Table 8 Personal factors reporting

Moral Distress

Staff moral distress levels

Survey

28/35 respondents reported that involving the clinical ethics service at least somewhat reduced their own moral distress; 7/35 reported no decrease

[66]

Clarity

and

Physician Confidence

and

Physician learning

Did consultations help to clarify thinking about ethical issues

Did consultations increase physicians’ confidence in their final management plans

How much did the consultations teach physicians?

Survey

39 consultations clarified thinking about ethical issues

41 consultations increased requesters' confidence in their final management plans, and only 3 decreased their confidence

Physicians reported learning much from 42 consultations (98%)

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Perceived value

How participants valued the importance of the goals of moral deliberation for themselves and their practice

Survey (Likert scale)

(1) to get knowledge of and insight in moral issues = 8.1

(2) to influence my attitude with respect to the case = 7.3

(3) to influence my behaviour with respect to the case = 7.1

(4) to improve my skills in dealing with moral issues = 7.5

(5) to deliver an answer or solution to the moral problem = 6.4

(6) to reach consensus within the group = 6.2

(7) to pay attention to reasons and arguments = 8.0

(8) to pay attention to feelings = 7.9

(9) to improve mutual understanding = 8.0

(10) to improve mutual cooperation = 7.9

(11) to active my job motivation = 9.7

(12) to frees my mind = 6.7

(13) to make me a better professional = 7.3

(14) to improve quality of care indirectly = 7.7

(15) to better ground decisions and reflect more on them = 7.7

[76]

Moral Distress

Address PICU provider moral distress

Survey (Pre/post survey using Moral Distress Scale Revised (MDS-R) (21-items) to rate "chronic" moral distress; every other month during data collection providers rated their "acute" moral distress using the expanded Moral Distress Thermometer (MDT)—single item scale with option to identify factors that contributed to moral distress)

There were three items on the instrument that showed statistically significant improvement in moral distress for nurses for both matched and aggregate data comparisons. On the aggregated comparison for nurses, four additional items showed a statistically significant drop in moral distress

‘‘Clinical Situations’’ represented the single most frequent contributing factor to moral distress

[89]

Experience and Impact of CEC

Overall assessment of CEC, impact on individual and values, and respondents’ expectations

Survey (11 items adapted from a tool developed by White, Dunn and Homer [47] and outcomes measures for EC (ASBH 2011)

Overall assessment of ECS was favourable. More than 90% felt the consultant explained things well, more than 80% felt the consultation validated the team's approach and provided support, and more than 70% felt the ECS clarified uncertainty, gave them a better understanding of ethical issues, and helped resolve a patient care problem. More than 80% felt the CEC recommendations were consistent with the organization's values, respected the respondent's values, and were consistent with their personal values. More than 60% felt the CEC helped clarify the values of the patient and/or patient's family, and helped respondents clarify their own values. Qualitative interviews uncovered some comments suggesting the EC could have communicated more effectively with members of the health care team

[90]

Experience of CES

Describing the experience of CES among professionals (“meeting in an ethical free zone”)

Qualitative interviews

CES sessions offered a chance to meet in an ethical free-zones allowing various professionals to relate to one another outside of roles, develop confidence to express points of view, and increase trust within the team. These "ethical free zones'' allowed them to develop a more integrated understanding, acquiring both knowledge and a more comprehensive view of it. The intervention seems to improve ability to act in practice, seeing CES as a way of becoming more prepared for dealing with care issues and developing resolutions from a shared standpoint

[54]

Experienced outcomes of CEC

The extent to which respondents had experienced outcomes (changes to perspective) during MCD or in their daily practice (developed skills, better managements, courage, security, greater awareness, etc.)

Survey (Euro MCD Instrument)

Percentage of respondents at T1 (not, somewhat, quite, and very):

(1) develop skills to analyze ethical conflict = 3 (not), 31 (somewhat), 65 (quite and very)

(2) more open communication = 4, 22 74

(3) consensus gained among co-workers re: situation management = 6, 36, 59

(4) enables better stress management = 22, 34, 45

(5) contributes to development of practice/policies = 12, 45, 43

(6) gives more courage to express ethical standpoint = 11, 30, 60

(7) feeling more secure to express doubts or uncertainty = 12, 30, 58

(8) better mutual understanding of other's reasoning = 3, 21, 77

(9) seeing the situation from different perspectives = 2, 19, 79

(10) more awareness of recurring situations = 7, 25, 68

(11) increase awareness of complexity of situation = 6, 26, 69

(12) enhancing understanding of ethical theory = 13, 37, 50

(13) enables decisions on concrete actions to manage situation = 9, 35, 55

(14) greater opportunity to have say = 6, 27, 67

(15) enhances possibility to share difficult emotions and thoughts = 4, 27, 70

(16) finding more courses of action = 5, 31, 64

(17) listening more seriously to other opinions = 12, 27, 61

(18) increase awareness of own emotions = 12, 31, 58

(19) strengthen self-confidence = 12, 32, 56

(20) develops ability to identify core ethical issues = 8, 35, 58

(21) more critical examination of existing policy/practice = 14, 34, 53

(22) more constructive management of disagreements = 14, 35, 52

(23) gaining more clarity about responsibility = 10, 34, 57

(24) enhancing mutual respect = 10, 28, 63

(25) more awareness of preconceived notions = 12, 31, 57

(26) better understanding of what it means to be a good professional = 12, 32, 56

