Ethical reflection and awareness in supervision
This is a scientific research article. It has been reviewed and approved by the editor in chief of the Norwegian Journal of Nursing Research and independent peer reviewers. It has been translated from Norwegian. The original Norwegian version can be accessed by clicking 'Norsk' in the upper right corner.
Background: Perceived personal responsibility in the interprofessional collaboration with patients can represent an ethical dilemma. We wanted to explore whether ethical reflection in supervision could stimulate reflection and raise awareness in relation to interaction in practice.
Objective: To examine how ethical reflection in supervision can help to raise awareness and prevent moral stress.
Method: The study was exploratory and descriptive. We collected data from two focus group interviews before and after eight supervision group meetings with nine psychiatric nurses. The supervision focused on two main questions: What was the core ethical challenge in the situation, and what was the main challenge in the collaboration related to this situation? A hermeneutic-phenomenological approach was used to analyse the data.
Results: The overall understanding is summarised in the statement: ‘I feel frustrated on the patient’s behalf’ – a statement that was used by several participants. We identified four themes: the tension between professional and ethical dilemmas, the dilemma between patient needs and the treatment system, the challenges of the collaboration and the impact of supervision on ethical awareness.
Conclusion: Collaboration can be described as an interaction in which a person’s values are under threat from different systems. Supervision can help to raise ethical awareness of what is at stake in the collaboration between the patient and the treatment system. Ethical awareness can help the professional practitioner to work up the courage to articulate and clarify important ethical care values in practice.
Clinical supervision is a complex activity that can be difficult to measure in terms of effect, and there are few randomised studies on the benefit of supervision. The studies that do exist show that supervision can be most effective when the focus is aimed at relevant and contextual themes. Due to the complexity of supervision, qualitative studies are best suited to exploring the impact of supervision and its potential transfer value in practice (1).
If supervision is to be successful, it must be anchored locally. The supervisor must recognise the contextually complex challenges experienced by professional practitioners in their work (1). Many decisions in nursing practice are taken intuitively. Nursing supervision can provide an opportunity to reflect on ethical challenges. The supervision can also strengthen the nurses’ awareness when faced with difficult ethical choices (2).
Obligations and ethical considerations
A study on nursing in primary mental health and substance abuse work (3) shows that nurses working within this field are well qualified, with relevant further education and extensive clinical experience in working with pertinent target groups. The study also reveals that nurses possess qualities such as flexibility and pragmatism, and that they give priority to a relational cooperation with the patient.
The binding relational cooperation with patients in different life crises at district psychiatric centres (DPC) entails a variety of ethical and professional requirements. Nurses may be affected by meetings with patients experiencing such life crises (4). The context in which the relational cooperation and the ethical requirement occurs can sometimes prevent nurses from doing what they feel is right for the patient. One such example may be when a nurse is instructed to discontinue an ongoing and unfinished collaboration process with a patient. An ethical awareness of what the nurse considers necessary, but is not allowed to carry through, may be a challenge, but it may also prevent moral stress in the long term (5).
Responsibility versus authority
It is important for professional practitioners to have collaborative relationships in which individuals’ ideas are challenged and safeguarded, and can develop jointly (6). Under the provisions of the Coordination Reform (7), professional practitioners at DPCs are required to collaborate with many different actors and agencies. The purpose of interprofessional, interdisciplinary and interagency collaboration in mental health work is to build a common value basis for the collaboration. Professional practitioners may, however, consider this challenging and complex (8, 9). Feeling a sense of personal responsibility when dealing with patients can sometimes represent an ethical dilemma and create problems (8). Nurses are responsible for their decisions, but they do not always have the authority to act in situations where other collaboration partners are involved. Responsibility and authority can be linked to both individuals and systems (2).
The purpose of the study is to examine how ethical reflection in supervision can help raise awareness and prevent moral stress.
We will elucidate two research questions:
- What can be the theme of a supervision group that specifically raises questions about ethical challenges and collaboration?
