OBJECTIVE: The vast majority of physicians frequently faces ethical dilemmas and feels overwhelmed as a result. Those at Boston Medical Center are no exception. Various studies show more adept handling of ethical issues can improve the quality of care and patient safety by reducing moral distress of physicians and fostering better patient-physician relationship. The method of Preventive Ethics, which actively identifies recurrent themes and underlying systematic issues among ethics consultations, is more effective than the traditional, case-by-case approach in reducing the number of ethical conflicts. The purpose of this study is to identify common themes prompting ethics consultations and any hotspots among recurrent ethical dilemmas at Boston Medical Center by using the Armstrong Clinical Ethics Coding System. METHODS: A total of 32 ethics consultations handled by the BMC Ethics Committee between October 2010 and April 2013 were reviewed. Each consultation was coded using the Armstrong Clinical Ethics Coding System. The data was analyzed to identify the types of ethical dilemma that are most prevalent at BMC. The consultations involving the most frequently occurring issues were evaluated further to expose common themes among these cases and potential underlying systematic failures. RESULT: "Clinical Candidacy or Risk / Benefit Analysis" (6.25%), "Concern About Decision Maker Choices" (14.6%) and "Futility / Inappropriate or Nonbeneficial Treatment" (13.5%) were the most prevalent types of ethical issues at BMC. Not only are these three frequently occurring, they also have a very high tendency to occur simultaneously. Further analysis of consultations involving these three issues revealed that at BMC, there are frequent instances of conflict, in which family members serving as healthcare proxies disagreed with physicians in deciding the best interest of patients with severe ailments, ultimately precipitating ethics consultations. DISCUSSION: Comparison with similar retrospective studies previously carried out at other institutions suggests that consultation involving the issue of futility may be more frequently occurring at BMC, which might be coming from unique systematic problems. Several interventions such as improved policies or educational training in physician-family communication should be considered. CONCLUSION: According to the principles of Preventive Ethics, the issue of physician-healthcare proxy conflict regarding patient futility should be issue to be addressed at BMC. The Armstrong Clinical Ethics Coding System can serve as a much needed standard documentation format for ethics consultations, which would open up the possibility of more detailed future studies

abstract: Within ethics, a number of scholars advocate an interdisciplinary approach of combining the two traditionally different professions of science and philosophy with the confidence that this collaboration will be a mutually beneficial experience. Current ethicist-scientist interactions include embedded-ethicists and research ethics consultation services. Both methods are employed with the hope that they will reduce social and ethical problems that could arise from scientific research, and enhance the reflective capacity of investigative teams. While much effort has been put forth in the endeavor of creating ethicist-scientist interactions, there remains opportunity to refine these new interaction models to make them more robust. There is need for ethicists to understand the context of ethical decision-making in the laboratory. By extension, before interacting with scientists in a research lab, research ethicists ought to have the ability to understand the science and also be familiar with the different factors that influence scientific research, such as funding, productivity requirements, time constraints, politics of laboratories and institutional reward structures. Through literature review and the analysis of qualitative data obtained from the ethnographic study in a neuroscience laboratory, this thesis explores the strengths and weaknesses of ethicist-scientist interactions and aims to understand the culture, traditions and values of this community and their perspectives on their role as scientists and their relationship to ethics. This study shows that the quantity and quality of ethics discussions in the lab are limited and dictated by time constraints and minimal incentives. Other influencing factors are the researchers' perspectives on ethics and how they view their role as a scientist in relation to the public. / Dissertation/Thesis / M.S. Applied Biological Sciences 2012

