Preventing burnout from moral distress amongst prehospital emergency personnel: action research to develop and test organizationally targeted clinical ethics support

Preventing burnout from moral distress amongst prehospital emergency personnel: action research to develop and test organizationally targeted clinical ethics support | 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 Article Preventing burnout from moral distress amongst prehospital emergency personnel: action research to develop and test organizationally targeted clinical ethics support Lotte Huniche, Louise Milling, Daniel Wittrock, Søren Mikkelsen, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4653025/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Dec, 2024 Read the published version in Scientific Reports → Version 1 posted 10 You are reading this latest preprint version Abstract Ethical challenges are integral to health care and are associated with moral distress among health professionals. Moral distress can turn into burnout with a range of negative effects for professionals, patients, relatives, collaborators, and the organisation. Based on action research a focus group study was conducted inclucing prehospital personnel from the emergency services in the Region of Southern Denmark. Results showed that ethical challenges arise in contexts of 1) caring for patients, 2) managing organizational demands, 3) collaborating. Ethical challenges are addressed informally by personnel in emergency vehicles, at ambulance stations, outside working hours, and ocationally involve family or friends with a background in health care. Further, prehospital physicians address ethically sensitive issues during monthly meetings. Voicing ethical challenges presupposes confidence, trust, and safety in relation to colleagues, management, and the organisation. Existing forms of clinical ethics support are ill suited to the prehospital emergency services. Targeted clinical ethics support initiatives are needed to address moral distress, prevent burnout, and build a supportive working environment. Initiatives must be developed collaboratively with personnel and tested bottom-up to identify and eliminate barriers for implementation. Biological sciences/Psychology Health sciences/Health care Health sciences/Medical research Prehospital emergency services The Region of Southern Denmark ethical challenges moral distress burnout clinical ethics support Background In clinical practice, health care professionals are faced with medical, legal, and value-related considerations [1, 2], that are deeply entangled with specific priorities regarding each patient and their relatives. Ethical challenges are thus unavoidably part of clinical decision-making and have been conceptualised as “a situation where there is doubt, uncertainty, or disagreement about what is morally good or right.” [3]. Ethical challenges have been researched in different clinical settings such as somatic medicine [4, 5], mental health [6-8], community health [9, 10] and among all types of health care professionals [11, 12]. Only few studies have focused on ethical challenges in the prehospital emergency services, where decision-making takes place in civil society settings, under time pressure, with limited access to information about the patient, and few possibilities for consulting with a colleague. Even if the ethical challenges are similar to those faced by clinicians in other areas of health care, the organizational framework for managing challenges differs fundamentally. Ethical challenges are associated with moral distress. Moral distress is recognised as a serious problem among nurses, physicians, and other health care professionals as it negatively affects their wellbeing, their relations with patients, relatives, colleagues, and external collaborators [13]. Further, moral distress is associated with burnout and the inclination to discontinue employment in health care [14-16]. In 1984 moral distress was defined in nursing as resulting from situations “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.” [17]. Other studies have demonstrated that moral distress applies to a range of other health care professionals [18] and a narrative synthesis of the literature points to the causal relationship between the experience of a moral event and psychological distress [19]. Psychological distress is expressed as psychological and/or physical reactions. Psychological reactions may vary, but include anxiety, frustration, guilt, anger, sadness, psychological exhaustion, helplessness, and depression. Likewise, physical symptoms may include insomnia, nausea, migraines, abdominal pain, a tendency to cry, and physical exhaustion. Supporting prehospital emergency personnel in managing ethical challenges can thus prevent moral distress turning into burnout. In turn, this can prevent spillover effects for patients, relatives, colleagues, external collaborators and may prevent personnel from resigning. Clinical ethics support can assist health care professionals in managing ethical challenges, and include clinical ethics committees [20, 21], clinical ethics consultation [22, 23], moral case deliberations [24, 25], and ethics reflection