A scenario – based assessment of the perceptions towards medical mediation in healthcare professionals: insights from a cross-sectional survey

A scenario – based assessment of the perceptions towards medical mediation in healthcare professionals: insights from a cross-sectional survey | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A scenario – based assessment of the perceptions towards medical mediation in healthcare professionals: insights from a cross-sectional survey Olympia Lioupi, Polychronis Kostoulas, Konstadina Griva, Charalambos Billinis, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8470897/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Medical mediation is a collaborative tool for resolving ethically complex disputes in healthcare. Though widely recognized in international clinical ethics it has only been recently introduced in Greece. The objective of this work was to assess healthcare professionals’ perceptions of medical mediation using a scenario-based survey, A structured, cross-sectional online questionnaire was completed by 431 healthcare professionals across Greece. The survey included three clinical vignettes on (1) end-of-life care, (2) religious refusal of treatment, and (3) medical error disclosure), Likert-scale items on attitudes toward mediation, and demographic information. Latent class analysis (LCA) was used to identify patterns of response across the scenarios and attitudinal items. Participants expressed strong support for mediation across all scenarios (median scores ≥ 9), with the highest support for medical error disclosure. LCA revealed three distinct respondent profiles: strongly supportive (73.3%), moderately supportive (14.6%), and cautiously positive (12.1%). Significant trends were observed across profiles for the perceived effectiveness of mediation and support for institutional training (p < 0.01). However, formal training and familiarity with mediation among the participants were low (< 5%). Despite limited training and formal implementation, Greek healthcare professionals show high support for medical mediation. The demand and need for structured mediation training and integration into the Greek healthcare system is strong. Health Law Medical mediation healthcare conflict clinical ethics Greece scenario-based survey latent class analysis Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Medical mediation is a critical tool for addressing ethical and communication challenges in modern healthcare. In settings where conflicts between patients, families, and healthcare professionals are frequent, mediation offers a structured framework for fostering dialogue, maintaining trust, and achieving ethically sustainable solutions. Globally, its effectiveness has been documented in various contexts, such as end-of-life decisions (Buchanan et al., 2002 ; Donnelly & Walker, 2024 ), religious objections to treatment (Khushf, 2019 ), and the disclosure of medical errors (Gallagher et al., 2018 ; Nakanishi, 2014 ). In countries like the United States and the United Kingdom, mediation has been institutionally recognized as part of clinical ethics support services, playing a decisive role in resolving conflicts in complex clinical cases (Johnson, 2024 ; Lyons et al., 2021 ). Further, several countries, such as Canada (Regis & Poitras, 2010 ), China (Wang et al., 2020 ), Hong Kong (Cheng & le Roux-Kemp, 2017 ), Italy (Mannozzi, 2015 ) and Singapore (Khan et al., 2020 ) among others have been utilizing mediation primarily in conflict resolution or end-of-life settings. In Greece, the application of mediation in general has only been recently introduced in 2010 (Law 3898/2010) on a voluntary basis and was made a mandatory pre‑trial step in 2020 (Law 4640/2019) for commercial trial that cover inter alia, medical‑liability claims. Thus, the implementation of medical mediation in Greece is currently limited. An additional constrain is that under current law it can only be applied in the case of medical errors in private healthcare settings and not in conflicts with the public health sector. Further previous published reports from Greece are limited. The importance of nurses acting as mediators has mediators between physicians and patients in futility cases has been discussed in a recent paper (Voultsos et al., 2021 ), while an earlier report discusses the absence of mediation in transplant-related ethical disputes in Greece (Zanni, 2014 ). Since, mediation has only been introduced recently it remains largely underutilized in the healthcare sector. Nevertheless, healthcare systems in Europe and internationally increasingly recognize the value of structured conflict resolution mechanisms and have introduced institutionalized setting beyond the USA and UK, as is the case, for example, in China, Taiwan and elsewhere. Given the proven uselessness of medical mediation as an alternative dispute resolution in various aspects of healthcare disputes, it is vital to investigate the perceptions and readiness of Greek healthcare professionals to adopt it. This this cross-sectional study aims to fill that gap by exploring the perceptions of healthcare professionals toward medical mediation through a scenario-based survey approach. Specifically, we assessed their responses to three different clinical and we subsequently identified distinct profiles of responses using latent class analysis. Materials and Methods Survey Instrument A structured, self-administered questionnaire was designed to assess perceptions of medical mediation among healthcare professionals. The instrument was developed in Greek and delivered online through a secure survey platform. The full questionnaire is available as Supplementary Material. It consisted of closed-ended items, including Likert-scale, multiple-choice, and categorical responses and was structured into three sections. Participation was anonymous, and no personally identifying information was collected. The questionnaire was disseminated nationwide between January and March 2024 through professional and institutional mailing lists and online communication channels. The primary distribution route was the Medical Association of Athens, the largest professional association of physicians in Greece, which circulated the survey invitation to its members. Additional dissemination occurred through regional health networks and professional groups to ensure inclusion of a broad spectrum of healthcare providers across levels of care. The first section was a scenario-based assessment with three clinical vignettes, each describing a distinct situation where medical mediation might be applicable. Specifically, the scenarios were: 1. Scenario 1: end-of-life decision-making. This was a case of an elderly patient in a persistent vegetative state, where a mediator facilitates consensus among family members with conflicting views, grounded in the patient’s previously expressed wishes and the clinical prognosis. 2. Scenario 2: eligious refusal of treatment. A patient refused a life-saving blood transfusion due to religious beliefs. The mediator works with both the clinical team and a religious leader to identify culturally respectful and clinically acceptable alternatives. 3. Scenario 3: disclosure of medical error. In this case of an intraoperative mistake (a retained surgical sponge) the mediator supports the healthcare team in reaching an ethically sound and empathetic strategy for disclosing the error to the patient and their family. Respondents were asked to rate their agreement with the mediator’s approach in each scenario using a 10-point Likert scale (1 = Strongly Disagree, 10 = Strongly Agree). The second section gathered information on the attitudes, familiarity, and experience with medical mediation and included items assessing (1) the beliefs about the effectiveness of medical mediation in resolving healthcare conflicts, (2) the need to provide training on medical mediation through healthcare institutions should provide training in medical mediation, (3) the self-reported prior involvement in a mediation process, (4) the self-reported familiarity with the concept of medical mediation and (5) whether the respondent had received any training in medical mediation. The third section was on sociodemographic and professional characteristics like age, gender, highest educational attained, years of work experience in the health sector, current role and level of service (e.g., primary, secondary, tertiary care). Finally, the respondents were asked how likely they were to recommend medical mediation to colleagues and their interest in participating in a follow-up qualitative interview (optional, with contact details). This cross-sectional study is reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies (see Supplementary Material). Statistical Analysis Data Preparation Only fully completed questionnaires were included in the analysis. Likert-scale responses for the three clinical scenarios were treated as ordinal numeric variables (1–10). A composite score was calculated as the average of the three scenario ratings, representing overall agreement with the mediator’s approach. The remaining variables were recoded as factors where appropriate, with consistent handling of response scales. Sample size and representativeness The final analytic sample comprised 431 fully completed questionnaires. Given the exploratory nature of this cross-sectional design and the use of non-parametric and latent class analyses, a formal a priori sample-size calculation was not applicable. Instead, adequacy was judged based on established recommendations for psychometric and latent class modeling, where a minimum of 300 observations is considered sufficient for stable class identification and robust convergence in models with up to four latent profiles. The achieved sample exceeded these thresholds and ensured reliable estimation of conditional probabilities and meaningful subgroup comparisons across sociodemographic and attitudinal variables. Moreover, the respondents covered all major healthcare levels (primary, secondary, tertiary), supporting a diverse and reasonably representative profile of the Greek healthcare workforce. Descriptive and Exploratory Analysis Descriptive statistics were computed for all variables with frequencies and percentages for categorical variables and mean (standard deviations) for continuous variables. Bar plots were used to visualize Likert responses that were grouped in three categories for interpretability: Disagree (1–4), Neutral (5–6), Agree (7–10). Internal Consistency and Concordance To assess the coherence of the scenario-based items, we calculated Cronbach’s alpha. To assess whether responses significantly differed across the three scenarios we conducted a Friedman test followed by pairwise Wilcoxon signed-rank