Introdução: As consultorias de Bioética Clínica auxiliam no processo de reflexão para a tomada de decisão dos profissionais, dos pacientes ou das famílias quando surge algum problema ou conflito ético durante o atendimento assistencial. As relações familiares dos pacientes podem estar envolvidas nestas situações, inclusive de forma a dificultá-la. Objetivos: Avaliar a presença e a influência das famílias nas consultorias de Bioética Clínica. Assim como, estabelecer o perfil das consultorias nas quais as relações familiares dificultaram a resolução do problema ou conflito ético, quanto aos solicitantes, às especialidades, aos registros em prontuários eletrônicos, aos pacientes e às relações familiares. Métodos: Foram avaliados 307 registros de consultoria de Bioética Clínica, por demanda assistencial, realizadas pelo Serviço de Bioética do Hospital de Clínicas de Porto Alegre de 2010 a 2011. Os dados foram coletados a partir dos registros do Serviço de Bioética e dos prontuários eletrônicos dos pacientes. Foram excluídas as consultorias proativas realizadas nos Rounds Clínicos regulares das equipes assistenciais, as reuniões do Serviço de Bioética e do Comitê de Bioética Clínica. Para análise qualitativa foi utilizada a Análise de Conteúdo e a classificação de Nelson e Nelson, de sete aspectos para as relações familiares. A avaliação quantitativa foi feita por meio de medidas descritivas e por associações, utilizando o programa SPSS 18.0. Resultados: Em 57% dos 307 registros de consultoria avaliados as relações familiares dos pacientes estavam envolvidas, predominantemente (38%) dificultando a resolução do problema ou conflito ético. Destas consultorias, cujas famílias agregaram dificuldades (n=116), 71% das consultorias foram geradas por solicitações de médicos. Os serviços de Medicina Interna, Pediatria e Psiquiatria demandaram 56% das consultorias. Em 79% dos registros foi possível identificar os prontuários dos pacientes associados. Quanto a resposta, 71% das consultorias foram atendidas no mesmo dia ou no dia seguinte à sua solicitação. Quando às características dos pacientes, a distribuição em relação ao sexo foi equilibrada, com predomínio da faixa etária adulta, e 54% eram procedentes de Porto Alegre. As relações familiares naturalmente impostas foram as mais identificadas (72%). Nestas mesmas 116 famílias foram identificados os sete aspectos das relações familiares: intimidade; não substituição; motivos; responsabilidade; vínculos; enredos familiares e modelagem. Conclusão: A compreensão da presença e da influência das famílias, principalmente quando estas dificultam a resolução do problema ou conflito ético, a identificação do perfil destas consultorias, bem como a reflexão sobre os aspectos das relações familiares, pode ampliar as possibilidades de avaliar os casos de Bioética Clínica e de planejar estratégias institucionais que envolvem o processo de tomada de decisão no atendimento assistencial. / Introduction: Clinical Bioethics consultants assist professionals, patients or families in the reflection of decision-making process when a problem or ethical conflict arises during assistance services. Family relationships of patients may be involved in these situations, including how to hinder it. Objectives: To evaluate the presence and influence of families in Clinical Bioethics consultations. As well to establish the consulting profile in which family relationships difficult to resolve the problem or ethical conflict: applicants, specialty, records in electronic medical records, patients and family relations. Methods: We analyzed 307 records of Clinical Bioethics ondemand assistance consultations, conducted by the Bioethics Division, Hospital de Clinicas de Porto Alegre from 2010 to 2011. Data were collected from the records of the Bioethics Division and electronic medical records of patients. Were excluded proactive consultancies carried out in regular Clinical Rounds of healthcare, the regular meetings of the Division and the meetings of Clinical Bioethics Committe. For qualitative analysis was used content analysis and classification of seven aspects for family relationships (Nelson and Nelson). The quantitative evaluation was performed by descriptive measures and associations, using SPSS 18.0. Results: In 57% of the 307 records of family relations consultant evaluated the patients involved were predominantly (38%) making it difficult to resolve the problem or ethical conflict. These consultancies, whose families have added difficulties (n = 116), 71% of consultations were generated by requests from physicians. Internal Medicine, Pediatrics and Psychiatry Services demanded 56% of consultants. In 79% of the records was possible to identify patient records associated with it. As for response, 71% of consultations were seen on the same day or the day after your request. The patient characteristics, distribution in relation to gender, was balanced, with a predominance of adult age group and 54% were from Porto Alegre. Family relationships identified as naturally imposed were the most predominant (72%). In the same 116 families were identified the seven aspects of family relationships: Intimacy, Not Replacement, Reasons, Responsibility, Links, Family Plots and Modeling. Conclusion: The understanding of the presence and influence of families, especially when they hinder the resolution of the problem or ethical conflict, identifying the profile of these consultants, as well as reflections on aspects of family relationships, can extend the possibilities to assess cases of Clinical Bioethics and institutional policies that involve the process of decision making in health care services.

