The significance of ethics reflection groups in mental health care: a focus group study among health care professionals

Background: Professionals within the mental health services face many ethical dilemmas and challenging situations regarding the use of coercion. The purpose of this study was to evaluate the significance of participating in systematic ethics reflection groups focusing on ethical challenges related to coercion. Methods: In 2013 and 2014, 20 focus group interviews with 127 participants were conducted. The interviews were tape recorded and transcribed verbatim. The analysis is inspired by the concept of ‘bricolage’ which means our approach was inductive. Results: Most participants report positive experiences with participating in ethics reflection groups: A systematic and well-structured approach to discuss ethical challenges, increased consciousness of formal and informal coercion, a possibility to challenge problematic concepts, attitudes and practices, improved professional competence and confidence, greater trust within the team, more constructive disagreement and room for internal critique, less judgmental reactions and more reasoned approaches, and identification of potential for improvement and alternative courses of action. On several wards, the participation of psychiatrists and psychologists in the reflection groups was missing. The impact of the perceived lack of safety in reflection groups should not be underestimated. Sometimes the method for ethics reflection was utilised in a rigid way. Direct involvement of patients and family was missing. Conclusion: This focus group study indicates the potential of ethics reflection groups to create a moral space in the workplace that promotes critical, reflective and collaborative moral deliberations. Future research, with other designs and methodologies, is needed to further investigate the impact of ethics reflection groups on improving health care practices.publishedVersio

Effekt av tiltak for å redusere potensielt uhensiktsmessig bruk av legemidler i sykehjem: en systematisk oversikt over randomiserte kontrollerte forsøk

Beskriver en systematisk litteraturstudie hvor hensikten var å undersøke effekt av tiltak for å redusere uhensiktsmessig legemiddelbruk i sykehjem.Bakgrunn: Studier har vist at beboere i sykehjem kan være utsatt for uhensiktsmessig medisinering, spesielt med psykofarmaka. Dette øker risikoen for uønskede bivirkninger. Oppdrag: Denne rapporten har identifisert, vurdert og sammenstilt forskning om effekten av tiltak for å redusere uhensiktsmessig bruk av legemidler i sykehjem. Rapporten ble bestilt av Helsedirektoratet i tilknytning til arbeidet med Omsorgsplan 2015. Hovedfunn: • Pedagogiske oppsøkende tiltak og undervisningstiltak gitt alene eller som del av en sammensatt pakke rettet mot helsepersonell er vist i noen sammenhenger å føre til reduksjon av antatt uhensiktsmessig legemiddelbruk. Dokumentasjonen for disse resultatene i sykehjem varierer fra svært lav til lav kvalitet. • Legemiddelgjennomgang med farmasøyt i et tverrfaglig samarbeid med sykehjemslegen og annet relevant helsepersonell er vist i noen sammenhenger å føre til reduksjon av uhensiktsmessig legemiddelbruk. Dokumentasjonen for disse resultatene varierer fra svært lav til lav kvalitet. • Bruk av geriatrisk team som ansvarlig for all medisinsk behandling av de eldre viste en statistisk signifikant effekt på forskrivning av legemidler i én studie med få deltagere og med høy risiko for systematisk skjevhet i resultatet. Dokumentasjonsgrunnlaget blir derfor av for lav kvalitet til å kunne bedømme om tiltaket kan påvirke uhensiktsmessig bruk av legemidler. • Tidlig psykiatrisk intervenering viste ingen statistisk signifikant effekt på bruk av psykofarmaka. Ettersom kvaliteten av dokumentasjonen for dette resultatet er svært lav kan vi ikke avgjøre om tiltaket påvirker bruk av legemidler. • Aktivitetstiltak til beboere gitt sammen med utdanningsmøter for helsepersonell viste ingen statistisk signifikant effekt på bruk av antipsykotika eller antall legemidler totalt. Ettersom kvaliteten av dokumentasjonen for dette resultatet er svært lav kan vi ikke avgjøre om tiltaket påvirker bruk av legemidler. • Kvaliteten av dokumentasjonsgrunnlaget er for lav til å bedømme om tiltak for å redusere antatt uhensiktsmessige legemidler påvirker helseutfall

Effect of interventions to reduce potentially inappropriate use of drugs in nursing homes: a systematic review of randomised controlled trials