groups [26, 27]. The organisation of these support initiatives vary (table 1). Table 1: Three organisational forms of clinical ethics support Clinical ethics committees Clinical ethics consultation Moral case deliberation Ethics reflection groups How does it work? A permanent committee discusses specific cases or general questions raised by hospital management, administration, clinicians, patients, or relatives A professional ethicist (or small team of ethicists) meets with clinicians routinely or on request to discuss ethical challenges experienced by clinicians A group of colleagues meet to discuss ethical challenges in clinical practice. A facilitator structures the process How is it organised? By one or several hospitals in a region By an ethicist employed at the hospital or as part of the services of a clinical ethics committee Within or across clinical units and departments Who facilitates? An ethicist or clinician trained as an ethics facilitator An ethicist or a clinician trained as an ethics facilitator An ethicist or a clinician trained as an ethics facilitator Who parti-cipates? Multidisciplinary clinicians, ethicists, priests, municipality representatives, lawyers, at times patients, relatives, or their representatives Multidisciplinary clinicians from a clinical unit or department Multidisciplinary clinicians from a clinical unit or department Clinical ethics committees take a top-down approach and commonly provide advice or recommendations [28]. Bottom-up approaches, such as moral case deliberation and ethics reflection groups, engage and stimulate reflection among clinicians about ethical challenges in their day-to-day work. Clinical ethics consultation is commonly led by professional ethicists and combines a top-down with a bottom-up approach. All of these forms of clinical ethics support are, for different reasons, ill-suited to the context of the prehospital emergency services. Thus, the aim of our study was to investigate ethical challenges and management strategies in prehospital settings and on that basis to develop and test organisationally targeted forms of ethics support to prevent moral distress turning into burnout or cause personnel to leave the emergency services. Methods Based on action research [29, 30] a core research group was established whose members (the authors of this paper) planned and coordinated the collaborative efforts aimed to investigate ethical challenges and management strategies (phase one: a focus group study), and to develop and test clinical ethics support targeted at core settings of the emergency services in the Region of Southern Denmark (phase two). The prehospital emergency services in Denmark The research project was based in the prehospital research unit in the Region of Southern Denmark, one of five health regions in Denmark. It covers an area of 12.191 km² with a population of 1.2 million. The Danish welfare state provides all citizens with access to free healthcare including the prehospital medical services, which are three-tiered. When a caller contacts the emergency dispatch center, the healthcare dispatcher takes the call and dispatches one or more of the following units: 1) An ambulance manned with two emergency medical technicians (EMTs) or paramedics (PMs) [31], 2) An ambulance and a rapid response paramedic unit, 3) An ambulance and an anesthesiologist-manned mobile emergency care unit (MECU) or helicopter (HEMS). Three in four missions are carried out by EMTs or paramedics alone, either as an ambulance or an ambulance supplemented by a paramedic-manned rapid response vehicle. MECUs or HEMS are dispatched in approximately one in four missions along with an ambulance according to a rendezvous model [32]. The dispatchers’ choice of ground-based or helicopter-based supplementary unit is dependent upon the geographical location of the incident, the medical needs of the patient, the estimated response times, and subsequent transport times to hospital. Design of the focus group study To provide a knowledge base for developing and testing organisationally targeted forms of clinical ethics support a focus group study including three focus groups was conducted [33]. Focus groups were chosen to elicit narrative descriptions based on social interaction amongst participants [34, 35]. The purpose was to gain insight into ethically challenging situations along with clinical reasoning and social negotiations concerning the best course of action for the patient and others involved in the specific circumstances. The participants were recruited through an internal prehospital information network. The majority of the ambulance crew participants were full-time employees and commonly teamed up with the same colleague during most shifts. Likewise, most of the anaesthesiologists had been manning the local MECUs since the inception in 2006. On average their prehospital workload was between two and five monthly 24-hour shifts, supplementing their in-hospital work. In total, 15 EMTs, PMs, and MECU physicians participated in the three focus groups [33] (table 2). Table 2: Focus group participants Prehospital emergency personnel MECU physicians EMTs and PMs Focus group 1 2 male, 0 female 2 male, 0 female Focus