Introdução: As consultorias de Bioética Clínica auxiliam no processo de reflexão para a tomada de decisão dos profissionais, dos pacientes ou das famílias quando surge algum problema ou conflito ético durante o atendimento assistencial. As relações familiares dos pacientes podem estar envolvidas nestas situações, inclusive de forma a dificultá-la. Objetivos: Avaliar a presença e a influência das famílias nas consultorias de Bioética Clínica. Assim como, estabelecer o perfil das consultorias nas quais as relações familiares dificultaram a resolução do problema ou conflito ético, quanto aos solicitantes, às especialidades, aos registros em prontuários eletrônicos, aos pacientes e às relações familiares. Métodos: Foram avaliados 307 registros de consultoria de Bioética Clínica, por demanda assistencial, realizadas pelo Serviço de Bioética do Hospital de Clínicas de Porto Alegre de 2010 a 2011. Os dados foram coletados a partir dos registros do Serviço de Bioética e dos prontuários eletrônicos dos pacientes. Foram excluídas as consultorias proativas realizadas nos Rounds Clínicos regulares das equipes assistenciais, as reuniões do Serviço de Bioética e do Comitê de Bioética Clínica. Para análise qualitativa foi utilizada a Análise de Conteúdo e a classificação de Nelson e Nelson, de sete aspectos para as relações familiares. A avaliação quantitativa foi feita por meio de medidas descritivas e por associações, utilizando o programa SPSS 18.0. Resultados: Em 57% dos 307 registros de consultoria avaliados as relações familiares dos pacientes estavam envolvidas, predominantemente (38%) dificultando a resolução do problema ou conflito ético. Destas consultorias, cujas famílias agregaram dificuldades (n=116), 71% das consultorias foram geradas por solicitações de médicos. Os serviços de Medicina Interna, Pediatria e Psiquiatria demandaram 56% das consultorias. Em 79% dos registros foi possível identificar os prontuários dos pacientes associados. Quanto a resposta, 71% das consultorias foram atendidas no mesmo dia ou no dia seguinte à sua solicitação. Quando às características dos pacientes, a distribuição em relação ao sexo foi equilibrada, com predomínio da faixa etária adulta, e 54% eram procedentes de Porto Alegre. As relações familiares naturalmente impostas foram as mais identificadas (72%). Nestas mesmas 116 famílias foram identificados os sete aspectos das relações familiares: intimidade; não substituição; motivos; responsabilidade; vínculos; enredos familiares e modelagem. Conclusão: A compreensão da presença e da influência das famílias, principalmente quando estas dificultam a resolução do problema ou conflito ético, a identificação do perfil destas consultorias, bem como a reflexão sobre os aspectos das relações familiares, pode ampliar as possibilidades de avaliar os casos de Bioética Clínica e de planejar estratégias institucionais que envolvem o processo de tomada de decisão no atendimento assistencial. / Introduction: Clinical Bioethics consultants assist professionals, patients or families in the reflection of decision-making process when a problem or ethical conflict arises during assistance services. Family relationships of patients may be involved in these situations, including how to hinder it. Objectives: To evaluate the presence and influence of families in Clinical Bioethics consultations. As well to establish the consulting profile in which family relationships difficult to resolve the problem or ethical conflict: applicants, specialty, records in electronic medical records, patients and family relations. Methods: We analyzed 307 records of Clinical Bioethics ondemand assistance consultations, conducted by the Bioethics Division, Hospital de Clinicas de Porto Alegre from 2010 to 2011. Data were collected from the records of the Bioethics Division and electronic medical records of patients. Were excluded proactive consultancies carried out in regular Clinical Rounds of healthcare, the regular meetings of the Division and the meetings of Clinical Bioethics Committe. For qualitative analysis was used content analysis and classification of seven aspects for family relationships (Nelson and Nelson). The quantitative evaluation was performed by descriptive measures and associations, using SPSS 18.0. Results: In 57% of the 307 records of family relations consultant evaluated the patients involved were predominantly (38%) making it difficult to resolve the problem or ethical conflict. These consultancies, whose families have added difficulties (n = 116), 71% of consultations were generated by requests from physicians. Internal Medicine, Pediatrics and Psychiatry Services demanded 56% of consultants. In 79% of the records was possible to identify patient records associated with it. As for response, 71% of consultations were seen on the same day or the day after your request. The patient characteristics, distribution in relation to gender, was balanced, with a predominance of adult age group and 54% were from Porto Alegre. Family relationships identified as naturally imposed were the most predominant (72%). In the same 116 families were identified the seven aspects of family relationships: Intimacy, Not Replacement, Reasons, Responsibility, Links, Family Plots and Modeling. Conclusion: The understanding of the presence and influence of families, especially when they hinder the resolution of the problem or ethical conflict, identifying the profile of these consultants, as well as reflections on aspects of family relationships, can extend the possibilities to assess cases of Clinical Bioethics and institutional policies that involve the process of decision making in health care services.