- How can supervision contribute to ethical awareness and reflection in interprofessional and interagency collaborations?
Design, data collection and the focus of the supervision
The study has a qualitative approach and a descriptive and exploratory design. We collected data from two 90-minute focus group interviews. The first of these was held in June 2013 prior to holding eight 90-minute supervision group meetings. The second focus group interview was held in August 2014 after the supervision group meetings. Focus group interviews are a suitable interview method for eliciting views and opinions about a specific topic. The group conversation can trigger various reflections and associations that can shed light on practices, thus providing a richer body of data than individual interviews (10). The second author led the focus group interviews. A digital audio recorder was used to record the interviews. The first author, who was also a group supervisor, transcribed the recordings verbatim.
After describing a practice situation and reflections on this, the supervisor asked two specific reflective questions:
- What do you think was the core ethical challenge in the situation that was presented?
- What do you think were the main challenges in the collaboration in this situation?
The keywords noted in a journal by the supervisor following the supervision group meetings also form part of the data source, and are included in the discussion.
We invited all of the nine psychiatric nurses at a DPC to take part in the study, and they all accepted. The participants were employed at the same workplace and therefore faced many of the same challenges in their daily work. Having a common starting point can be a benefit in the supervision (1). Seven of the participants were affiliated with the centre’s general psychiatric outpatient clinic, and two were affiliated with the substance abuse outpatient clinic. The participants had worked as psychiatric nurses at the centre for more than ten years.
The invitation to participate in supervision and a focus group interview was cleared with the participants’ manager. Because the supervision was part of a research project at our college, it was provided free of charge by the first author. All of the participants received written and oral information about the project and gave written consent to participation. We have not recorded personal data relating to the participants, their collaboration partners and/or patients and their families. Only the professional and ethical content of the collaborative situations has been described and analysed. The Norwegian Centre for Research Data (NSD) did not impose a notification requirement on the study.
We have used a hermeneutic-phenomenological method to analyse the text with a view to understanding and describing the nurses’ subjective experiences of their working day. As researchers, we have searched for meaning and understanding through an interpretative process: we first read the text whilst remaining as open-minded and non-judgemental as possible. Then we conducted a structural analysis before formulating an overall understanding (11).
On first reading, we endeavoured to maintain an open mind, and were empathic to the content of the text. Repeated readings led us to a structural analysis. The structural analysis was conducted by identifying statements that link the participants’ experiences in four meaningful themes. The overall understanding emanates from the participants’ descriptions of different collaborative situations.
The first and second author carried out the main analysis. The third author was a participant in the focus group interview and the supervision group. She subsequently participated in the research process by reading the texts and giving comments.
Here we present first the researchers’ overall understanding of the ethical challenges described by the study participants. We have summarised the overall understanding in a statement used by several interviewees. The statement is: ‘I feel frustrated on the patient’s behalf’. Then we describe the study results from the structural analysis through four meaningful themes.
The statement reflecting the overall understanding of the study was used by the participants to describe situations where they considered the treatment offered to the patients to be inadequate. They expressed concern that patients did not receive the necessary health care within a reasonable period of time. The statement was also linked to the participants’ perception that the assistance offered to the patients was not good enough. One participant said the following in relation to how it feels when management lacks understanding in such situations:
‘We feel a bit useless sometimes. Patients are suffering. Treatment doesn’t help. When I raise the issue with management, they say, “What do you want me to tell you? Just end the treatment!” All I ask is that we discuss what is beneficial.’
Theme 1: The tension between professional and ethical dilemmas
‘Patient assessment means moving away from ethics – there are an increasing number of assessments and diagnoses.’
This is a quote from a participant who described the sense of tension between professional and moral dilemmas when dealing with patients. On the one hand, participants felt a professional obligation to follow the existing guidelines. On the other hand, they felt a sense of loyalty to protect the patient ethically. One participant made the following comment:
‘Prioritising means rejecting the patient – it leads to a feeling of shame and touches on existential issues.’