group 2 1 male,1 female 4 male, 0 female Focus group 3 1 male, 1 female 2 male, 1 female Total 4 male, 2 female 8 male, 1 female Each focus group lasted two hours and was conducted in a meeting room at an ambulance station. Authors LH and HB facilitated all three focus groups while LM collected written consent forms and audio recorded the sessions. During focus groups notes were written on a flip chart in plain view for all to comment. Authors SM and DW did not participate in the focus groups in any capacity due to their respective positions as lead consultant of the MECU and head of the department for quality and education in the regional ambulance services. Audio files were transcribed verbatim. During transcription and further processing of data, any names of persons and places mentioned during the focus groups were pseudonymised. Audio files, interview transcripts, and photographs of the flip charts were stored on a secure server. Data analyses Data were transferred to and systematised in NVivo (QSR International, Burlington, Massachusetts, USA). The analytic procedure was guided by systematic text condensation [36]. First, all transcripts were read to gain an overall impression of the content. As data proved rich in descriptions of both experiences with and management of ethical challenges, the research team decided to focus on each separately. The first round of analysis focused on the ethical challenges experienced from the first-person perspectives of the prehospital emergency personnel in their clinical day-to-day work [33]. The second round focussed on ways of managing ethical challenges [37]. Results Prehospital emergency personnel conveyed that from their first-person perspective ethical challenges arise in day-to-day work when clinical guidelines, legal requirements, and clinicians’ professional and personal value systems are in conflict and complicate decision-making processes. Ethical challenges arise in contexts of 1) caring for patients, 2) managing organizational demands, 3) collaborating. In the context of caring for patients Ethical challenges arise during incidents when the patients’ autonomous decision-making capacity is reduced or absent. For example, in unconscious or semi-conscious patients with cardiac arrest or severe trauma, and in patients with impaired cognitive functioning due to organ malfunctioning, head injury, anxiety, pain, shock, or substance abuse. Reduced or absent decision-making capacity renders it difficult or impossible for the prehospital emergency personnel to honor the patients’ right to participate in decisions related to their health. In such situations, the personnel has no choice but to determine the best course of action for the patient without their input or clearly statet consent. Examples involve patients with cardiac arrest where experienced EMTs and PMs find it ethically challenging if they have to put legal requirements to start resuscitation before what they consider to be in the best interest of a patient. In cases involving intoxicated and incapacitated patients a typical ethical challenge concerns the patient refusing what the personnel consider necessary medical attention in a hospital. In other cases the personnel are ethically challenged when they are not able to treat or refer patients to appropriate professional assistance. For example, in cases where patients suffer from mental health issues or long term substance abuse. With no alternative treatment option spending time caring for such patients means withholding vital ambulance resources. Other kinds of ethically challenging situations arise when the patient is a child or an adolescent. Several examples of infants dying at home or in the ambulance were mentioned during the focus groups. Such events shift the focus from caring for the patient to caring for parents, siblings, and others present at the scene, including colleagues. In the prehospital setting, no procedure is available for sufficiently addressing the emotional needs of those present at a child’s death. In other cases, the ethical challenge is about deciding if a child without any signs of severe disease should be taken to hospital for further examination to calm extremely worried and insecure parents. Conversely, the personnel can face a difficult decision about whether or not to report potential threaths to the health and safety of children. Despite their extended legal obligation to notify the social services, the clinicians find these situations ethically challenging and morally distressing. Unless there are obvious signs of abuse or physical danger the clinicians’ decision rests on a snapshot of the child’s circumstances. They must form an immediate opinion without having any say in what happens next and with no means of knowing whether a notification to the authorities will turn out to be helpful or might ultimately cause more harm than good to the child and the family. Ethical challenges are also related to taking the considerations of relatives into account when evaluating what is in the best interest of an adult patient. Sometimes relatives or others who are involved in the life and care of a patient can constitute an invaluable source of information regarding