tests with Bonferroni adjustment. Latent Class Analysis To identify distinct underlying patterns of response among participants, we performed a Latent Class Analysis (LCA) based on the ratings of the three clinical scenarios and the likelihood of recommending medical mediation. These items were treated as categorical indicators, reflecting respondents’ agreement with the mediator’s approach in each situation. LCA models with 2 to 4 latent classes were fitted using the poLCA package in R, with multiple random starts (nrep) to ensure convergence to a global maximum likelihood solution. Model fit was evaluated using the Bayesian Information Criterion (BIC), Akaike Information Criterion (AIC), and log-likelihood. The selected class solution was based primarily on BIC and AIC minimization and interpretability. Following the selection the optimal number of latent classes, individuals were assigned to their most likely class (modal assignment), and class profiles were interpreted based on conditional response probabilities. Finally, to characterize the identified classes, we compared them on a range of attitudinal, experiential, and demographic variables using Chi-square tests for categorical variables and Kruskal–Wallis tests or Jonckheere–Terpstra tests for ordinal variables. Software All statistical analyses were conducted using R (R Core Team, 2013) within the RStudio environment. The tidyverse suite of packages (Wickham et al., 2019), including dplyr, ggplot2, and tidyr, was used for data manipulation and visualization. We used the using kruskal.test() and JonckheereTerpstraTest() from the DescTools package (Signorell et al., 2019) for ordinal comparisons and the psych package for reliability analysis and the LCA was implemented using the poLCA package (Linzer & Lewis, 2011). Ethics approval statement This research was approved by the Institutional Review Board of [redacted for peer review]. Results A total of 431 healthcare professionals completed the questionnaire. Their responses are summarized in Table 1. The gender distribution was balanced and most respondents were aged between 41 and 60 years (59.4%). In terms of educational attainment, the majority held a bachelor’s (39.2%) or master’s degree (31.1%), while 20.9% had obtained a doctoral degree, and only 8.8% reported postdoctoral training. Nearly two-thirds (64.3%) had more than 15 years of experience in the healthcare sector, were predominantly in medical professions (93.0%), and evenly distributed across the primary (39.0%) and tertiary (43.6%) levels of care, with fewer from secondary care settings (17.4%). More than half of the respondents were not at all familiar, or reported very little familiarity while a small proportion (1.9%) reported being very familiar with MM. In line with this, training on MM was limited, with 80% reporting no training, 16.9% reporting informal training, and only 3% reporting formal training. Nevertheless, 34.1% reported that had participated in a medical mediation process, affirmatively and support for institutional training in MM was overwhelmingly high, with 80.7% agreeing that institutions should always provide such training. Further, the perceived effectiveness of MM in resolving healthcare disputes was high, with 97.2% indicating that it was at least “sometimes” effective and 30.4% indicating it was “always” effective. Table 1. Distribution of sociodemographic, educational, and professional characteristics of participants, and their familiarity with medical mediation (MM). Variable Value Count Percent (%) Sex Female 213 49.4 Male 218 50.6 Age 20–30 years 46 10.7 31–40 years 56 13 41–50 years 133 30.9 51–60 years 123 28.5 61+ years 73 16.9 Education Bachelor’s degree 169 39.2 Master’s degree 134 31.1 Doctorate (PhD) 90 20.9 Postdoctoral studies 38 8.8 Work Experience Less than 1 year 14 3.2 1–5 years 44 10.2 6–10 years 41 9.5 11–15 years 55 12.8 More than 15 years 277 64.3 Type of work Administrative 18 4.2 Allied health roles 12 2.8 Medical professions 401 93 Healthcare level Primary 168 39 Secondary 75 17.4 Tertiary 188 43.6 Familiarity with MM Not at all 110 25.5 Very little 129 29.9 A little 121 28.1 Quite a bit 63 14.6 Very much 8 1.9 Have you participated in MM No 284 65.9 Yes 147 34.1 Should institutions provide training on MM? Never 3 0.7 Rarely 1 0.2 Sometimes 79 18.3 Always 348 80.7 Have you been trained on MM? No 345 80 Yes, informal training 73 16.9 Yes, formal training 13 3 Do you think that MM is an effective tool for Heathcare? Never 2 0.5 Rarely 10 2.3 Sometimes 288 66.8 Always 131 30.4 The participants’ ratings of the mediator’s approach generally revealed high levels of support (Figures 1 & 2). The highest mean score was observed for scenario 3 (medical error disclosure), with a mean of 8.67 (SD = 2.10) and a median of 10, scenario 1 (end-of-life decision-making) received a mean score of 8.22 (SD = 2.52) and a median of 9 and s cenario 2 (religious refusal of treatment) had a lower mean of 7.94 (SD = 2.64) but shared the same median of 9. All scenarios had the full response range from 1 (strongly disagree) to 10 (strongly agree). In line with these, the Friedman test for repeated measures revealed a statistically significant difference in the distribution of responses among the scenarios (χ²(2) = 27.54, p < 0.001). Pairwise comparisons using the Wilcoxon signed-rank test with Bonferroni adjustment revealed that scenario 3 (medical error disclosure) had significantly higher scores than both scenario 1 (end-of-life decision; p = 0.011) and scenario 2 (refusal of treatment due to religious beliefs; p < 0.001), while the difference between scenarios 1 and 2 was borderline significant. (p = 0.050). A Cronbach’s alpha was α = 0.56 (95% CI: 0.49–0.63). Hence, there is modest internal consistency, indicating that while the three items are related, they are not highly interchangeable or reflective of a single underlying construct. Item-wise, all three scenarios showed positive item-total correlations (r = 0.74 for scen_1 and r = 0.67 for scen_3), implying that each contributes positively to the scale. Further, alpha did not increase substantially with the removal of any single item, supporting the view that the scenarios provide complementary, but not redundant, information. Latent Class Analysis (LCA) revealed 3 classes as the optimal number of distinct classes. Thus, three different profiles were formulated based in the ratings for the three clinical scenarios and the likelihood of recommending medical mediation. Class 1, the “Strongly supportive” profile with participants in this class consistently rating the mediator’s approach very positively across all scenarios and having the highest probability of recommending mediation, class 2, the “Moderately supportive” profile with members of this class expressing moderate agreement with the mediator’s role across all scenarios combined with moderate recommendation levels and class 3, the “Cautiously positive” profile showing a mixed support of the different scenarios and their recommendation levels being lower, with a higher probability of selecting “neutral” stance. The conditional response probabilities by class are in Figure 3 the exact probabilities are provided in the supplement. The model-based proportions for each profile were: 16.0% for Moderately supportive, 16.3% for Cautiously positive, and 67.6% for Strongly supportive. A posteriori modal assignment resulted in 14.6% of participants being classified as Moderately supportive (n = 63), 12.1% as Cautiously positive (n = 52), and 73.3% as Strongly supportive (n = 316). Finally, the comparison of the latent classes across the attitudinal and demographic variables, with the Chi-squared and the Jonckheere–Terpstra (JT) tests, revealed that a significant trend for the belief that healthcare institutions should provide mediation training (trainbyinstit, JT p = 0.008) with recorded scores increasing significantly across profiles from Skeptical to Moderate to Supportive. SA similar trend was observed the perceived effectiveness of mediation in healthcare (never, JT p < 0.001) (Figure 4). The variables prior training, familiarity, age, sex, education, work type and level did not reveal significant trends or differences between the three profiles (Detailed reports of all comparison are in the supplement). Discussion This is the first large-scale report on the perceptions towards medical mediation in healthcare professionals in Greece. The questionnaire was officially disseminated by the Athens Medical Association, the largest medical association in the country. Previous studies discussed the important role of nurses acting as mediators between physicians and patients in futility cases (Voultsos et al., 2021 ) and highlighted the lack of bioethical mediation in transplant-related ethical disputes in Greece in contrast to other countries where medical mediation has produced astounding results (Zanni, 2014 ). To the best of our knowledge these are the only studies relating to medical mediation in Greece. Perhaps, the scarcity of relevant literature could be due to the absence of a legislative framework for mediation until recently. In comparison to other EU jurisdictions, Greece adopted mediation relatively late. Specifically, voluntary mediation was first enabled in 2010 (Law 3898/2010), followed by mandatory pre‑trial mediation that was only activated in 2020 (Law 4640/2019) and covers inter alia, medical‑liability claims. Although more than 2 000 mediators have been accredited, and several specialized centers exist there are no available data on the number of conflicts that have been resolved through medical mediation. However, the number is expected to be low given that medical mediation under the current legislative framework can only be applied in the case of medical‑liability claims with private and not public healthcare institutions. Indeed, only 3% of the participants in this study reported formal training on medical mediation and only 1.9% reported being very familiar while 80% reported no training at all, and more than half of the respondents were not familiar. Nevertheless, at least one third of the participants reported that they had participated in an “informal” medical mediation process during their professional life and the affirmative support for the need for institutional training in medical mediation was overwhelmingly high, with 80.7% agreeing that institutions should always provide such training. This demand on medical mediation was also evident from the responses on the three scenarios. Although the overall attitude of Greek Health professionals could be affected by the fact that those who chose to respond may differ systematically from those who did not, there was a consistent pattern of high agreement with the mediator’s approach across the three distinct