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Background: Changes in healthcare governance and the rise of evidence-based medicine (EBM) have over the last decades contributed to an increase in guideline-driven management of general practice. There is a lack of recent studies investigating how this continuous development affects the practice of Swedish general practitioners (GPs) from a broad perspective. Thus, this study aims to explore how Swedish GPs relate to management control through guidelines, how it affects their daily practice and work environment, and how they reflect on its consequences.

Methods: We conducted semi-structured, face-to-face interviews during 2024 with 11 GPs from all across Sweden. The transcribed interview data were analysed using thematic analysis.

Results: We constructed three themes, each representing a field of tension created by guidelines: (1) Torn between high ambitions and their resulting negative side effects, (2) Guidelines promote measurable over unmeasurable knowledge, and (3) Although autonomy in relation to guidelines is highly valued, there are compelling reasons to submit.

The first theme reflects a broad agreement on the benefits of guidelines and support of the growing ambitions they reflect. However, guidelines also result in increasing work-load and reduce flexibility in healthcare collaboration. The second theme highlights that because guidelines tend to prioritise measurable over non-measurable knowledge, other aspects of GPs’ professional skills risk being underused and underdeveloped. The third theme captures how GPs exercise a high degree of autonomy in relation to guidelines, yet occasionally relinquish their clinical discretion. These tensions may result in side-effects such as a deteriorating work environment, crowding-out effects, fragmented healthcare, and potentially reduced quality in areas of general practice that are difficult to measure.

Conclusions: While management control through guidelines entails many benefits, the participants in this study also reported several adverse effects on both the quality of care and the work environment. Promoting quality by organizing healthcare through increasingly complex guidelines may seem like a natural approach in a system that focuses strongly on measuring outcomes, but it is also important for healthcare decisionmakers and guideline developers to acknowledge its potential side effects.

Children's assent is an ethical and legal requirement for research that involves them. Nevertheless, studies suggest that children with cancer are not always involved in research decisions. This raises important ethical questions about how children's participation in assent should be supported and on what ethical grounds. In this paper, we explore three dimensions of autonomy in research with children: autonomy as a right, as a value, and as relational. We argue that it is important not only to respect children's autonomy but to also promote it as a value, by actively supporting children's autonomy. Central to this approach is an understanding of how relationships and trust can both enable and constrain children's autonomy. We suggest that children's autonomy may be supported in practice through capacity-sensitive participation, child-adapted and iterative information provision. This requires ongoing dialogue that is responsive to children's emotional, cognitive, and relational contexts, with particular attention to fears, decision-making challenges, and voluntariness. While concern for the well-being of children with cancer is essential, it should not be used as a justification to exclude them from the assent process. Respect for children as persons should guide recruitment to paediatric oncology research.

Clinical Ethics Support (CES) includes various forms of systematic support to deal with ethical challenges in healthcare and case-based CES (C-CES) is used for CES in particular cases. The aim was to describe and normatively discuss organizational and methodological aspects of C-CES used in Swedish healthcare. A mixed-methods approach was used. A descriptive survey was answered regarding eight organizations on hospital, regional and national level, with large variations in the number of conducted C-CES activities. Data were compiled and frequencies calculated. Based on the survey results, normative questions were formulated. Six participants, with expertise of C-CES, participated in a normative group discussion. Field notes and transcribed data were analysed qualitatively. The top ranked goal of C-CES was “Supporting decision making”. Mainly prospective cases were used and C-CES was carried out as un-planned and pre-planned sessions. The normative results showed the importance of avoiding making C-CES unattractive to clinicians, for instance by keeping the time frame. The professional backgrounds of C-CES leaders varied greatly and arguments were provided for the facilitating role and that C-CES leaders ought not facilitate where they have been clinically engaged. Identified challenges included variations in uptake of C-CES activities that do not mirror the ethical challenges of the context. The unfair uptake of C-CES can be compared with the uptake in Norway where there are legal requirements for CES. In this study patients and families were not reported to request or attend C-CES. Thus, further research and interventions are needed to ensure their representation in Swedish C-CES.

Background

Many patients in medical wards lack decision-making capacity and cannot provide valid consent. As a result, nurses and other healthcare professionals often face a dilemma: whether to neglect the medical needs of such patients, or provide healthcare interventions without obtaining valid consent. Previous studies have indicated that many interventions are provided without consent; however, there is insufficient knowledge about how staff in this context reason about the ethical dilemmas they encounter.

Aim

To explore the ethical reasons provided by nurses and other healthcare professionals in medical wards for and against providing healthcare interventions without patients’ consent.

Research design

The study employed a qualitative explorative design. Eight focus group interviews were held with 37 staff across five different professions, mainly nurses, at two Swedish hospitals. The material was subjected to qualitative analysis, following a Reflective Thematic Analysis framework.

Ethical considerations

Ethical approval for this study was obtained from the Swedish Ethical Review Authority. All participants were informed orally and in writing about the study’s aims and its voluntary nature. No sensitive personal information was registered. Participants provided their oral consent to participate before the interviews took place.

