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.

<p>Ongoing structural and financial changes in the health care sector have resulted in increased risks for ethical dilemmas and moral distress. It is purported that increased ethical competence will help staff manage ethical dilemmas and hence decrease moral distress. To enhance ethical competence several approaches may be used – theoretical education, and methods focusing on reflection and decision-making abilities.</p><p>Ethics rounds are a widespread systematic method hypothesized to improve ethical competence, nurture a reflective climate, and help in ethical decision-making. Despite its popularity, its effects on moral distress have hitherto never been evaluated in a controlled study.</p><p>The purpose of this thesis was to evaluate the impact of an intervention, including ethics rounds; the hypothesis being that the intervention would decrease perceived moral distress. An additional aim was exploring the concept of moral distress in various health care establishments, including pharmacies.</p><p>Focus groups were conducted to explore the concept of moral distress. To evaluate the intervention a scale assessing staff-perceived moral distress was designed, validated, and implemented.</p><p>Results showed that moral distress is evident in diverse health care settings. Some factors associated with this were lack of resources, conflicts of interest, and rules that are incompatible with practice. An expanded definition of moral distress was presented.</p><p>The training program was much appreciated by participants. However, no significant effects on perceived moral distress were found. Reasons could be that the intervention was too short or otherwise ineffective, there is no association between ethical competence and moral distress, the assessment scale was not sensitive enough, or management was not sufficiently involved.</p><p>There is a need to further refine the various aspects of ethical dilemmas in clinical settings, and to evaluate the most efficient means to enhance skills for dealing with ethical dilemmas, for the benefit of staff, patients, institutions, and society.</p>

Ongoing structural and financial changes in the health care sector have resulted in increased risks for ethical dilemmas and moral distress. It is purported that increased ethical competence will help staff manage ethical dilemmas and hence decrease moral distress. To enhance ethical competence several approaches may be used – theoretical education, and methods focusing on reflection and decision-making abilities. Ethics rounds are a widespread systematic method hypothesized to improve ethical competence, nurture a reflective climate, and help in ethical decision-making. Despite its popularity, its effects on moral distress have hitherto never been evaluated in a controlled study. The purpose of this thesis was to evaluate the impact of an intervention, including ethics rounds; the hypothesis being that the intervention would decrease perceived moral distress. An additional aim was exploring the concept of moral distress in various health care establishments, including pharmacies. Focus groups were conducted to explore the concept of moral distress. To evaluate the intervention a scale assessing staff-perceived moral distress was designed, validated, and implemented. Results showed that moral distress is evident in diverse health care settings. Some factors associated with this were lack of resources, conflicts of interest, and rules that are incompatible with practice. An expanded definition of moral distress was presented. The training program was much appreciated by participants. However, no significant effects on perceived moral distress were found. Reasons could be that the intervention was too short or otherwise ineffective, there is no association between ethical competence and moral distress, the assessment scale was not sensitive enough, or management was not sufficiently involved. There is a need to further refine the various aspects of ethical dilemmas in clinical settings, and to evaluate the most efficient means to enhance skills for dealing with ethical dilemmas, for the benefit of staff, patients, institutions, and society.

Bakgrund: Ambulansens uppdrag har utvecklats och numer bedrivs bland annat avancerad vård. Den äldre befolkningen ökar vilket även speglar ambulansuppdragen. Den äldre befolkningen kan vid sjukdom eller på grund av åldrande ha en nedsatt beslutsförmåga, vilket gör dessa bedömningar svårare. För att bemöta de äldre i ambulanssjukvården behöver den etiska kompetensen synliggöras. Ett sätt att belysa etiken och det etiska arbetsklimatet är genom etikronder. Syfte: Beskriva ambulanspersonalens erfarenheter av etikronder beträffande vård av äldre inom ambulanssjukvården.  Metod: Kvalitativ intervjustudie med induktiv ansats. Deltagare rekryterades utifrån de som deltagit i etikronder, den insamlade data analyserades med hjälp av Erlingsson och Brysiewicz (2017) kvalitativ innehållsanalys. Resultat: Resultatet resulterade i två teman; ”trygg och öppen atmosfär under etikronden”, vilken innehåller beskrivningar av olika aspekter av faktorer som bidrog till upplevelsen av etikronden, och ”etikrondens avtryck på både personlig och kollegial nivå”, vilken innehåller tankar, reflektioner och resultat som har kommit efter att ha deltagit i etikronder. Slutsats: Etikronder är en positiv upplevelse, med en moderator som lederdiskussionen framåt i ett öppet klimat synliggörs etiska dilemman. Detta hjälper ambulanspersonal att hantera etiska svårigheter och den etiska kompetensen förbättras, en ökad trygghet i bedömningar av patienter upplevs. Detta kan leda till att vården av de äldre patienterna blir mer anpassad och att den moraliska stressen minskar hos ambulanspersonal. För att fortsätta denna utveckling efterfrågas etikronder mer regelbundet och att alla på arbetsplatsen ska delta. / Introdution: The ambulance assignments has developed and now has the ability to provide advanced care. The increase in the elderly polpulation reflects in the ambulance missions. The elderly population may, in case of sickness or due to ageing, have a reduced decision-making abilit, which make these assessments more challenging. In order to approach the elderly in the prehospital care, the ethical competence needs to be made more visible, one way to highlight ethics and the ethical work climate is through etics rounds. Aim: To describe the ambulance personell experience of ethics rounds regarding the care of elderly in prehospital care. Method: Qualitative interview study with an inductive approach. Participants were recruited based on who had participated in ethics rounds, the collected data was analyzed using Erlingsson and Brysiewicz (2017) qualitative content analysis.Result: The result resulted in two themes; "safe and open atmosphere during the ethics round", which contains descriptions of various aspects of factors that contributed to the experience of the ethics round, and "the impact of the ethics round on both a personal and collegial level", which contains thoughts, reflections and outcomes that have come after participating in ethics rounds. Conclusion: Ethics rounds are a positive experience, with a facilitator who leads the discussions forward in an open climate and makes ethical dilemmas visible. This helps paramedics deal with ethical difficulties and the ethical competence is improved, and increased moral confidence in assessments of patients is experienced. The effect can lead to the care of the elderly patients becoming more adapted and reduced moral stress for ambulance personell. To continue this development, ethics rounds are requested more regularly and that everyone in the workplace should participate.