ethically complex clinical vignettes. In all cases the median value was 9 (i.e., strong support of medical mediation). expected since medical mediation has been documented to play a pivotal role in healthcare by fostering open communication, empathy, and the preservation of relationships between patients and providers (Dimitrov & Miteva-Katrandzhieva, 2024 ; Dubler, 1998 ; Fiester, 2007 ) It has been applied effectively across various domains, including end-of-life care (Buchanan et al., 2002 ), religious objections (Khushf, 2019 ), and medical error disclosure (Wang et al., 2020 ) three domains that correspond to the three scenarios offered to the participants of this study. Although the responses revealed an affirmative stance on medical mediation, they also demonstrated significant differences across the scenarios. Cronbach’s alpha indicated a modest agreement in the participants’ ratings and the response to scenario 3 (medical error disclosure) was significantly higher compared to scenarios 1 and 2 and the difference between scenarios 1 and 2 was borderline significant with scenario 2 (religious refusal of treatment) having the lowest rating. This is expected, since religious objections to treatment present more complex ethical dilemmas, where mediation may face structural limitations because religious language can function as a “conversation stopper,” making compromise more challenging (Khushf, 2019 ). In contrast, medical professionals in Greece see medical mediation as more valuable in the cases of medical errors - scenario 3 - where transparency and restorative dialogue are clearly beneficial (Hyman et al., 2010 ) and institutionalization has been promoted (Chen et al., 2023 ; Gallagher et al., 2018 ; Wang et al., 2020 ). Finally, scenario 1 (end-of-life decision-making) was ranked in the middle. The use of medical mediation in the case of end-of-life dilemmas has been proven to be a constructive way to handle emotionally charged treatment dilemmas, without disrupting the therapeutic alliance between clinicians, patients, and families (Bowman, 2000 ; Donnelly & Walker, 2024 ; Gatter, 1999 ). Furthermore, latent class analysis revealed three profiles of responses in terms of rating the three scenarios and the probability of suggesting mediation: the “Strongly supportive” profile with participants consistently rating the mediator’s approach very positively across all scenarios and having the highest probability of recommending mediation, the “Moderately supportive” profile with members of this class expressing moderate agreement with the mediator’s role across all scenarios combined with moderate recommendation levels and the “Cautiously positive” profile showing a mixed support of the different scenarios and their recommendation levels being lower, with a higher probability of selecting “neutral” stance. Importantly, a posteriori modal assignment resulted in most of the participants 73.3% (n = 316) classified as strongly supportive, which further confirms the demand of medical mediation by health professionals. Notably, there was no difference in the training and familiarity levels (because both were very low) or in the demographic characteristics (age, sex, education, work type and level) between the profiles. This pattern is consistent with international evidence that attitudes toward conflict‑resolution tools are often shaped far more by experiential and value‑based factors than by sociodemographic traits. Indeed, these belief‑driven differences were underscored by the significant trend we observed: from the Skeptical to the Moderate to the Supportive profile, the proportion of respondents who (i) view mediation as an effective tool and (ii) endorse mandatory institutional training had a significant upward trend. This study has limitations that should be acknowledged. First, participation was voluntary and conducted online, which may have introduced self-selection bias, as respondents more supportive of mediation could have been more likely to complete the survey. Secondly, all data were self-reported, and measures of familiarity or prior involvement in mediation processes may be affected by recall or social desirability bias. Finally, although the sample was relatively large, it may not fully represent healthcare professionals working in rural or underserved areas. Despite these limitations, the internal consistency of responses and the clear latent class structure observed suggest that the findings reliably capture prevailing perceptions of medical mediation among Greek healthcare professionals. Thus, this work provides information on the attitude of health professionals towards medical mediation which is an internationally proven effective tool of conflict resolution in healthcare. Greek health professionals believe in the usefulness of medical mediation and on the need of training on the field. This information can be useful to health policy makers towards the development of a properly structured approach for the resolution of disputes in healthcare. Declarations Participant consent statement: This study was a non-interventional, cross-sectional survey conducted exclusively through an anonymous, self-administered online questionnaire addressed to healthcare professionals. Participation was entirely voluntary. At the beginning of the questionnaire, participants were informed about the purpose of the study, the anonymous and confidential nature of data collection, and the use of the data solely for research purposes. No personal or sensitive identifying information was collected. Informed consent was implied by the voluntary completion of the questionnaire. The study protocol was approved by the University of Thessaly Ethics Committee. Author Contributions Conceptualization, O.L. and C.T..; Methodology, O.L. and P.K.; Formal Analysis, P.K.; Investigation and Data Curation, O.L.; Writing - Original Draft Preparation, O.L.; Writing -Review and Editing, C.T. and K.G.; Supervision, K.G. and C.T.; Resources and Institutional Support, C.B. All authors have read and approved the final manuscript. Funding This research received no external funding. Competing Interests The authors declare no competing interests. Ethics Approval This study was approved by the University of Thessaly Ethics Committee (Approval No. UTH-DEY/EC/2023-12-08; Date: 2023-12-08). Acknowledgments and AI Use Disclosure During the preparation of this manuscript, the authors used ChatGPT (GPT-5, OpenAI, 2025) to assist with English-language editing, figure formatting, and data visualization. All outputs were reviewed, verified, and revised by the authors, who take full responsibility for the content and integrity of this publication. References Bowman, K. W. (2000). Communication, negotiation, and mediation: Dealing with conflict in end-of-life decisions. Journal of Palliative Care , 16 Suppl , S17-23. Buchanan, S. F., Desrochers, J. M., Henry, D. B., Thomassen, G., & Barrett, P. H. J. (2002). A mediation/medical advisory panel model for resolving disputes about end-of-life care. The Journal of Clinical Ethics , 13 (3), 188–202. Chen, P.-Y., Fu, C.-P., & Wang, C.-C. (2023). Narratives in the medicolegal field from the perspective of physicians involved in medical dispute mediation meetings in Taiwan. Heliyon , 9 (2), e13716. https://doi.org/10.1016/j.heliyon.2023.e13716 Cheng, K. K., & le Roux-Kemp, A. (2017). Mediation and resolving disputes involving emergency nurses in Hong Kong: A legal empirical inquiry. Hong Kong Law Journal , 47 , 763–791. Scopus. Dimitrov, K., & Miteva-Katrandzhieva, T. (2024). Mediation in Healthcare: Enhancing Conflict Resolution Between Patients and Physicians Beyond the Courtroom. Cureus , 16 (12), e75487. https://doi.org/10.7759/cureus.75487 Donnelly, S., & Walker, S. (2024). Enabling first and second year doctors to negotiate ethical challenges in end-of-life care: A qualitative study. BMJ Supportive & Palliative Care , 14 (e3), e2595–e2602. https://doi.org/10.1136/bmjspcare-2020-002672 Dubler, N. N. (1998). Mediation and managed care. Journal of the American Geriatrics Society , 46 (3), 359–364. https://doi.org/10.1111/j.1532-5415.1998.tb01054.x Fiester, A. (2007). Mediation and moral aporia. The Journal of Clinical Ethics , 18 (4), 355–356. Gallagher, T. H., Mello, M. M., Sage, W. M., Bell, S. K., McDonald, T. B., & Thomas, E. J. (2018). Can Communication-And-Resolution Programs Achieve Their Potential? Five Key Questions. Health Affairs (Project Hope) , 37 (11), 1845–1852. https://doi.org/10.1377/hlthaff.2018.0727 Gatter, R. (1999). Unnecessary adversaries at the end of life: Mediating end-of-life treatment disputes to prevent erosion of physician-patient relationships. Boston University Law Review. Boston University. School of Law , 79 (5), 1091–1137. Hyman, C. S., Liebman, C. B., Schechter, C. B., & Sage, W. M. (2010). Interest-based mediation of medical malpractice lawsuits: A route to improved patient safety? Journal of Health Politics, Policy and Law , 35 (5), 797–828. https://doi.org/10.1215/03616878-2010-028 Johnson, S. W. (2024). Mediation As An Alternative Dispute Resolution Tool In Healthcare Malpractice . Khan, H. A., Bastiampillai, A., & Mon, S. W. (2020). Mediation as a suitable dispute resolution method in medical negligence cases: Special reference to the Malaysian position. Pertanika Journal of Social Sciences and Humanities , 28 (3), 2309–2323. Khushf, G. (2019). When Religious Language Blocks Discussion About Health Care Decision Making. HEC Forum : An Interdisciplinary Journal on Hospitals’ Ethical and Legal Issues , 31 (2), 151–166. https://doi.org/10.1007/s10730-019-09371-x Linzer, D. A., & Lewis, J. B. (2011). poLCA: An R package for polytomous variable latent class analysis. Journal of Statistical Software , 42 , 1–29. Lyons, O., Forbat, L., Menson, E., Chisholm, J. C., Pryde, K., Conlin, S., Felton, V., Ingle, S., McKenzie, C., Ramachandran, R., Sayer, C., Snowball, C., Strachan-Gadsby, E., Tisovszky, N., & Barclay, S. (2021). Transforming training into practice with the conflict management framework: A mixed methods study. BMJ Paediatrics Open , 5 (1), e001088. https://doi.org/10.1136/bmjpo-2021-001088 Mannozzi, G. (2015). Mediating conflicts in the medical sector: General considerations from the Italian perspective. Global Jurist , 15 (3), 291–327. Nakanishi, T. (2014). Disclosing unavoidable causes of adverse events improves patients’ feelings towards doctors. The Tohoku Journal of Experimental Medicine , 234 (2), 161–168. https://doi.org/10.1620/tjem.234.161 R Core Team, R. (2013). R: A language and environment for statistical computing . Regis, C., & Poitras, J. (2010). Healthcare mediation and the need for apologies. Health Law Journal , 18 , 31–49. Scopus. Signorell, A., Aho, K., Alfons, A., Anderegg, N., Aragon, T., Arppe, A., Baddeley, A., Barton, K., Bolker, B., & Borchers, H. W. (2019). DescTools: Tools for descriptive statistics. R Package Version 0.99 , 28 , 17. Voultsos, P., Tsompanian, A., & Tsaroucha, A. K. (2021). The medical futility experience of nursing professionals in Greece. BMC Nursing , 20 (1), 254. https://doi.org/10.1186/s12912-021-00785-y Wang, M., Liu, G. G., Zhao, H., Butt, T., Yang, M., & Cui, Y. (2020). The role of mediation in solving medical disputes in China. BMC Health Services Research , 20 (1), 225. https://doi.org/10.1186/s12913-020-5044-7 Wickham, H., Averick, M., Bryan, J., Chang, W., McGowan, L. D., François, R., Grolemund, G., Hayes, A., Henry, L., & Hester, J. (2019). Welcome to the Tidyverse. Journal of Open Source Software , 4 (43), 1686. Zanni, A. (2014). Organ transplantation in Greece: The need for mediation. Transplantation Proceedings , 46 (9), 3164–3167. https://doi.org/10.1016/j.transproceed.2014.09.157 Additional Declarations The authors declare no competing interests. Supplementary Files STROBEmedmed.