a patient’s medical history, cultural traditions, and personal preferences. On the other hand, relatives can get in the way or even obstruct the efforts of the personnel if intoxicated, emotionally distressed, or suffering from mental health issues. Some relatives actively injure or cause harm to patients, some are vulnerable and potentially in need of care themselves. Relatives do on occasion insist on treatment and procedures that are not medically indicated, nor in the best interest of the patient: “If the relatives expect that [non-indicated] treatment will be initiated, one can ‘hurry slowly’, give a little oxygen on a face mask and a probe on the finger, then it looks as if something is being done anyway.” Sometimes personnel are confronted with patient values grounded in unfamiliar religious or cultural traditions and may either not know, not understand, or downright disagree with them. Thus, personnel can be ethically challenged and morally distressed by patient choices that go against their professional judgement or personal values. In the context of managing organizational demands Prehospital emergency personnel can be ethically challenged when balancing their professional and legal duties towards the patient with safeguarding themselves, colleagues, and others. One example is the transportation of very sick patients at high-speed using lights and sirens versus the safety of ambulance passengers and bystanders. Another example is treating patients while handling angry and violent relatives posing a threat to personnel or others. One further example is weighing out the risks of entering premises that expose personnel to physical danger such as fire, explosives, or structural collapse versus getting to patients requiring immediate care. Other ethically challenging balancing acts involve values related to the responsible use of prehospital resources. For example EMTs and PMs sometimes struggle when patients are assigned to an ambulance, if the patient has no clinically indicated need for emergency transportation: It’ll take an hour and a half to transport this patient to the hospital, who in principle should drive himself. That is an hour and a half where we are not available [for other tasks], where an ambulance is taken out of service to transport this broken finger. Conversely, personnel are relatively frequently challenged to the point of moral distress when leaving a bereaved relative, a mentally ill patient, or others whose needs do not explicitly fall within the remit of emergency care in order to ensure sufficient capacity for other incidents. A particular challenge is when EMTs and PMs are repeatedly called out to patients with mental health issues: Many of our patients are ‘regulars’. Recently we had a patient where I was kind of shocked that he wasn’t admitted to a place with only a handle on the outside of the door [a psychiatric ward]. He sits and stabs himself deeply in the stomach with a knife. We transport [the patient] to [the emergency department]... He is stitched up and discharged with a “have a nice day”. Equally, for some personnel it is ethically challenging to witness how patients with a long history of abuse do not really benefit from emergency interventions or hospital-based treatment, but to have nowhere else to refer these patients to. In the context of collaborating In day-to-day collaboration within the emergency services a common ethical challenge for EMTs and PMs is being tasked with or expected to accept courses of action that they do not believe are right. A value conflict can follow between loyalty towards a decision made at the dispatch center or by a superior versus loyalty to one’s own conviction regarding ‘best treatment’. In such situations potential benefits from attempting to change a course of action is weighed against the risks for the patient of a delay (however short) and of causing anxiety and mistrust in both patients and relatives as this may undermine their confidence in the actions of the whole team. Occasionally conflicts regarding the best course of action to treat a patient also arise among EMTs and PMs. This is a reason why most prefer to team up with the same few colleagues who they know and trust to share similar values. Prehospital emergency personnel also interact or collaborate with a wide range of professionals from other services on a daily basis. These include nursing homes, emergency departments, psychiatric units, shelters for the homeless, the police, the fire brigade, etc. A common ethical challenge relates to collaboration around end-of-life decisions in nursing homes. Particularly during evening and night shifts care assistants may be temporarily employed with no or limited medical training, and may call on the emergency services in situations when emergency intervention is not necessarily in the best interest of an old, fragile resident with serious comorbidities. In cases where an advance directive exists, care assistants might not know where it is kept or cannot access it. Prehospital emergency personnel agree that dying peacefully and with dignity is preferable to dying during futile interventions or while being rushed to a hospital. Sometimes, when we are dispatched