clashes. Ethical issues are embedded in “complexes of routine” and the fact that nurses are subordinates.23 Complexes of routine can be seen in the present study in terms of the organisational shortcomings such as the lack of patient care continuity as a result of the doctors’ schedules. Chambliss23 found that nursing’s ethical problems are systematic, whereby the “same problems recur time and again in various settings”. Other, more powerful actors determine nurses’ work. The doctors make the decisions and the nurses have to carry them out. It is the nurse who has to deal hour after hour with the severely ill patient who is not progressing, feeling frustration at the futility of the treatment.23

In the rounds experienced as being positive, however, the nurses perceived themselves as being on equal ground with the doctors. The rounds may have brought about a sense of having increased influence in accordance with the “degree of influence” scale presented by Granberg.24 The nurses’ sense of having an influence seemed to advance on the scale from just being informed of a decision to being involved in the deliberation. Melia1 advocated teamwork when dealing with ethical problems. Doctors are now under pressure to relinquish their dominant professional position and develop a more team-oriented approach. In this study, the doctors acquired an “insight into moral responsibility” to continue the dialogue with the nurses, which suggests a team-oriented approach.

This study offers knowledge of how to learn a way through ethical problems and what ethics rounds may contain regarding cognitive, social and emotional experiences. The positive and negative experiences can provide knowledge about which approaches to the teaching of ethics are desirable in the clinical context. Regarding the cognitive experiences, the philosophers seemed to play an important role in structuring and stimulating reasoned arguments, which seems similar to the approach of the “critical thinking school”.25 It implies a concern with rational aspects and counteracts an oversubjective approach. Regarding both the cognitive and social experiences, the approach seems to resemble that of the “situation ethics school”. The latter school is distinguished by the attention to the demands of the specific situation and the object with a view to broadening the capacity to empathise with other people and to develop personal insights. This is illustrated in the present study by “sense of connecting” and “seeing from different perspectives”, as well as “understanding of moral responsibility”. Present but not predominant was the emotional experience, “emotional relief”, which resembles the approach of the “ventilatory school”. This school focuses on how people feel about ethical problems and not just on rational considerations.25 One possible reason why the emotional experiences seemed to be only a minor part is that the male philosophers belonged to the “critical thinking school”, representing a typically male perspective involving a striving for objectivity.25 Maybe the experiences would have been different with feminist moral philosophers. They are critical of reason being regarded as the supreme principle of morality. They argue that reason is not value neutral and that sound moral deliberation requires an appeal to emotion and intuition as well as reason.26

When the rounds in the present study seemed to be of value to the interviewees, they can be conceptualised as a combination chiefly of the approach of the “situation ethics school” and the goal of the American Task Force on Standards for Bioethics Consultation to assist in problem solving.9 Interviewees’ own suggested means of addressing ethical issues, however, indicating in the first place the establishment of team conferences for the purpose of achieving a common goal in care, seemed to have priority over ethics rounds with an outside leader.

Methodological considerations

The findings may be transferable to other groups of nurses and doctors caring for severely ill patients in Scandinavia and some of the other European countries. In this study only four ethics rounds at each hospital were evaluated, which may be considered more as a systematic evaluation of an application of ethics rounds than as an evaluation of an implemented model. It may generate knowledge about how to conduct future rounds.

The interviewers used somewhat different interview techniques: a probing technique (MS) as compared with a conversational style (RL). In the case of the first technique there may have been too much focus on the research questions whereby the nurses may have been hindered from offering new ideas. When it came to the doctors, some interesting reasoning was not followed up but the relaxed interview atmosphere may have stimulated them to be more open. This was taken into consideration because both manifest and latent analysis was performed, depending on the nature of the statements. We do not consider that it affected credibility. Nor do we consider that one of the philosophers being a co-author (HT) affected credibility or that the first author’s pre-understanding and commitment regarding the idea of ethics rounds steered the analysis towards themes that showed fulfilment of the goal set for the ethics rounds. The open nature of the questions asked, the systematic analysis and the dialogue between all the co-authors, who come from a diversity of disciplines (nursing, medicine, philosophy and theology), should have prevented this and increased the reliability. The findings revealed mixed descriptions with both positive and negative experiences, which may be a sign of a high level of reliability.

A shortcoming in this study was that two of the philosophers lacked experience of ethics discussions in connection with clinical practice. It is not possible to assess on the basis of our study whether philosophy is a suitable discipline in ethics rounds. A planning limitation may have affected the experience that the patient cases were unmoving. The decision to have regularly scheduled rounds and that staff members from both the dialysis unit and the ward should be familiar with the patient was reported as the reason that the more moving cases were missed.

Implications

The findings suggest that the most important need is the opportunity for interprofessional team dialogue to discuss a common goal for the care of severely ill patients on a regular basis. We have summarised the overall results in a model of how ethical problems may be dealt with through interprofessional team dialogue in fig 1. The basis is team conferences and the readiness to involve an ethicist if participants find the situation ethically complicated. If ethics rounds are to be implemented, it is advisable to find a balance between ethical analysis, conflict resolution and problem-solving. Either one or two rounds may be needed, depending on the severity of the problem. The ethicist leading the discussion may only facilitate problem-solving—the decision as to what course of action to take is to be made without the ethicist, preferably with patient/family involvement. This process may appear time-consuming but can lead not only to an ethical decision but also to improved relations between professionals, as well as serving as a learning experience that may prevent future ethical problems. The model (fig 1) constitutes a tentative, practical suggestion regarding how to arrange interprofessional team dialogue. It needs to be tested in future research before it can be applied to clinical practice for the elucidation and resolution of ethical issues.

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Figure 1 A model based on the findings that illustrates one possible way of dealing with ethical problems in patient care.

Ethics approval for the research was obtained from the Regional Ethical Review Board in Uppsala, Sweden.