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8470897","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":566699520,"identity":"def2d503-9c39-4749-9497-f3433e5601b0","order_by":0,"name":"Olympia Lioupi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAp0lEQVRIiWNgGAWjYDACdsYGICkhx8DAQ6wWZogWYwY24rVAqMQGorXwMzM3PubdYZG+4X7vAcave4jQItnM2GzMe0Yid8MxvgRmmWdEaDE4zNgmzdsG0sJjwCxxgAQt6QYka0kAaWH8QIwWkF8M556RMJx5LMfgMAMxWvjZ2x8+eLujTp7v8BnDhz+I0QIG4NgEgsNExyZcC+MPorWMglEwCkbBSAIA8iQxakfrRngAAAAASUVORK5CYII=","orcid":"","institution":"University of Thessaly","correspondingAuthor":true,"prefix":"","firstName":"Olympia","middleName":"","lastName":"Lioupi","suffix":""},{"id":566699521,"identity":"4d25b335-4f86-47f4-ad98-4fa5332f7b64","order_by":1,"name":"Polychronis Kostoulas","email":"","orcid":"","institution":"University of Thessaly","correspondingAuthor":false,"prefix":"","firstName":"Polychronis","middleName":"","lastName":"Kostoulas","suffix":""},{"id":566699522,"identity":"b52fe3dc-6e6d-4d24-84c4-0cbbbf53c445","order_by":2,"name":"Konstadina Griva","email":"","orcid":"","institution":"Nanyang Technological University","correspondingAuthor":false,"prefix":"","firstName":"Konstadina","middleName":"","lastName":"Griva","suffix":""},{"id":566699523,"identity":"89d83d7b-aecf-4b03-8c5c-d8aba049691d","order_by":3,"name":"Charalambos Billinis","email":"","orcid":"","institution":"University of Thessaly","correspondingAuthor":false,"prefix":"","firstName":"Charalambos","middleName":"","lastName":"Billinis","suffix":""},{"id":566699524,"identity":"3921b033-5ff0-42eb-b829-c7c119c390e7","order_by":4,"name":"Costas Tsiamis","email":"","orcid":"","institution":"University of Thessaly","correspondingAuthor":false,"prefix":"","firstName":"Costas","middleName":"","lastName":"Tsiamis","suffix":""}],"badges":[],"createdAt":"2025-12-29 08:32:34","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8470897/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8470897/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":99746507,"identity":"8e7dab3b-f785-4aaf-8619-9b9dd4fb003a","added_by":"auto","created_at":"2026-01-08 02:29:45","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":572148,"visible":true,"origin":"","legend":"","description":"","filename":"medmedqforeditors.docx","url":"https://assets-eu.researchsquare.com/files/rs-8470897/v1/5c728721fa5c6b41e99b93ac.docx"},{"id":99746511,"identity":"be1cfd5a-6150-40d7-aff0-243045317475","added_by":"auto","created_at":"2026-01-08 02:29:46","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":342,"visible":true,"origin":"","legend":"","description":"","filename":"rs8470897.json","url":"https://assets-eu.researchsquare.com/files/rs-8470897/v1/9c69744c0e5f255132042050.json"},{"id":99746516,"identity":"8ffab1e0-4594-47d1-9b2f-10fb2a42cea3","added_by":"auto","created_at":"2026-01-08 02:29:46","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":84528,"visible":true,"origin":"","legend":"","description":"","filename":"rs84708970enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8470897/v1/d847ac4cc437d751b7d304cf.xml"},{"id":99746503,"identity":"43e87be9-c322-4467-bf70-967ef94cefec","added_by":"auto","created_at":"2026-01-08 02:29:45","extension":"jpeg","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":285247,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8470897/v1/0c9d8c40d4521fa64527b063.jpeg"},{"id":99746518,"identity":"d2ab964e-fb7a-40c6-84ef-ca15be8d84bd","added_by":"auto","created_at":"2026-01-08 02:29:46","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":109386,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8470897/v1/30322ce0f8a1acd532a460d9.png"},{"id":99746513,"identity":"4f63506d-cab3-49c8-b1f9-cc292ebde7a7","added_by":"auto","created_at":"2026-01-08 02:29:46","extension":"jpeg","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":427217,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8470897/v1/74a29a766935560ff8390164.jpeg"},{"id":99797248,"identity":"34b9b148-e07c-49ac-bd37-482feeebc35d","added_by":"auto","created_at":"2026-01-08 13:45:29","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":120288,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8470897/v1/62f9da6a955d82e21259975a.png"},{"id":99746506,"identity":"64de816f-7bc7-49a4-a978-c3035953d036","added_by":"auto","created_at":"2026-01-08 02:29:45","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":50318,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8470897/v1/d0a73ade36eb23139ae1e633.png"},{"id":99746515,"identity":"1f6726df-5f5b-4980-965f-fa9c68f25747","added_by":"auto","created_at":"2026-01-08 02:29:46","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":32420,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8470897/v1/3b9003f6a082cb117b589d95.png"},{"id":99746509,"identity":"f9de8484-2668-4393-9326-6b25845c1657","added_by":"auto","created_at":"2026-01-08 02:29:46","extension":"png","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":55633,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8470897/v1/0d2316f778fdbbe9302bc926.png"},{"id":99746505,"identity":"9391eafb-8eb1-4472-a71e-6e150863e772","added_by":"auto","created_at":"2026-01-08 02:29:45","extension":"png","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":42070,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8470897/v1/ba6a65c56a524edc0c0b2fa9.png"},{"id":99746508,"identity":"401eda35-f9db-4b7a-9e4c-08b014b2c2a1","added_by":"auto","created_at":"2026-01-08 02:29:45","extension":"xml","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":82571,"visible":true,"origin":"","legend":"","description":"","filename":"rs84708970structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8470897/v1/628d527bfdcd66ef24e75aa6.xml"},{"id":99746519,"identity":"873e1be6-06e9-48b7-af0d-d4c52ab2d44e","added_by":"auto","created_at":"2026-01-08 02:29:46","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":90374,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8470897/v1/c35a81fcb2d39ff06fd6b9fd.html"},{"id":99746502,"identity":"c4194143-7e36-4fdd-b0e6-531810432e68","added_by":"auto","created_at":"2026-01-08 02:29:44","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":39963,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of Agreement Scores Across Clinical Scenarios\u003c/p\u003e","description":"","filename":"Fig1medmed.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8470897/v1/eaa841eb30c23b716299462e.jpg"},{"id":99746517,"identity":"e0e1343a-0898-4ebe-9321-5de25bf62136","added_by":"auto","created_at":"2026-01-08 02:29:46","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":39963,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of Agreement Scores Across Clinical Scenarios\u003c/p\u003e","description":"","filename":"Fig1medmed.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8470897/v1/779d7db25b2214c7c8502a38.jpg"},{"id":99798554,"identity":"917ee875-ef0c-4402-864b-95250c3a2906","added_by":"auto","created_at":"2026-01-08 13:48:36","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":64913,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of the conditional probabilities among the “Moderate”, “Sceptical” and “Supportive” profiles by scenario and the willingness to suggest mediation.\u003c/p\u003e","description":"","filename":"Fig3medmed.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8470897/v1/a97987cf8f264b950c14655a.jpg"},{"id":99798230,"identity":"e49fc8f2-39b6-4c3c-85b2-5b5b874f594a","added_by":"auto","created_at":"2026-01-08 13:47:40","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":55691,"visible":true,"origin":"","legend":"\u003cp\u003eBelief the MM is effective, and the need of Institutional support od MM training for each profile.\u003c/p\u003e","description":"","filename":"Fig4medmed.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8470897/v1/1c1962e4210dd68b2c851670.jpg"},{"id":99805633,"identity":"86bfa24d-c8cd-448b-8ddf-b1f33f9f47d5","added_by":"auto","created_at":"2026-01-08 14:16:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":834568,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8470897/v1/f8c1e9b9-2f13-4c38-a076-35032dfed494.pdf"},{"id":99746512,"identity":"8c5ef778-1708-47c6-9016-7c557f6a12a8","added_by":"auto","created_at":"2026-01-08 02:29:46","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":33532,"visible":true,"origin":"","legend":"","description":"","filename":"STROBEmedmed.docx","url":"https://assets-eu.researchsquare.com/files/rs-8470897/v1/e32c27a4486ce26ddf3eb88e.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eA scenario – based assessment of the perceptions towards medical mediation in healthcare professionals: insights from a cross-sectional survey\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMedical mediation is a critical tool for addressing ethical and communication challenges in modern healthcare. In settings where conflicts between patients, families, and healthcare professionals are frequent, mediation offers a structured framework for fostering dialogue, maintaining trust, and achieving ethically sustainable solutions. Globally, its effectiveness has been documented in various contexts, such as end-of-life decisions (Buchanan et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; Donnelly \u0026amp; Walker, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), religious objections to treatment (Khushf, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), and the disclosure of medical errors (Gallagher et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Nakanishi, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). In countries like the United States and the United Kingdom, mediation has been institutionally recognized as part of clinical ethics support services, playing a decisive role in resolving conflicts in complex clinical cases (Johnson, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Lyons et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Further, several countries, such as Canada (Regis \u0026amp; Poitras, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2010\u003c/span\u003e), China (Wang et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), Hong Kong (Cheng \u0026amp; le Roux-Kemp, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), Italy (Mannozzi, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) and Singapore (Khan et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) among others have been utilizing mediation primarily in conflict resolution or end-of-life settings.