The participants spoke about meetings with patients that touched them personally. At the same time, they felt an obligation to take into account the requirements of the treatment system, which they were also part of. One such statement was as follows:
‘I am often touched by a situation, and when I am, I have a good tool to draw on. When I'm not affected; those are the ones I spend the most time on in supervision.’
Emotional experiences such as sadness, loss of confidence, feelings of inadequacy, shame, and being unable to adapt the nursing care to the individual patient were topics discussed. Participants expressed the feeling of being unable to show compassion and having insufficient time to get more involved as ethical and professional dilemmas.
I despair about the things I don’t have time to do and that I am not allowed to do. Sometimes I do it in secret.Focus group participant
The participants felt they had a solid professional basis for considering what they thought was necessary for the patients they were responsible for. This self-assuredness could present a challenge when they were expected to follow management’s wishes and requirements. The following two statements exemplify this:
‘A bad conscience for not doing what you should.’
‘I despair about the things I don’t have time to do and that I am not allowed to do. Sometimes I do it in secret.’
According to the participants, ethical questions were neither adequately discussed nor prioritised in their daily work. The participants often felt alone when dealing with ethical issues, with one making the following observation:
‘Ethics and ethical issues sound good – like decorations on a cake. But any time I have raised the subject, I haven’t got anywhere.’
Theme 2: The dilemma between patient needs and the treatment system
The participants described how the framework for the help they should give has become narrower. They meet patients with major challenges, but find that the systems in the specialist health service and the first line do not have a holistic approach and are limited in terms of time. One participant described the experience of not being able to accommodate the patient due to a constricted framework as follows:
‘The patient is falling by the wayside. The framework is not fit for purpose.’
The participants put a large emphasis on situations where they had to refer a patient for treatment at a different level when they knew that treatment did not work or did not exist. Expressions like ‘to witness’, ‘end the treatment and then what?’ and ‘to feel shame’ were used in relation to such experiences.
They experienced several ethical dilemmas. One example was the treatment system’s guidelines, which were not adapted to individual patients’ needs for time and pace. Another example was that the treatment should be quick and effective:
‘Challenge the patient at a suitable pace – don’t just thrust her into exposure therapy! That would be unethical.’
The participants used the relationship between professional practitioners and systems to describe ethical reflection in the team collaboration. The participants had varying experiences here; some expressed that there was no ethical reflection in the collaboration, while others commented that ethical reflection was an integral part of the daily collaboration in the team.
Theme 3: The challenges of the collaboration
The participants described ethical challenges related to collaborative situations, where, as nurses, they felt the gap between treatment needs and treatment options was too great. They also told of collaborative situations where they felt that the dignity and autonomy of patients were not adequately protected. They described situations where the duty of confidentiality obstructed therapeutic openness. They discussed the need for fast and seamless interventions instead of slow systems bound by rules. One participant described how rules that are too stringent can mean less flexibility:
‘Being tied down by rules gives fewer opportunities to act.’
The participants described ethically challenging situations where the duty of confidentiality obstructed the necessary therapeutic openness.
Several of the professional groups in the team they belonged to shared this opinion. Ethical issues in different collaborative situations were in evidence irrespective of the profession according to the participants, as reflected in the following statement:
‘The systems are after all made up of people... Rigidity exists in all disciplines.’
The participants described ethically challenging situations when the duty of confidentiality obstructed the necessary therapeutic openness. One such example was a patient who did not want his GP to know that he was receiving treatment for substance abuse at a DPC.
Theme 4: The impact of supervision on ethical awareness and exercising resolve
The participants said that the supervision had positive effects, such as strengthening their resolve and making them more aware of their values. Other examples were that they became more reflective and articulate, particularly when there was a disagreement in the collaboration:
‘Explaining ethical dilemmas can have an effect on the system – the system world. The supervision has strengthened my courage.’
The participants felt that the systematic and specific ethical reflection in the supervision was practical and relevant. It also helped to clarify the values of their professional role and the moral responsibility they had for the patients. Some participants felt a sense of shame when they were unable to act, in terms of their own values, the patients’ needs and the requirements of the treatment system.