Percentage of respondents at T2 (not, somewhat, quite and very):

(1) develop skills to analyze ethical conflict = 2, 30, 68

(2) more open communication = 3, 21, 76

(3) consensus gained among co-workers re: situation management = 3, 36, 60

(4) enables better stress management = 13, 45, 43

(5) contributes to development of practice/policies = 9, 44, 47

(6) gives more courage to express ethical standpoint = 7, 24, 70

(7) feeling more secure to express doubts or uncertainty = 5, 27, 68

(8) better mutual understanding of other's reasoning = 1, 21, 78

(9) seeing the situation from different perspectives = 1, 23, 76

(10) more awareness of recurring situations = 1, 28, 71

(11) increase awareness of complexity of situation = 3, 22, 75

(12) enhancing understanding of ethical theory = 7, 36, 57

(13) enables decisions on concrete actions to manage situation = 4, 34, 62

(14) greater opportunity to have say = 2, 18, 80

(15) enhances possibility to share difficult emotions and thoughts = 2, 24, 74

(16) finding more courses of action = 2,30, 68

(17) listening more seriously to other opinions = 3, 18, 80

(18) increase awareness of own emotions = 5, 27, 67

(19) strengthen self-confidence = 7, 31, 62

(20) develops ability to identify core ethical issues = 4, 33, 63

(21) more critical examination of existing policy/practice = 8, 36, 56

(22) more constructive management of disagreements = 11, 33, 57

(23) gaining more clarity about responsibility = 4, 30, 66

(24) enhancing mutual respect = 4, 24, 72

(25) more awareness of preconceived notions = 5, 37, 58

(26) better understanding of what it means to be a good professional = 5, 36, 60

[59]

Learning Effects

and

Enhanced emotional support

and

Moral Reflexivity

and

Improved Moral Attitude

Becoming more aware of certain issues and moral dilemmas after they were discussed at a MCD and able to apply learning to similar cases

This domain included 5 items: (1) Enhances possibility to share difficult emotions and thoughts with co-workers; (2) strengthens my self-confidence when managing ethically difficult situations; (3) Enables me to better manage the stress caused by ethically difficult situations; (4) Increases awareness of my own emotions regarding ethically difficult situations; (5) I feel more secure to express doubts or uncertainty regarding ethically difficult situations

This domain includes 5 items: (1) Develops my skills to analyze ethically difficult situations; (2) increases my awareness of the complexity of ethically difficult situations; (3) develops my ability to identify the core ethical questions in the difficult situations; (4) I see the ethically difficult situations from different perspectives; (5) enhances my understanding of ethical theories (ethical principles, values, norms)

This domain includes 5 items: (1) I become more aware of my preconceived notions; (2) I gain more clarity about my own responsibility in the ethically difficult situations; (3) I listen more seriously to others' opinions; (4) Gives me more courage to express my ethical standpoint; (5) I understand better what it means to be a good professional

Survey (Euro-MCD Survey)

Participants reported becoming more aware of certain issues and moral dilemmas after they were discussed at a MCD and being able to apply learning to similar cases

Least often experienced outcomes during MCD session (t1, n = 22), assessed as "not experienced" or "experienced to some extent": "boosts my self-confidence when managing ethically difficult situations (67%)"; "enables me to better manage the stress caused by ethically difficult situations (63%)". Least often experienced outcomes in daily work after MCD sessions: "enables me to better manage the stress caused by ethically difficult situations (85%)."

Least often experienced outcomes during MCD session (t1, n = 22): "enhances my understanding of ethical theories, principles, values and norms (65%). Most frequently experienced outcomes in daily work after MCD sessions (t1, n = 22): "I see ethically difficult situations from different perspectives (55%). Least often experienced outcomes in daily work after MCD sessions: "enhances my understanding of ethical theories (75%)

Most frequently experienced outcomes experienced during MCD session (t1, n = 22): "my co-workers and I become more aware of recurring, ethically difficult situations (85%). Most frequently experienced outcomes in daily work after the MCD session: "my co-workers and I became more aware of recurring, ethically difficult situations (55%)"

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