\u003c/p\u003e \u003cp\u003eIn Greece, the application of mediation in general has only been recently introduced in 2010 (Law 3898/2010) on a voluntary basis and was made a mandatory pre‑trial step in 2020 (Law 4640/2019) for commercial trial that cover inter alia, medical‑liability claims. Thus, the implementation of medical mediation in Greece is currently limited. An additional constrain is that under current law it can only be applied in the case of medical errors in private healthcare settings and not in conflicts with the public health sector. Further previous published reports from Greece are limited. The importance of nurses acting as mediators has mediators between physicians and patients in futility cases has been discussed in a recent paper (Voultsos et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), while an earlier report discusses the absence of mediation in transplant-related ethical disputes in Greece (Zanni, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Since, mediation has only been introduced recently it remains largely underutilized in the healthcare sector. Nevertheless, healthcare systems in Europe and internationally increasingly recognize the value of structured conflict resolution mechanisms and have introduced institutionalized setting beyond the USA and UK, as is the case, for example, in China, Taiwan and elsewhere. Given the proven uselessness of medical mediation as an alternative dispute resolution in various aspects of healthcare disputes, it is vital to investigate the perceptions and readiness of Greek healthcare professionals to adopt it.\u003c/p\u003e \u003cp\u003eThis this cross-sectional study aims to fill that gap by exploring the perceptions of healthcare professionals toward medical mediation through a scenario-based survey approach. Specifically, we assessed their responses to three different clinical and we subsequently identified distinct profiles of responses using latent class analysis.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSurvey Instrument\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA structured, self-administered questionnaire was designed to assess perceptions of medical mediation among healthcare professionals. The instrument was developed in Greek and delivered online through a secure survey platform. The full questionnaire is available as Supplementary Material. It consisted of closed-ended items, including Likert-scale, multiple-choice, and categorical responses and was structured into three sections. Participation was anonymous, and no personally identifying information was collected.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe questionnaire was disseminated nationwide between January and March 2024 through professional and institutional mailing lists and online communication channels. The primary distribution route was the Medical Association of Athens, the largest professional association of physicians in Greece, which circulated the survey invitation to its members. Additional dissemination occurred through regional health networks and professional groups to ensure inclusion of a broad spectrum of healthcare providers across levels of care.\u003c/p\u003e\n\u003cp\u003eThe first section was a scenario-based assessment with three clinical vignettes, each describing a distinct situation where medical mediation might be applicable. Specifically, the scenarios were:\u003c/p\u003e\n\u003cp\u003e1. Scenario 1: end-of-life decision-making. This was a case of an elderly patient in a persistent vegetative state, where a mediator facilitates consensus among family members with conflicting views, grounded in the patient\u0026rsquo;s previously expressed wishes and the clinical prognosis.\u003c/p\u003e\n\u003cp\u003e2. Scenario 2: eligious refusal of treatment. A patient refused a life-saving blood transfusion due to religious beliefs. The mediator works with both the clinical team and a religious leader to identify culturally respectful and clinically acceptable alternatives.\u003c/p\u003e\n\u003cp\u003e3. Scenario 3: disclosure of medical error. In this case of an intraoperative mistake (a retained surgical sponge) the mediator supports the healthcare team in reaching an ethically sound and empathetic strategy for disclosing the error to the patient and their family.\u003c/p\u003e\n\u003cp\u003eRespondents were asked to rate their agreement with the mediator\u0026rsquo;s approach in each scenario using a 10-point Likert scale (1 = Strongly Disagree, 10 = Strongly Agree).\u003c/p\u003e\n\u003cp\u003eThe second section gathered information on the attitudes, familiarity, and experience with medical mediation and included items assessing (1) the beliefs about the effectiveness of medical mediation in resolving healthcare conflicts, (2) the need \u0026nbsp; to provide training on medical mediation through healthcare institutions should provide training in medical mediation, (3) the self-reported prior involvement in a mediation process, (4) the self-reported familiarity with the concept of medical mediation and (5) whether the respondent had received any training in medical mediation.\u003c/p\u003e\n\u003cp\u003eThe third section was on sociodemographic and professional characteristics like age, gender, highest educational attained, years of work experience in the health sector, current role and level of service (e.g., primary, secondary, tertiary care).\u003c/p\u003e\n\u003cp\u003eFinally, the respondents were asked how likely they were to recommend medical mediation to colleagues and their interest in participating in a follow-up qualitative interview (optional, with contact details).\u003c/p\u003e\n\u003cp\u003eThis cross-sectional study is reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies (see Supplementary Material).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStatistical Analysis\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Preparation\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOnly fully completed questionnaires were included in the analysis. Likert-scale responses for the three clinical scenarios were treated as ordinal numeric variables (1\u0026ndash;10). A composite score was calculated as the average of the three scenario ratings, representing overall agreement with the mediator\u0026rsquo;s approach. The remaining variables were recoded as factors where appropriate, with consistent handling of response scales.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSample size and representativeness\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe final analytic sample comprised 431 fully completed questionnaires. Given the exploratory nature of this cross-sectional design and the use of non-parametric and latent class analyses, a formal a priori sample-size calculation was not applicable. Instead, adequacy was judged based on established recommendations for psychometric and latent class modeling, where a minimum of 300 observations is considered sufficient for stable class identification and robust convergence in models with up to four latent profiles. The achieved sample exceeded these thresholds and ensured reliable estimation of conditional probabilities and meaningful subgroup comparisons across sociodemographic and attitudinal variables. Moreover, the respondents covered all major healthcare levels (primary, secondary, tertiary), supporting a diverse and reasonably representative profile of the Greek healthcare workforce.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDescriptive and Exploratory Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were computed for all variables with frequencies and percentages for categorical variables and mean (standard deviations) for continuous variables. Bar plots were used to visualize Likert responses that were grouped in three categories for interpretability: Disagree (1\u0026ndash;4), Neutral (5\u0026ndash;6), Agree (7\u0026ndash;10).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInternal Consistency and Concordance\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo assess the coherence of the scenario-based items, we calculated Cronbach\u0026rsquo;s alpha. To assess whether responses significantly differed across the three scenarios we conducted a Friedman test followed by pairwise Wilcoxon signed-rank tests with Bonferroni adjustment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLatent Class Analysis\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo identify distinct underlying patterns of response among participants, we performed a Latent Class Analysis (LCA) based on the ratings of the three clinical scenarios and the likelihood of recommending medical mediation. These items were treated as categorical indicators, reflecting respondents\u0026rsquo; agreement with the mediator\u0026rsquo;s approach in each situation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLCA models with 2 to 4 latent classes were fitted using the poLCA package in R, with multiple random starts (nrep) to ensure convergence to a global maximum likelihood solution. Model fit was evaluated using the Bayesian Information Criterion (BIC), Akaike Information Criterion (AIC), and log-likelihood. The selected class solution was based primarily on BIC and AIC minimization and interpretability. Following the selection the optimal number of latent classes, individuals were assigned to their most likely class (modal assignment), and class profiles were interpreted based on conditional response probabilities. Finally, to characterize the identified classes, we compared them on a range of attitudinal, experiential, and demographic variables using Chi-square tests for categorical variables and Kruskal\u0026ndash;Wallis tests or Jonckheere\u0026ndash;Terpstra tests for ordinal variables. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSoftware\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll statistical analyses were conducted using R (R Core Team, 2013) within the RStudio environment. The tidyverse suite of packages (Wickham et al., 2019), including dplyr, ggplot2, and tidyr, was used for data manipulation and visualization. We used the using kruskal.test() and JonckheereTerpstraTest() from the DescTools package (Signorell et al., 2019) for ordinal comparisons and the psych package for reliability analysis and the LCA was implemented using the poLCA package (Linzer \u0026amp; Lewis, 2011). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthics approval statement\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis research was approved by the Institutional Review Board of [redacted for peer review].\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 431 healthcare professionals completed the questionnaire. Their responses are summarized in Table 1. The gender distribution was balanced and most respondents were aged between 41 and 60 years (59.4%). In terms of educational attainment, the majority held a bachelor\u0026rsquo;s (39.2%) or master\u0026rsquo;s degree (31.1%), while 20.9% had obtained a doctoral degree, and only 8.8% reported postdoctoral training. Nearly two-thirds (64.3%) had more than 15 years of experience in the healthcare sector, were predominantly in medical professions (93.0%), and evenly distributed across the primary (39.0%) and tertiary (43.6%) levels of care, with fewer from secondary care settings (17.4%). More than half of the respondents were not at all familiar, or reported very little familiarity while a small proportion (1.9%) reported being very familiar with MM. In line with this, training on MM was limited, with 80% reporting no training, 16.9% reporting informal training, and only 3% reporting formal training. Nevertheless, 34.1% reported that had participated in a medical mediation process, affirmatively and support for institutional training in MM was overwhelmingly high, with 80.7% agreeing that institutions should always provide such training. Further, the perceived effectiveness of MM in resolving healthcare disputes was high, with 97.2% indicating that it was at least \u0026ldquo;sometimes\u0026rdquo; effective and 30.4% indicating it was \u0026ldquo;always\u0026rdquo; effective.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1. Distribution of sociodemographic, educational, and professional characteristics of participants, and their familiarity with medical mediation (MM).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"568\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCount\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercent\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e213\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e49.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e218\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e50.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003e20\u0026ndash;30 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e10.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003e31\u0026ndash;40 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003e41\u0026ndash;50 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e133\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e30.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003e51\u0026ndash;60 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e28.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003e61+ years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e16.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e169\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e39.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eMaster\u0026rsquo;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e31.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eDoctorate (PhD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e20.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003ePostdoctoral studies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e8.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWork Experience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eLess than 1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003e1\u0026ndash;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003e11\u0026ndash;15 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e12.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eMore than 15 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e277\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e64.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of work\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eAdministrative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eAllied health roles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eMedical professions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e401\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealthcare level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e168\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e17.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e188\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e43.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamiliarity with MM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eNot at all\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e25.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eVery little\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e129\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e29.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eA little\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e28.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eQuite a bit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e14.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eVery much\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHave you participated in MM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e284\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e65.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e34.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eShould institutions provide training on MM?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eRarely\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eSometimes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e18.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eAlways\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e348\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e80.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHave you been trained on MM?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e345\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eYes, informal training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e16.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eYes, formal training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDo you think that MM is an effective tool for Heathcare?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eRarely\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eSometimes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e288\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e66.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34.2707%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8893%;\"\u003e\n \u003cp\u003eAlways\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.6292%;\"\u003e\n \u003cp\u003e131\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.2109%;\"\u003e\n \u003cp\u003e30.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe participants\u0026rsquo; ratings of the mediator\u0026rsquo;s approach generally revealed high levels of support (Figures 1 \u0026amp; 2). The highest mean score was observed for \u003cem\u003escenario 3\u003c/em\u003e (medical error disclosure), with a mean of 8.67 (SD = 2.10) and a median of 10, \u003cem\u003escenario 1\u003c/em\u003e (end-of-life decision-making) received a mean score of 8.22 (SD = 2.52) and a median of 9 and s\u003cem\u003ecenario 2\u003c/em\u003e (religious refusal of treatment) had a lower mean of 7.94 (SD = 2.64) but shared the same median of 9. All scenarios had the full response range from 1 (strongly disagree) to 10 (strongly agree).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn line with these, the Friedman test for repeated measures revealed a statistically significant difference in the distribution of responses among the scenarios (\u0026chi;\u0026sup2;(2) = 27.54, p \u0026lt; 0.001). Pairwise comparisons using the Wilcoxon signed-rank test with Bonferroni adjustment revealed that scenario 3 (medical error disclosure) had significantly higher scores than both scenario 1 (end-of-life decision; p = 0.011) and scenario 2 (refusal of treatment due to religious beliefs; p \u0026lt; 0.001), while the difference between scenarios 1 and 2 was borderline significant. (p = 0.050).\u003c/p\u003e\n\u003cp\u003eA Cronbach\u0026rsquo;s alpha was \u0026alpha; = 0.56 (95% CI: 0.49\u0026ndash;0.63). Hence, there is modest internal consistency, indicating that while the three items are related, they are not highly interchangeable or reflective of a single underlying construct. Item-wise, all three scenarios showed positive item-total correlations (r = 0.74 for scen_1 and r = 0.67 for scen_3), implying that each contributes positively to the scale. Further, alpha did not increase substantially with the removal of any single item, supporting the view that the scenarios provide complementary, but not redundant, information.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLatent Class Analysis (LCA) revealed 3 classes as the optimal number of distinct classes. Thus, three different profiles were formulated based in the ratings for the three clinical scenarios and the likelihood of recommending medical mediation. Class 1, the \u0026ldquo;Strongly supportive\u0026rdquo; profile with participants in this class consistently rating the mediator\u0026rsquo;s approach very positively across all scenarios and having the highest probability of recommending mediation, class 2, the \u0026ldquo;Moderately supportive\u0026rdquo; profile with members of this class expressing moderate agreement with the mediator\u0026rsquo;s role across all scenarios combined with moderate recommendation levels and class 3, the \u0026ldquo;Cautiously positive\u0026rdquo; profile showing a mixed support of the different scenarios and their recommendation levels being lower, with a higher probability of selecting \u0026ldquo;neutral\u0026rdquo; stance. The conditional response probabilities by class are in Figure 3 the exact probabilities are provided in the supplement. The model-based proportions for each profile were: 16.0% for Moderately supportive, 16.3% for Cautiously positive, and 67.6% for Strongly supportive. A posteriori modal assignment resulted in 14.6% of participants being classified as Moderately supportive (n = 63), 12.1% as Cautiously positive (n = 52), and 73.3% as Strongly supportive (n = 316).