Awareness of own values in a collaborative situation is probably also more important than finding clear answers, with one participant making the following observation:
‘A dilemma is by its very nature unsolvable – which makes it hard to come up with good answers! The question that has been asked: What is the core challenge here? I think that’s good. It makes us think. And finding an answer isn’t easy.’
Another theme was that raising issues ‘behind someone’s back’, such as in a supervision group where the other party is not present, could in itself be an area of vulnerability and be perceived as an ethical dilemma.
The overall understanding of the study ‘I feel frustrated on the patient’s behalf’ can be interpreted as an expression that the nurses recognise and care about the patients’ unfortunate experiences in their dealings with treatment systems. The participants’ descriptions of their practice confirm that they are expert nurses (12), and as such their work with the patient is based on intuitive clinical judgment and a large degree of flexibility (3). They also describe how these characteristics clash with the restrictive frameworks and guidelines.
The phrase ‘on the patient’s behalf’ can be understood as an expression of values that relate to the nurses’ personal and professional responsibilities and obligations in their dealings with individual patients. General basic values in nursing are linked to the individual’s life and inherent dignity (13). The participants describe how individual adaptation of measures is often ignored in favour of more general measures. One example of individual adaptation was an appropriate timeframe and pace for a young person who needs a certain amount of time to build a relationship of trust with the nurse.
Ethical dilemmas could arise because clinical judgment and desired treatment for the patient are at odds with systems that prevent the nurses from fulfilling the individual patient’s needs. Such individual adaptation can be described as ‘tailored’, while the term ‘ready-made’ could be applied to measures that are appropriate for a group of patients with the same diagnosis (14).
Experiencing moral stress and shame
The nurses in this study reported experiencing moral stress when working in systems that made it difficult for them to act in accordance with their responsibilities and obligations (15). Moral stress differs from other forms of stress, and is manifested when professional obligations and professional integrity are compromised, thus creating a barrier to acting in an ethically appropriate manner (15).
Loyalty to what is necessary for the patient appears to play a significant role in the participants’ professional and ethical considerations.
The study participants reported that they were prevented from performing the nursing care they considered necessary and in line with basic care values. This made them feel a sense of shame. Shame is linked to the self or to the person we want to be (16). We may feel shame when we are party to actions that are contrary to the ideals we formed during our education, and which we wish to live by (17). The participants associate shame and existential issues with priorities that led them to reject patients. Loyalty to what is necessary for the patient appears to play a significant role in the participants’ professional and ethical considerations.
One participant claimed that ‘ethical reflection helps prevent the lifeworld from being colonised by the system world’. The statement can be understood as a perceived conflict of values when the practitioner’s values are compromised in interaction situations in which they act on the patient’s behalf. Work on ethical awareness in supervision may have served as a counterweight to structural power that empowers professional practitioners (18). If nurses are to clearly identify problems and find good alternatives for action, both the lifeworld and the system world must be discussed and differentiated in the supervision (19). Although framework conditions may be at odds with a person’s conscience and the professional code of ethics, being aware of the moral responsibility in every situation will make the nurses more attentive and vigilant (20).
When the scope to act was too constricted, the participants sometimes dealt with their ethical challenges, or the dilemma they were facing, by keeping actions secret from collaboration partners. This may be a way of taking back power in a context where power structures define the content of a patient’s treatment. Dealing with the ethical challenges in this way can accommodate the patient’s needs and reduce the nurse’s dilemma.
Based on a more comprehensive and societal argument, using this method to deal with ethically challenging situations may undermine important professional and ethical grounds for what patients need. If conversations about ethical challenges, choices and decisions are part of the professional practitioner’s working day, they can become an interdisciplinary and interprofessional collaboration. In the long term, this may benefit more patients (21).