Introdução: As consultorias de Bioética Clínica auxiliam no processo de reflexão para a tomada de decisão dos profissionais, dos pacientes ou das famílias quando surge algum problema ou conflito ético durante o atendimento assistencial. As relações familiares dos pacientes podem estar envolvidas nestas situações, inclusive de forma a dificultá-la. Objetivos: Avaliar a presença e a influência das famílias nas consultorias de Bioética Clínica. Assim como, estabelecer o perfil das consultorias nas quais as relações familiares dificultaram a resolução do problema ou conflito ético, quanto aos solicitantes, às especialidades, aos registros em prontuários eletrônicos, aos pacientes e às relações familiares. Métodos: Foram avaliados 307 registros de consultoria de Bioética Clínica, por demanda assistencial, realizadas pelo Serviço de Bioética do Hospital de Clínicas de Porto Alegre de 2010 a 2011. Os dados foram coletados a partir dos registros do Serviço de Bioética e dos prontuários eletrônicos dos pacientes. Foram excluídas as consultorias proativas realizadas nos Rounds Clínicos regulares das equipes assistenciais, as reuniões do Serviço de Bioética e do Comitê de Bioética Clínica. Para análise qualitativa foi utilizada a Análise de Conteúdo e a classificação de Nelson e Nelson, de sete aspectos para as relações familiares. A avaliação quantitativa foi feita por meio de medidas descritivas e por associações, utilizando o programa SPSS 18.0. Resultados: Em 57% dos 307 registros de consultoria avaliados as relações familiares dos pacientes estavam envolvidas, predominantemente (38%) dificultando a resolução do problema ou conflito ético. Destas consultorias, cujas famílias agregaram dificuldades (n=116), 71% das consultorias foram geradas por solicitações de médicos. Os serviços de Medicina Interna, Pediatria e Psiquiatria demandaram 56% das consultorias. Em 79% dos registros foi possível identificar os prontuários dos pacientes associados. Quanto a resposta, 71% das consultorias foram atendidas no mesmo dia ou no dia seguinte à sua solicitação. Quando às características dos pacientes, a distribuição em relação ao sexo foi equilibrada, com predomínio da faixa etária adulta, e 54% eram procedentes de Porto Alegre. As relações familiares naturalmente impostas foram as mais identificadas (72%). Nestas mesmas 116 famílias foram identificados os sete aspectos das relações familiares: intimidade; não substituição; motivos; responsabilidade; vínculos; enredos familiares e modelagem. Conclusão: A compreensão da presença e da influência das famílias, principalmente quando estas dificultam a resolução do problema ou conflito ético, a identificação do perfil destas consultorias, bem como a reflexão sobre os aspectos das relações familiares, pode ampliar as possibilidades de avaliar os casos de Bioética Clínica e de planejar estratégias institucionais que envolvem o processo de tomada de decisão no atendimento assistencial. / Introduction: Clinical Bioethics consultants assist professionals, patients or families in the reflection of decision-making process when a problem or ethical conflict arises during assistance services. Family relationships of patients may be involved in these situations, including how to hinder it. Objectives: To evaluate the presence and influence of families in Clinical Bioethics consultations. As well to establish the consulting profile in which family relationships difficult to resolve the problem or ethical conflict: applicants, specialty, records in electronic medical records, patients and family relations. Methods: We analyzed 307 records of Clinical Bioethics ondemand assistance consultations, conducted by the Bioethics Division, Hospital de Clinicas de Porto Alegre from 2010 to 2011. Data were collected from the records of the Bioethics Division and electronic medical records of patients. Were excluded proactive consultancies carried out in regular Clinical Rounds of healthcare, the regular meetings of the Division and the meetings of Clinical Bioethics Committe. For qualitative analysis was used content analysis and classification of seven aspects for family relationships (Nelson and Nelson). The quantitative evaluation was performed by descriptive measures and associations, using SPSS 18.0. Results: In 57% of the 307 records of family relations consultant evaluated the patients involved were predominantly (38%) making it difficult to resolve the problem or ethical conflict. These consultancies, whose families have added difficulties (n = 116), 71% of consultations were generated by requests from physicians. Internal Medicine, Pediatrics and Psychiatry Services demanded 56% of consultants. In 79% of the records was possible to identify patient records associated with it. As for response, 71% of consultations were seen on the same day or the day after your request. The patient characteristics, distribution in relation to gender, was balanced, with a predominance of adult age group and 54% were from Porto Alegre. Family relationships identified as naturally imposed were the most predominant (72%). In the same 116 families were identified the seven aspects of family relationships: Intimacy, Not Replacement, Reasons, Responsibility, Links, Family Plots and Modeling. Conclusion: The understanding of the presence and influence of families, especially when they hinder the resolution of the problem or ethical conflict, identifying the profile of these consultants, as well as reflections on aspects of family relationships, can extend the possibilities to assess cases of Clinical Bioethics and institutional policies that involve the process of decision making in health care services.