\u003c/p\u003e\n\u003cp\u003eFinally, the comparison of the latent classes across the attitudinal and demographic variables, with the Chi-squared and the Jonckheere\u0026ndash;Terpstra (JT) tests, revealed that a significant trend for the belief that healthcare institutions should provide mediation training (trainbyinstit, JT p = 0.008) with recorded scores increasing significantly across profiles from Skeptical to Moderate to Supportive. SA similar trend was observed the perceived effectiveness of mediation in healthcare (never, JT p \u0026lt; 0.001) (Figure 4). The variables prior training, familiarity, age, sex, education, work type and level did not reveal significant trends or differences between the three profiles (Detailed reports of all comparison are in the supplement).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is the first large-scale report on the perceptions towards medical mediation in healthcare professionals in Greece. The questionnaire was officially disseminated by the Athens Medical Association, the largest medical association in the country. Previous studies discussed the important role of nurses acting as mediators between physicians and patients in futility cases (Voultsos et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) and highlighted the lack of bioethical mediation in transplant-related ethical disputes in Greece in contrast to other countries where medical mediation has produced astounding results (Zanni, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). To the best of our knowledge these are the only studies relating to medical mediation in Greece. Perhaps, the scarcity of relevant literature could be due to the absence of a legislative framework for mediation until recently. In comparison to other EU jurisdictions, Greece adopted mediation relatively late. Specifically, voluntary mediation was first enabled in 2010 (Law 3898/2010), followed by mandatory pre‑trial mediation that was only activated in 2020 (Law 4640/2019) and covers inter alia, medical‑liability claims. Although more than 2 000 mediators have been accredited, and several specialized centers exist there are no available data on the number of conflicts that have been resolved through medical mediation. However, the number is expected to be low given that medical mediation under the current legislative framework can only be applied in the case of medical‑liability claims with private and not public healthcare institutions. Indeed, only 3% of the participants in this study reported formal training on medical mediation and only 1.9% reported being very familiar while 80% reported no training at all, and more than half of the respondents were not familiar. Nevertheless, at least one third of the participants reported that they had participated in an \u0026ldquo;informal\u0026rdquo; medical mediation process during their professional life and the affirmative support for the need for institutional training in medical mediation was overwhelmingly high, with 80.7% agreeing that institutions should always provide such training.\u003c/p\u003e \u003cp\u003eThis demand on medical mediation was also evident from the responses on the three scenarios. Although the overall attitude of Greek Health professionals could be affected by the fact that those who chose to respond may differ systematically from those who did not, there was a consistent pattern of high agreement with the mediator\u0026rsquo;s approach across the three distinct ethically complex clinical vignettes. In all cases the median value was 9 (i.e., strong support of medical mediation). expected since medical mediation has been documented to play a pivotal role in healthcare by fostering open communication, empathy, and the preservation of relationships between patients and providers (Dimitrov \u0026amp; Miteva-Katrandzhieva, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Dubler, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e1998\u003c/span\u003e; Fiester, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2007\u003c/span\u003e) It has been applied effectively across various domains, including end-of-life care (Buchanan et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2002\u003c/span\u003e), religious objections (Khushf, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), and medical error disclosure (Wang et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) three domains that correspond to the three scenarios offered to the participants of this study. Although the responses revealed an affirmative stance on medical mediation, they also demonstrated significant differences across the scenarios. Cronbach\u0026rsquo;s alpha indicated a modest agreement in the participants\u0026rsquo; ratings and the response to scenario 3 (medical error disclosure) was significantly higher compared to scenarios 1 and 2 and the difference between scenarios 1 and 2 was borderline significant with scenario 2 (religious refusal of treatment) having the lowest rating. This is expected, since religious objections to treatment present more complex ethical dilemmas, where mediation may face structural limitations because religious language can function as a \u0026ldquo;conversation stopper,\u0026rdquo; making compromise more challenging (Khushf, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). In contrast, medical professionals in Greece see medical mediation as more valuable in the cases of medical errors - scenario 3 - where transparency and restorative dialogue are clearly beneficial (Hyman et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) and institutionalization has been promoted (Chen et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Gallagher et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Wang et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Finally, scenario 1 (end-of-life decision-making) was ranked in the middle. The use of medical mediation in the case of end-of-life dilemmas has been proven to be a constructive way to handle emotionally charged treatment dilemmas, without disrupting the therapeutic alliance between clinicians, patients, and families (Bowman, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2000\u003c/span\u003e; Donnelly \u0026amp; Walker, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Gatter, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e1999\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, latent class analysis revealed three profiles of responses in terms of rating the three scenarios and the probability of suggesting mediation: the \u0026ldquo;Strongly supportive\u0026rdquo; profile with participants consistently rating the mediator\u0026rsquo;s approach very positively across all scenarios and having the highest probability of recommending mediation, the \u0026ldquo;Moderately supportive\u0026rdquo; profile with members of this class expressing moderate agreement with the mediator\u0026rsquo;s role across all scenarios combined with moderate recommendation levels and the \u0026ldquo;Cautiously positive\u0026rdquo; profile showing a mixed support of the different scenarios and their recommendation levels being lower, with a higher probability of selecting \u0026ldquo;neutral\u0026rdquo; stance. Importantly, a posteriori modal assignment resulted in most of the participants 73.3% (n\u0026thinsp;=\u0026thinsp;316) classified as strongly supportive, which further confirms the demand of medical mediation by health professionals. Notably, there was no difference in the training and familiarity levels (because both were very low) or in the demographic characteristics (age, sex, education, work type and level) between the profiles. This pattern is consistent with international evidence that attitudes toward conflict‑resolution tools are often shaped far more by experiential and value‑based factors than by sociodemographic traits. Indeed, these belief‑driven differences were underscored by the significant trend we observed: from the Skeptical to the Moderate to the Supportive profile, the proportion of respondents who (i) view mediation as an effective tool and (ii) endorse mandatory institutional training had a significant upward trend.\u003c/p\u003e \u003cp\u003eThis study has limitations that should be acknowledged. First, participation was voluntary and conducted online, which may have introduced self-selection bias, as respondents more supportive of mediation could have been more likely to complete the survey. Secondly, all data were self-reported, and measures of familiarity or prior involvement in mediation processes may be affected by recall or social desirability bias. Finally, although the sample was relatively large, it may not fully represent healthcare professionals working in rural or underserved areas. Despite these limitations, the internal consistency of responses and the clear latent class structure observed suggest that the findings reliably capture prevailing perceptions of medical mediation among Greek healthcare professionals.\u003c/p\u003e \u003cp\u003eThus, this work provides information on the attitude of health professionals towards medical mediation which is an internationally proven effective tool of conflict resolution in healthcare. Greek health professionals believe in the usefulness of medical mediation and on the need of training on the field. This information can be useful to health policy makers towards the development of a properly structured approach for the resolution of disputes in healthcare.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cspan\u003eParticipant consent statement: This study was a non-interventional, cross-sectional survey conducted exclusively through an anonymous, self-administered online questionnaire addressed to healthcare professionals. Participation was entirely voluntary. At the beginning of the questionnaire, participants were informed about the purpose of the study, the anonymous and confidential nature of data collection, and the use of the data solely for research purposes. No personal or sensitive identifying information was collected. Informed consent was implied by the voluntary completion of the questionnaire. The study protocol was approved by the University of Thessaly Ethics Committee.\u003c/span\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, O.L. and C.T..; Methodology, O.L. and P.K.; Formal Analysis, P.K.; Investigation and Data Curation, O.L.; Writing - Original Draft Preparation, O.L.; Writing -Review and Editing, C.T. and K.G.; Supervision, K.G. and C.T.; Resources and Institutional Support, C.B. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the University of Thessaly Ethics Committee (Approval No. UTH-DEY/EC/2023-12-08; Date: 2023-12-08).