Bad conscience when they are unable to meet their obligation
The phenomena ‘responsibility’ and ‘duty’ appear to represent important care values for the nurses in this study. The way in which they describe their sense of responsibility can be understood as a combination of professional responsibility as enshrined in the legislation (22) and work ethics guidelines (13), and a personally perceived responsibility that can be understood as an individual and existentially substantiated responsibility (20).
When the participants find that they are unable to meet their obligation, they feel a sense of despair and have a bad conscience. They describe it as being witness to something they consider inadequate or wrong for the individual patient. The perceived dilemma can be understood as a gap between what they think is appropriate and correct for a patient and what is actually offered. For the nurses, witnessing something can entail watching something happen without being able to exercise their responsibility and carry out their duty. This can partly explain the bad conscience that participants expressed in several of the supervision group meetings and the focus group interviews.
The study’s other research question asks how supervision can contribute to ethical awareness and reflection in interprofessional and interagency collaborations. The participants consider the opportunity that the supervision provides for focused reflection on ethics and collaboration to be more important than finding clear answers. This concurs with other descriptions of expert nurses’ experiences and needs in supervision (8).
The results from the focus group interviews are consistent with the themes in the supervision group, which are, for the most part, descriptions of challenges related to systems and frameworks as opposed to the participants’ day-to-day collaboration partners. The participants described it as an ethical dilemma ‘to go behind someone’s back’, and did not therefore want to discuss collaborative situations from the interprofessional team they worked with on a daily basis. Supervision teams, made up of various professions working together on treating patients, could generate a wider variety of perspectives (23) than supervision groups composed of just one profession.
Reflection in the supervision
In this study, we sought to delimit our focus on the supervision by using two specific reflective questions for the narratives about practice. One question was aimed at the core of the ethical challenge in situations from practice. This delimitation can make the supervision more targeted and more measurable (1). The opportunity to think about defined themes and in a focused manner was appreciated by the participants.
One participant describes how reflections in supervision related to ethics and collaboration have given them the resolve to influence the systems.
One participant describes how reflections in supervision related to ethics and collaboration have given them the courage to influence the systems. Courage can be attributed to qualities such as strength, resolve and boldness (24). As such, we suggest that supervision that focuses on reflection on ethical challenges and collaboration can help create a greater scope to act.
Supervision can be described as the ‘space for reflection’, where we consider practice with the benefit of hindsight, and where professional practitioners have the time and opportunity to think slowly (8). Clinical practice, where meetings with patients and collaboration take place, is on the other hand characterised by rapid, instinctive and emotional assessments and decisions (25). We can use the term ‘slow thinking’ about the form of ethical awareness that took place in the supervision in this study (25). The term entails a slower and more reflective process than when in the middle of complex and challenging practice situations. In a supervision group, the supervisor can ensure that professional practitioners review ethically challenging situations from practice at a slow pace. The slow review enables plenty of time for reflection, and can help the practitioner to make more integrated, conscious and moral choices (2), which in turn strengthen courage.
Limitations of the study
This study focuses on describing how nurses can reflect on ethical challenges in the collaboration with the patient and treatment system. Such reflection can lead to greater awareness of ethical values. The results of the study may have been influenced by the fact that the participants were all from the same workplace and the supervisor had a dual role as a researcher and professional. Proximity with the field of research is useful, but may also be a weakness, and requires conscious reflection on preconceptions (26). If the results are to be useful to others, the interpretations in the study must provide recognition and meaning in the reader’s lifeworld. In addition, the results must be used to improve practice.
Collaboration can be described as an interaction in which individuals’ values are under threat from different systems. The system world can be at odds with and affect individual values and norms for good practice, and can represent a source of anguish for professional practitioners. When supervision specifically focuses on reflection on ethical dilemmas in interprofessional and interagency collaborations, it appears that the choice of values faced by professionals becomes clearer. Raising awareness in supervision can help the individual professional practitioner to find the courage to articulate and clarify important ethical care values in practice. The fact that courage can be the result of ethical awareness in supervision is a new and interesting phenomenon to pursue in further research.
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