to patients who are perhaps very old or physiologically in a miserable state, then, if you apply a certain ethical approach, you can say that it might be better not to move heaven and earth rushing [the patient] to hospital for them to die in a strange place. Instead, why don’t we call the next of kin. However, even if advance directives are available they do not always solve the ethical challenge of securing a dignified death. Often, advance directives are incomplete or outdated. In these cases, EMTs and PMs are legally obliged to initiate resuscitation and continue until a physician has decided to terminate treatment. Ethically challenging situations also arise in relation to collaboration with police authorities. In cases where a person dies unwitnessed the police is required to investigate. Consequently, personnel and police officers attend the scene for different reasons and have different tasks. The clinicians are tasked with confirming death and attending to the body while the police are tasked with assessing whether the death is the result of a criminal act. These different roles and tasks may result in opposing approaches to the situation, the deceased, and in particular, to any relatives present at the scene. Strategies for managing ethical challenges Actions based on ethical considerations can be coined as moral conduct [ 38 ]. In this definition moral conduct is broken down into a three-part sequence initiated by moral perception , followed by moral judgment , leading to moral action . Moral perception is a precondition for moral judgement and involves the individual being receptive to the events taking place. Moral judgement encompasses the interpretation, understanding, and balancing of the welfare, interests, and rights of the concerned parties. The ability to perceive what is morally significant and to feel affected by a situation that affects the well-being of others is furthermore an expression of the individual’s capacity for empathy. Empathy is thus an important aspect of moral conduct. Moral perception In health care morally relevant perception pertains to any signs that indicate the patient’s state of health or can otherwise contribute to an understanding of the patient’s situation. A typical strategy reported by prehospital emergency personnel is gathering as much information about the patient as possible to aid the decision-making further down the line, including decisions that may prove ethically challenging. Examples are picking up on signs around the home, e.g. assistive devises, daily medication, a hospital bed, a pre-packed box of palliative medication, etc. Well, [we try to] understand what the medical history is, along with what [we] find in the patient […], are there any medical records or papers, is there anything [that can inform us about the patient’s condition]. What kind of medication is given, if any. It can be very informative, and also, has the patient been declared terminally ill? Okay then we know, then someone has decided [the level of treatment], and we more or less know where we are in the process. Moral judgement Moral judgement is guided by various resources. Some physicians refer to bioethical principles such as utilitarianism, e.g. to arrive at the greatest good for the greatest number. Other principles mentioned are paternalism and autonomy, e.g. when considering when and how a patient should be consulted and have a say in decisions relevant to their health and welfare: The fact is that you, as a physician, at least to some extent, think in that slightly paternalistic way; we are trained like that a bit, and may have to make some decisions on behalf of others [who are incapacitated]. But that autonomy thing, it doesn’t apply to them [most prehospital patients]. I’m trained in making decisions and things like that, but I’m not always sure that it’s the right one […] Maybe the patient is admitted [to hospital], and then, you know what, no complaints. I can go home at nine o’clock tomorrow morning, and I won’t hear any more of it. On the other hand, if you dare to stick out your neck a little and maybe do the right thing by letting them [the patients] stay at home, you might… [get into trouble]. Some personnel also referred to a non-specific “gut feeling” as a basis for moral judgement. A PM explained how he relied on his gut feeling to guide his classification of patients as conscious and competent or not, and from that decided on relevant action. One physician drew attention to the ethical challenges arising from his negative moral judgement of particular patients such as rapists or violent offenders. In the light of selective negative moral judgement it can be a challenge to empathise with and treat all patients equally. Further, experienced personnel reported that generally their moral judgment had changed over time and with increased experience. Moral action EMTs, PMs, and physicians have different scopes for moral action, as their tasks and responsibilities differ. For the most part EMTs and PMs work independently at the scene and engage in moral perception, judgement, and action without the presence of a physician. However, most EMTs and PMs regularly request support from a physician for example