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments and AI Use Disclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the preparation of this manuscript, the authors used ChatGPT (GPT-5, OpenAI, 2025) to assist with English-language editing, figure formatting, and data visualization. All outputs were reviewed, verified, and revised by the authors, who take full responsibility for the content and integrity of this publication.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBowman, K. W. (2000). Communication, negotiation, and mediation: Dealing with conflict in end-of-life decisions. \u003cem\u003eJournal of Palliative Care\u003c/em\u003e, \u003cem\u003e16 Suppl\u003c/em\u003e, S17-23.\u003c/li\u003e\n \u003cli\u003eBuchanan, S. F., Desrochers, J. M., Henry, D. B., Thomassen, G., \u0026amp; Barrett, P. H. J. (2002). A mediation/medical advisory panel model for resolving disputes about end-of-life care. \u003cem\u003eThe Journal of Clinical Ethics\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e(3), 188\u0026ndash;202.\u003c/li\u003e\n \u003cli\u003eChen, P.-Y., Fu, C.-P., \u0026amp; Wang, C.-C. (2023). Narratives in the medicolegal field from the perspective of physicians involved in medical dispute mediation meetings in Taiwan.\u0026nbsp;\u003cem\u003eHeliyon\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(2), e13716. https://doi.org/10.1016/j.heliyon.2023.e13716\u003c/li\u003e\n \u003cli\u003eCheng, K. K., \u0026amp; le Roux-Kemp, A. (2017). Mediation and resolving disputes involving emergency nurses in Hong Kong: A legal empirical inquiry. \u003cem\u003eHong Kong Law Journal\u003c/em\u003e, \u003cem\u003e47\u003c/em\u003e, 763\u0026ndash;791. Scopus.\u003c/li\u003e\n \u003cli\u003eDimitrov, K., \u0026amp; Miteva-Katrandzhieva, T. (2024). Mediation in Healthcare: Enhancing Conflict Resolution Between Patients and Physicians Beyond the Courtroom. \u003cem\u003eCureus\u003c/em\u003e, \u003cem\u003e16\u003c/em\u003e(12), e75487. https://doi.org/10.7759/cureus.75487\u003c/li\u003e\n \u003cli\u003eDonnelly, S., \u0026amp; Walker, S. (2024). Enabling first and second year doctors to negotiate ethical challenges in end-of-life care: A qualitative study.\u0026nbsp;\u003cem\u003eBMJ Supportive \u0026amp; Palliative Care\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(e3), e2595\u0026ndash;e2602. https://doi.org/10.1136/bmjspcare-2020-002672\u003c/li\u003e\n \u003cli\u003eDubler, N. N. (1998). Mediation and managed care. \u003cem\u003eJournal of the American Geriatrics Society\u003c/em\u003e, \u003cem\u003e46\u003c/em\u003e(3), 359\u0026ndash;364. https://doi.org/10.1111/j.1532-5415.1998.tb01054.x\u003c/li\u003e\n \u003cli\u003eFiester, A. (2007). Mediation and moral aporia. \u003cem\u003eThe Journal of Clinical Ethics\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(4), 355\u0026ndash;356.\u003c/li\u003e\n \u003cli\u003eGallagher, T. H., Mello, M. M., Sage, W. M., Bell, S. K., McDonald, T. B., \u0026amp; Thomas, E. J. (2018). Can Communication-And-Resolution Programs Achieve Their Potential? Five Key Questions. \u003cem\u003eHealth Affairs (Project Hope)\u003c/em\u003e, \u003cem\u003e37\u003c/em\u003e(11), 1845\u0026ndash;1852. https://doi.org/10.1377/hlthaff.2018.0727\u003c/li\u003e\n \u003cli\u003eGatter, R. (1999). Unnecessary adversaries at the end of life: Mediating end-of-life treatment disputes to prevent erosion of physician-patient relationships. \u003cem\u003eBoston University Law Review. Boston University. School of Law\u003c/em\u003e, \u003cem\u003e79\u003c/em\u003e(5), 1091\u0026ndash;1137.\u003c/li\u003e\n \u003cli\u003eHyman, C. S., Liebman, C. B., Schechter, C. B., \u0026amp; Sage, W. M. (2010). Interest-based mediation of medical malpractice lawsuits: A route to improved patient safety? \u003cem\u003eJournal of Health Politics, Policy and Law\u003c/em\u003e, \u003cem\u003e35\u003c/em\u003e(5), 797\u0026ndash;828. https://doi.org/10.1215/03616878-2010-028\u003c/li\u003e\n \u003cli\u003eJohnson, S. W. (2024). \u003cem\u003eMediation As An Alternative Dispute Resolution Tool In Healthcare Malpractice\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eKhan, H. A., Bastiampillai, A., \u0026amp; Mon, S. W. (2020). Mediation as a suitable dispute resolution method in medical negligence cases: Special reference to the Malaysian position. \u003cem\u003ePertanika Journal of Social Sciences and Humanities\u003c/em\u003e, \u003cem\u003e28\u003c/em\u003e(3), 2309\u0026ndash;2323.\u003c/li\u003e\n \u003cli\u003eKhushf, G. (2019). When Religious Language Blocks Discussion About Health Care Decision Making. \u003cem\u003eHEC Forum : An Interdisciplinary Journal on Hospitals\u0026rsquo; Ethical and Legal Issues\u003c/em\u003e, \u003cem\u003e31\u003c/em\u003e(2), 151\u0026ndash;166. https://doi.org/10.1007/s10730-019-09371-x\u003c/li\u003e\n \u003cli\u003eLinzer, D. A., \u0026amp; Lewis, J. B. (2011). poLCA: An R package for polytomous variable latent class analysis. \u003cem\u003eJournal of Statistical Software\u003c/em\u003e, \u003cem\u003e42\u003c/em\u003e, 1\u0026ndash;29.\u003c/li\u003e\n \u003cli\u003eLyons, O., Forbat, L., Menson, E., Chisholm, J. C., Pryde, K., Conlin, S., Felton, V., Ingle, S., McKenzie, C., Ramachandran, R., Sayer, C., Snowball, C., Strachan-Gadsby, E., Tisovszky, N., \u0026amp; Barclay, S. (2021). Transforming training into practice with the conflict management framework: A mixed methods study. \u003cem\u003eBMJ Paediatrics Open\u003c/em\u003e, \u003cem\u003e5\u003c/em\u003e(1), e001088. https://doi.org/10.1136/bmjpo-2021-001088\u003c/li\u003e\n \u003cli\u003eMannozzi, G. (2015). Mediating conflicts in the medical sector: General considerations from the Italian perspective. \u003cem\u003eGlobal Jurist\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(3), 291\u0026ndash;327.\u003c/li\u003e\n \u003cli\u003eNakanishi, T. (2014). Disclosing unavoidable causes of adverse events improves patients\u0026rsquo; feelings towards doctors. \u003cem\u003eThe Tohoku Journal of Experimental Medicine\u003c/em\u003e, \u003cem\u003e234\u003c/em\u003e(2), 161\u0026ndash;168. https://doi.org/10.1620/tjem.234.161\u003c/li\u003e\n \u003cli\u003eR Core Team, R. (2013). \u003cem\u003eR: A language and environment for statistical computing\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eRegis, C., \u0026amp; Poitras, J. (2010). Healthcare mediation and the need for apologies. \u003cem\u003eHealth Law Journal\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e, 31\u0026ndash;49. Scopus.\u003c/li\u003e\n \u003cli\u003eSignorell, A., Aho, K., Alfons, A., Anderegg, N., Aragon, T., Arppe, A., Baddeley, A., Barton, K., Bolker, B., \u0026amp; Borchers, H. W. (2019). DescTools: Tools for descriptive statistics. \u003cem\u003eR Package Version 0.99\u003c/em\u003e, \u003cem\u003e28\u003c/em\u003e, 17.\u003c/li\u003e\n \u003cli\u003eVoultsos, P., Tsompanian, A., \u0026amp; Tsaroucha, A. K. (2021). The medical futility experience of nursing professionals in Greece. \u003cem\u003eBMC Nursing\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(1), 254. https://doi.org/10.1186/s12912-021-00785-y\u003c/li\u003e\n \u003cli\u003eWang, M., Liu, G. G., Zhao, H., Butt, T., Yang, M., \u0026amp; Cui, Y. (2020). The role of mediation in solving medical disputes in China. \u003cem\u003eBMC Health Services Research\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(1), 225. https://doi.org/10.1186/s12913-020-5044-7\u003c/li\u003e\n \u003cli\u003eWickham, H., Averick, M., Bryan, J., Chang, W., McGowan, L. D., Fran\u0026ccedil;ois, R., Grolemund, G., Hayes, A., Henry, L., \u0026amp; Hester, J. (2019). Welcome to the Tidyverse. \u003cem\u003eJournal of Open Source Software\u003c/em\u003e, \u003cem\u003e4\u003c/em\u003e(43), 1686.\u003c/li\u003e\n \u003cli\u003eZanni, A. (2014). Organ transplantation in Greece: The need for mediation.\u0026nbsp;\u003cem\u003eTransplantation Proceedings\u003c/em\u003e, \u003cem\u003e46\u003c/em\u003e(9), 3164\u0026ndash;3167. https://doi.org/10.1016/j.transproceed.2014.09.157\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University Of Thessaly","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Medical mediation, healthcare conflict, clinical ethics, Greece, scenario-based survey, latent class analysis","lastPublishedDoi":"10.21203/rs.3.rs-8470897/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8470897/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eMedical mediation is a collaborative tool for resolving ethically complex disputes in healthcare. Though widely recognized in international clinical ethics it has only been recently introduced in Greece. The objective of this work was to assess healthcare professionals\u0026rsquo; perceptions of medical mediation using a scenario-based survey, A structured, cross-sectional online questionnaire was completed by 431 healthcare professionals across Greece. The survey included three clinical vignettes on (1) end-of-life care, (2) religious refusal of treatment, and (3) medical error disclosure), Likert-scale items on attitudes toward mediation, and demographic information. Latent class analysis (LCA) was used to identify patterns of response across the scenarios and attitudinal items. Participants expressed strong support for mediation across all scenarios (median scores\u0026thinsp;\u0026ge;\u0026thinsp;9), with the highest support for medical error disclosure. LCA revealed three distinct respondent profiles: strongly supportive (73.3%), moderately supportive (14.6%), and cautiously positive (12.1%). Significant trends were observed across profiles for the perceived effectiveness of mediation and support for institutional training (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). However, formal training and familiarity with mediation among the participants were low (\u0026lt;\u0026thinsp;5%). Despite limited training and formal implementation, Greek healthcare professionals show high support for medical mediation. The demand and need for structured mediation training and integration into the Greek healthcare system is strong.\u003c/p\u003e","manuscriptTitle":"A scenario – based assessment of the perceptions towards medical mediation in healthcare professionals: insights from a cross-sectional survey","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-08 02:29:39","doi":"10.21203/rs.3.rs-8470897/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"07c08e5b-7ff4-4742-b5c9-feb446848298","owner":[],"postedDate":"January 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":60744733,"name":"Health Law"}],"tags":[],"updatedAt":"2026-01-08T02:29:39+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-08 02:29:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8470897","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8470897","identity":"rs-8470897","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}