The starting point of the present thesis is nurses’ reported experiences of disagreements with physicians for pushing life sustaining treatment too far. The overall aim was to describe and compare nurses’ and physicians’ perspectives on the boundaries for life-sustaining treatment and to evaluate whether ethics rounds could promote mutual understanding and stimulate ethical reflection. A mixed methods design with qualitative and quantitative data was used, including interviews and questionnaires. The health professionals’ experiences/perceptions were based on known patients foremost from general wards, but also intensive care units, at four Swedish hospitals. The first two studies treated the perspective on boundaries for life-sustaining treatment and the last two evaluated philosopher- ethicist led ethics rounds. Analysis of data was performed using a phenomenological approach and content analysis as well as comparative and descriptive non-parametric statistics. In the first study, the essence of the physicians’ decision-making process to limit life-sustaining treatment for ICU patients, was a process of principally medical considerations in discussions with other physicians. In the second study, there were more similarities than differences between nurses’ and physicians’ opinions regarding the 714 patients studied. The physicians considered limited treatment as often as the nurses did. The ethics rounds studies generated mixed experiences/perceptions. It seemed that more progress was made toward the goal of promoting mutual understanding than toward the goal of stimulating ethical reflection. Above all, the rounds seemed to meet the need for a forum for crossing over professional boundaries. The most salient finding was the insight to enhance team collaboration, that the interprofessional dialogue was sure to continue. Predominating new insights after rounds were interpreted as corresponding to a hermeneutic approach. One of nurses’ negative experiences of the ethics rounds was associated with the lack of solutions. Based on the present findings, one suggestion for improvement of the model of ethics rounds is made with regard to achieving a balance between ethical analyses, conflict resolution and problem solving. In conclusion, the present thesis provides strong evidence that differences in opinions regarding boundaries for life-sustaining treatment are not associated with professional status. The findings support the notion of a collaborative team approach to end-of-life decision-making for patients with diminished decisionmaking capacity. There is an indication that stimulation of ethical reflection in relation to known patients may foremost yield psychosocial insights. This could imply that social conflicts may overshadow ethical analysis or that ethical conflicts and social conflicts are impossible to distinguish.

No description available.