Findings/Results

Thematic analysis resulted in four main themes: Coercion is a bad word; Reasons to accept coercion; Coercion is part of ward culture, and Unacceptable coercion.

Conclusions

Participants overwhelmingly supported the current use of ‘consentless measures’ at the investigated wards. Most situations described either needed no justification, according to participants, or could be easily justified by reference to the benefit of the patient, the patient’s poor decision-making capacity, or the benefit of others. A range of implicit, contextual, and institutional justifications were also given. Suboptimal ward culture was considered a prime driver of consentless measures and a force that compromises nurses’ agency in the patient encounter.

In healthcare priority setting, the concept of severity often plays an important role, to voice the aspect of need. It has been observed that severity is an under-theorized concept. The recent pandemic raised a number of practical but also theoretical issues; one such aspect is how to handle severity in heterogeneous patient groups, e.g. when we have to vaccinate a large group, but only a fraction of them is at the risk of suffering severe disease. The aim of this article is to explore, what we call such heterogeneous severity. In the article, we explore three approaches, the trump, the average and the additive approach and find that all of these alternatives are wanting given the rationale for taking severity into account. Instead, we examine a double threshold and a stepwise trump approach, and find that they both have a better match with the rationale for taking severity into account when having to consider budget constraints. However, neither of these will provide input to acceptable cost-effectiveness threshold, and therefore will have to be combined with a weighted additive approach. Comparing the double threshold and stepwise trump approach, we find the latter advantageous in avoiding problematic threshold effects.

Hur tvångsvård fungerar skiljer sig markant mellan olika delar av välfärden. Forskare vid Uppsala universitet kräver att en utredning tar ett samlat grepp om de sju olika lagar som i dag gäller för tvångsvård i Sverige.

Background: The consequences of moral challenges among healthcare workers (HCWs) have been increasingly recognized. To date, however, there is limited knowledge about the predictors of and associations between moral distress, moral residue, and other psychological consequences among HCWs working in a pandemic context.

Objective: We aimed to assess the levels of, and the associations between HCWs’ experiences of moral distress and moral residue with traumatic stress, burnout, and general psychological distress, and evaluate the role of empathic and compassion aspects for these outcomes, while adjusting for demographic and professional factors.

Methods: This is a cross-sectional study of 6551 Swedish HCWs participating in a survey during the COVID-19 pandemic, in the autumn of 2020. The survey included questions related to moral challenges, moral distress and residue, and self-report scales for general psychological distress (GHQ-5), traumatic stress (ITQ), compassion satisfaction and fatigue (ProQoL), empathic ability (B-IRI), and burnout (SMBQ).

Results: There were strong associations between moral challenges and moral distress and residue. There were also clear associations between moral distress and residue and psychological distress scales. Empathic ability, compassion fatigue, and compassion satisfaction were associated with moral residue whereas compassion satisfaction was not associated with moral distress. Demographic and professional predictors included gender, age, and occupational role. No interactions between moral challenges and empathic ability were found for moral distress or residue.

Discussion/conclusion: Moral distress and moral residue share some variance with both general and stress-related psychological distress; however, moral distress and residue are both theoretically and empirically distinct outcomes of moral challenges as compared to other established psychological consequences of occupational stress. Empathic ability was associated with moral distress, but not with moral residue. Moving forward, longitudinal research is needed to better understand the interplay among moral aspects relevant to HCWs.

  Objective

The objective of this study was to examine the correctness of the statement that the diagnosis of shaken baby syndrome (SBS) is a “medical conclusion.”

Design

If the outcome of an event is considered bad, people tend to attribute intent or responsibility. Against this backdrop, a randomized, blinded trial was applied using two case-based questionnaires of possible violent shaking of an infant, identical except for the outcome: fatal or nonfatal.

Setting

We used a report of a 2-month-old baby who had suddenly stopped breathing and was subsequently shaken by the father with the intention to resuscitate him. After admission, encephalopathy, subdural hemorrhages, and retinal hemorrhages were detected.

Participants

A total of 1269 randomly selected physicians received the questionnaire, whose distribution was randomized and blinded. The participants were not informed about the existence of two versions of the questionnaire.

Results

The participants who responded to the fatal version considered in a significantly higher proportion (79% [95% CI: 73−85]) that shaking caused the triad findings than those who responded to the nonfatal version (68% [95% CI: 61−75]) (p = 0.01). When pediatricians and ophthalmologists are merged, the corresponding proportions were (91% [95% CI: 86−96]) versus (74% [95% CI: 66−82]) (p = 0.001). Radiologists and forensic pathologists did not distinguish significantly between fatal and nonfatal outcomes.

Conclusion

The study indicates that among pediatricians and ophthalmologists, the diagnostic process in suspected SBS is more value-based than evidence-based. As these two specialties dominate the SBS diagnostic procedure, the SBS diagnosis is, in this sense, not strictly a “medical conclusion.”