Background Studies have shown that residents in nursing homes often are exposed to inappropriate medication. Particular concern has been raised about the consumption of psychoactive drugs, which are commonly prescribed for nursing home residents suffering from dementia. This review is an update of a Norwegian systematic review commissioned by the Norwegian Directorate of Health. The purpose of the review was to identify and summarise the effect of interventions aimed at reducing potentially inappropriate use or prescribing of drugs in nursing homes. Methods We searched for systematic reviews and randomised controlled trials in the Cochrane Library, MEDLINE, EMBASE, ISI Web of Knowledge, DARE and HTA, with the last update in April 2010. Two of the authors independently screened titles and abstracts for inclusion or exclusion. Data on interventions, participants, comparison intervention, and outcomes were extracted from the included studies. Risk of bias and quality of evidence were assessed using the Cochrane Risk of Bias Table and GRADE, respectively. Outcomes assessed were use of or prescribing of drugs (primary) and the health-related outcomes falls, physical limitation, hospitalisation and mortality (secondary). Results Due to heterogeneity in interventions and outcomes, we employed a narrative approach. Twenty randomised controlled trials were included from 1631 evaluated references. Ten studies tested different kinds of educational interventions while seven studies tested medication reviews by pharmacists. Only one study was found for each of the interventions geriatric care teams, early psychiatric intervening or activities for the residents combined with education of health care personnel. Several reviews were identified, but these either concerned elderly in general or did not satisfy all the requirements for systematic reviews. Conclusions Interventions using educational outreach, on-site education given alone or as part of an intervention package and pharmacist medication review may under certain circumstances reduce inappropriate drug use, but the evidence is of low quality. Due to poor quality of the evidence, no conclusions may be drawn about the effect of the other three interventions on drug use, or of either intervention on health-related outcomes

Gender similarities in doctors' preferences -- and gender differences in final specialisation

This article is based on a career history study of gender differences and similarities in recruitment to and transitions between specialities among Norwegian doctors. A questionnaire on career and family history was sent to all Norwegian doctors authorised in 1980-1983. Descriptive statistics and logistic regression were used to describe and analyse completion of specialisation in the specialty in which they started their career. Survival analysis was used to analyse transitions between medical specialities. The findings clearly contradict the idea that the low proportion of women in male dominated areas of medicine reflects women's lack of interest in specialities like surgery and internal medicine. Women were as likely as men to start their career in these fields. The problem is their not completing specialist training. A far higher proportion of men than women completed their specialist training in surgery. The reasons for this are complex. Heavy work loads with duties and "nights on call" make it difficult for women to combine childcare and work and make them change to other specialities. Also, female specialists in surgery and internal medicine postpone having their first child compared to women in other medical specialities. However, the fact that some women change from surgery to gynaecology and obstetrics, a specialty which to a considerable extent are comparable with surgery with regard to duty and work loads, indicate that structural barriers in combining childcare and a hospital career do not fully explain the flux of women. The possible existence of other closure mechanisms in surgery, as indicated by some doctors in this and in other studies, have to be further explored.Medical careers Specialist choice Gender Norway

Women doctors in Norway: the challenging balance between career and family life

In most Western countries, women doctors are still underrepresented in the higher positions in the medical hierarchy and in the most prestigious specialities. A crucial question is whether family responsibilities affect female and male career differently. The article examines how Norwegian physicians balance their work and family responsibilities and demonstrates differences in the way doctors combine work and family obligations, between women and compared with men. Among women doctors, the probability of becoming a specialist decreased with an increasing number of children. Moreover, postponing the birth of the first child increased the probability of completing hospital specialities. Although more women than men work part-time, this was the case only for a small proportion of women doctors. Transition from full-time to part-time work is primarily an accommodating strategy to family responsibilities, however strongly influenced by variations in the opportunity structure of different specialities. The findings further demonstrate that being married to another doctor had a positive impact on the career, especially for women doctors.Medical profession Woman doctors Norway

Medical women -- towards full integration? An analysis of the specialty choices made by two cohorts of Norwegian doctors

In Norway, as in most Western countries, doctors' choice of specialty has been strongly gendered. Female physicians have tended both to specialise to a lesser degree and to enter other specialties than male colleagues. In spite of the increase of women in medicine, previous studies have not managed to show any changes in this pattern. Comparing data from two cohorts of Norwegian doctors, authorised in 1970-73 and 1980-83 respectively, this article demonstrates that changes are in fact taking place. The changes are, however, not unequivocal. Firstly, women in these cohorts specialise to a very high degree and just as much as their male colleagues. Secondly, women doctors of the 1980s cohort spread their choice of specialisation over more fields than their predecessors did. They have, for example, started to enter surgery, although still not as often as men. Thirdly, proportionally more doctors of the 1980s cohort than the 1970s cohort have chosen general practice as their main specialty, and this applies to both women and men. Fourthly, there are tendencies towards an increasing concentration of women in some disciplines such as obstetrics and gynaecology, as well as paediatrics. These changes in doctors' pattern of specialisation are discussed as consequences of socially shaped individual preferences, structural aspects of the Norwegian health system and the existence of gendered closure mechanisms within specific medical fields. Although the medical profession still appears as a gender differentiated community, the article gives a more dynamic and in some respects a more optimistic picture than earlier studies.Medical women Choice of specialty Gender differences Norway