Cette recherche s’intéresse aux processus communicationnels utilisés dans les comités d’éthique clinique (CEC) en Amérique du nord dans leur fonction de consultation. Selon la littérature, les CEC bénéficieraient de «pay closer attention to group process [as an] effective communication in a HEC is essential to a committee’s function» (Berchelmann and Blechner 2002 p.143). Or, très peu de données sur les dynamiques de groupe et les modes de communication en CEC sont disponibles. Ce travail cherche à savoir si l’approche dialogique peut être utile au soutien des discussions de groupe des CEC. Dans un premier temps, une revue de littérature rend compte, à partir de son historique, de l’état actuel des CEC. Sont ensuite explorées et analysées, dans leurs avantages et leurs limites, les diverses méthodes utilisées afin de mener les discussions dans le cadre des consultations. Dans un deuxième temps, les barrières communicationnelles qui affectent potentiellement les CEC sont identifiées. Par la suite, afin d’améliorer le processus de communication (et diminuer l’effet des barrières), une nouvelle piste de solution est proposée : le dialogue tel que développé par le milieu organisationnel. Le dialogue est alors conceptualisé et mis en lien avec les besoins des CEC en matière de communication. Bien que le dialogue propose plusieurs contributions avantageuses pour les CEC et leurs membres, certaines contraintes réduisent sa faisabilité d’une façon globale dans le contexte particulier des CEC. Par contre, en l’utilisant comme formation complémentaire, le dialogue permet le développement de l’individu et du groupe et demeure une approche intéressante et utile pour les CEC qui éprouvent des difficultés systémiques et comprennent les implications de sa démarche. / This research focuses on communication processes used in hospital ethics committees (HECs) in North America in their consultation role. According to the literature, HECs would benefit if they ―pay closer attention to group process [as an] effective communication in a HEC is essential to a committee’s function‖ (Berchelmann and Blechner 2002 359 p.143). However, very little data on group dynamics and modes of communication are available. This thesis explores whether the dialogical approach may be useful to supporting group discussion in HECs. The first part of this thesis presents a literature review and history to situate the current state of HECs. The various methods used to conduct discussions in ethics consultations are then explored and analyzed, with regards to their advantages and limitations. The second part of the thesis examines communication barriers that potentially affect HECs, and then proposes a possible solution to improve the communication process (and reduce the effect of barriers), that is, the dialogic approach as developed by the organizational setting. This approach is then conceptualized and linked with the communication needs of HECs. Although dialogue can provide several beneficial contributions to HECs and their members, some contextual constraints reduce its feasibility for a comprehensive application. However, using it as a means of additional training, dialogue enables the development of the individual and the group and remains an interesting and useful approach for HECs facing difficulties, and who are able to understand the systemic implications of this approach.

Cette recherche s’intéresse aux processus communicationnels utilisés dans les comités d’éthique clinique (CEC) en Amérique du nord dans leur fonction de consultation. Selon la littérature, les CEC bénéficieraient de «pay closer attention to group process [as an] effective communication in a HEC is essential to a committee’s function» (Berchelmann and Blechner 2002 p.143). Or, très peu de données sur les dynamiques de groupe et les modes de communication en CEC sont disponibles. Ce travail cherche à savoir si l’approche dialogique peut être utile au soutien des discussions de groupe des CEC. Dans un premier temps, une revue de littérature rend compte, à partir de son historique, de l’état actuel des CEC. Sont ensuite explorées et analysées, dans leurs avantages et leurs limites, les diverses méthodes utilisées afin de mener les discussions dans le cadre des consultations. Dans un deuxième temps, les barrières communicationnelles qui affectent potentiellement les CEC sont identifiées. Par la suite, afin d’améliorer le processus de communication (et diminuer l’effet des barrières), une nouvelle piste de solution est proposée : le dialogue tel que développé par le milieu organisationnel. Le dialogue est alors conceptualisé et mis en lien avec les besoins des CEC en matière de communication. Bien que le dialogue propose plusieurs contributions avantageuses pour les CEC et leurs membres, certaines contraintes réduisent sa faisabilité d’une façon globale dans le contexte particulier des CEC. Par contre, en l’utilisant comme formation complémentaire, le dialogue permet le développement de l’individu et du groupe et demeure une approche intéressante et utile pour les CEC qui éprouvent des difficultés systémiques et comprennent les implications de sa démarche. / This research focuses on communication processes used in hospital ethics committees (HECs) in North America in their consultation role. According to the literature, HECs would benefit if they ―pay closer attention to group process [as an] effective communication in a HEC is essential to a committee’s function‖ (Berchelmann and Blechner 2002 359 p.143). However, very little data on group dynamics and modes of communication are available. This thesis explores whether the dialogical approach may be useful to supporting group discussion in HECs. The first part of this thesis presents a literature review and history to situate the current state of HECs. The various methods used to conduct discussions in ethics consultations are then explored and analyzed, with regards to their advantages and limitations. The second part of the thesis examines communication barriers that potentially affect HECs, and then proposes a possible solution to improve the communication process (and reduce the effect of barriers), that is, the dialogic approach as developed by the organizational setting. This approach is then conceptualized and linked with the communication needs of HECs. Although dialogue can provide several beneficial contributions to HECs and their members, some contextual constraints reduce its feasibility for a comprehensive application. However, using it as a means of additional training, dialogue enables the development of the individual and the group and remains an interesting and useful approach for HECs facing difficulties, and who are able to understand the systemic implications of this approach.