Livspuslespillet

Målet med undersøkelsen har vært å finne virkemidler som kunne akselerere kvinners karriere, som ledere både i privat og offentlig sektor. Undersøkelsen har vært eksplorerende, ikke representativ eller anonym, men ment å være innovativ i forhold til å generere ny kunnskap om hva som kan hjelpe til å vurdere og forbedre balansen mellom arbeids- og familieliv for kvinner som arbeider som ledere. Undersøkelsen omfattet 109 kvinner, 57 mellomledere og 52 toppledere, fordelt på 58 i offentlig sektor og 51 i privat. Undersøkelsen er gjennomført i to omganger som en del av NHOs Female Future-program våren 2007 og som en felles tiltak for de ni andre organisasjonene av parter i arbeidslivet, høsten 2008. Den siste undersøkelsen fikk navnet Livspuslespillet

End-of-life care communications and shared decision-making in Norwegian nursing homes - experiences and perspectives of patients and relatives

Background Involving nursing home patients and their relatives in end-of-life care conversations and treatment decisions has recently gained increased importance in several Western countries. However, there is little knowledge about how the patients themselves and their next-of-kin look upon involvement in end-of-life care decisions. The purpose of this paper is to explore nursing home patients’ and next-of-kin’s experiences with- and perspectives on end-of-life care conversations, information and shared decision-making. Methods The study has a qualitative and explorative design, based on a combination of individual interviews with 35 patients living in six nursing homes and seven focus group interviews with 33 relatives. The data was analysed applying a “bricolage” approach”. Participation was based on informed consent, and the study was approved by the Regional Committees for Medical and Health Research Ethics. Results Few patients and relatives had participated in conversations about end-of-life care. Most relatives wanted such conversations, while the patients’ opinions varied. With some exceptions, patients and relatives wanted to be informed about the patient’s health condition. The majority wanted to be involved in the decision-making process, but leave the final decisions to the health professionals. Among the patients, the opinion varied; some patients wanted to leave the decisions more or less completely to the nursing home staff. Conversations about end-of-life care issues are emotionally challenging, and very few patients had discussed these questions with their family. The relatives’ opinions of the patient’s preferences were mainly based on assumptions; they had seldom talked about this explicitly. Both patients and relatives wanted the staff to raise these questions. Conclusion Nursing home staff should initiate conversations about preferences for end-of-life care, assisting patients and relatives in talking about these issues, while at the same time being sensitive to the diversity in opinions and the timing for such conversations. As the popularity of advance care planning increases in many Western countries, discussions of patients’ and relatives’ perspectives will be of great interest to a broader audience

Refleksjon, handling og mestring

Prosjektet ”Refleksjon, handling og mestring – et forsknings- og utviklingsprosjekt” Steen, Arild Henriktet opp i 2005, og ble avsluttet med et erfaringsseminar i februar 2011. Prosjektet har i hele perioden vært finansiert fra Helsedirektoratet. Tanken bak prosjektet var gjennom et feltbasert forsknings- og utviklingsprosjekt å bidra til økt kunnskap og bedre mestring av det daglige pleie- og omsorgs-arbeidet. Prosjektet har hatt et interaktivt design, og utviklet seg over flere faser. I tett samarbeid med ansatte i sykehjem og hjemmebaserte tjenester i ni kommuner har vi utviklet håndboka ”Hjerte, hode, hender – et refleksjonsverktøy for mestring i pleie- og omsorgstjenesten”, samt drevet opplæring av fasilitatorer til selv å lede refleksjonsgrupper i egen arbeidsorganisasjon. Håndboka er trykket i til sammen 19 000 eksemplarer. Arbeidet i denne sektoren foregår i tett samarbeid med brukerne og er preget av daglige utfordringer det er av stor betydning å mestre på en god måte. Dette er viktig for brukerne og det er viktig for de ansatte. Evalueringen av prosjektet viser at det å delta i gruppene gir opplevelse av økt mestring, i tillegg til at det er positivt for arbeidsmiljøet. Erfaringene fra prosjektet bekrefter at systematisk refleksjon oppleves meningsfullt for de ansatte – og at det bør være en integrert del av virksomheten. Dette forutsetter imidlertid forankring på flere ledelsesnivåer og vilje til å sette av tid og ressurser i en travel hverdag. Se også håndboka ”Hjerte, hode, hender – et refleksjonsverktøy for mestring i pleie- og omsorgstjenesten