if they need their “backs covered”, look for “an assessment of available options”, or want “help to settle a disagreement”. Whether physicians are present or not, it is important to the EMTs and PMs that they have confidence in the physicians’ medical competences as a basis for decision-making and moral action, whether they agree with them or not. However, sometimes the EMTs and PMs feel overruled by physicians, for example if they do not make their reasons explicit or do not take the considerations of the EMTs or PMs into account when deciding on a course of action. EMTs and PMs employ various strategies to influence physicians to take the kinds of actions that they would prefer, such as trying to point out alternatives or using sarcasm. On occasions, an EMT or PM disagrees with a physician to an extent where they see not other option than to withdraw from the situation altogether. For example by turning to legitimate practical tasks unrelated to the treatment of the patient, such as preparing the ambulance for leaving the scene. The physicians stage their professional competencies as the starting point for assessing the optimal action in a specific situation. In addition, the physicians’ actions are guided by legal requirements. The physicians are aware that what is legally warranted may not always be in the best interest of the patient or relatives, and the risk of a complaint sometimes plays a role in decision-making: So if you just, well, if you’re a doctor, for example, and you admit everyone, you’ll never get your ass on the line. There will never be any formal complaints. […] There are no relatives who complain that their relative has been admitted to hospital. Isn’t it just fantastic? But they don’t understand what it means to be admitted to the hospital when you are 90 years old, confused, demented. Although the considerations of the EMTs and PMs are generally not the physicians’ top priority, some are conscious of actively involving EMTs and PMs in the decision-making process. The physicians are aware that their decisions and actions, including their personal conduct, have an impact on how an incident is managed overall. If a physician is considered as acting in an unprofessional, unreasonable, or ethically questionable manner, it can affect the entire team and their actions. Organisational support of moral conduct In the present study the EMTs, PMs, and physicians all stress that medically and morally sound patient care depend on mutually respectful and supportive working relations. Further, they point out that sharing thoughts on ethical challenges is important not just for qualifying patient care and for maintaining good working relations, but also for long-term mental health and work satisfaction among personnel. At the time of the investigation the emergency services in the region of Southern Denmark have debriefing and defusing procedures in place, but no clinical ethics support. Personnel address ethical challenges and value conflicts in informal settings , such as en route in the ambulance or rapid response vehicle, at the ambulance station between assignments, and occasionally outside work with colleagues, or a family member or friend with a background in health care: The biggest challenge in the ambulance is that it obviously depends a lot on who you are driving with. […] I would be more inclined to have a defusing session or a conversation about certain matters with a colleague I already know and trust, than someone I only just met on… [this particular shift]. Physicians have the opportunity to introduce and discuss ethically challenging issues at mandatory monthly meetings for physicians only. This forum is described as providing a legitimate and safe space for sharing and discussing actions taken. In general sharing and discussing ethical challenges presupposes confidence inspired by medical skills and experience, trust that conversational partners will respond caringly and with integrity, and last but not least, organisational safety, i.e. to be able to rest assured that conveying difficulties or uncertainty does not entail repercussions. Developing and testing clinical ethics support Based on the investigation of ethical challenges and management strategies, and on insider knowledge of organisational structures, the members of the project group agreed to anchor the development of targeted clinical ethics support in a particular model for structured ethics reflection [ 6 , 21 ]. Three settings within the prehospital emergency services in the region of Southern Denmark were targeted for the development and testing phase. Setting 1: Prehospital anaesthesiologists’ monthly meetings The research project and the model was introduced to the prehospital anaesthesiologists and structured ethics reflection was facilitated by HB and LH at three concecutive meetings. This was followed up by an evaluation and discussion of how to proceed with ethics reflection among the anesthesiologists themselves and how anesthesiologists might support ethics reflection in relevant contexts of day-to-day clinical practice with other personnel. Setting 2: Regional training modules for EMTs and PMs Collaboration was established with two key employees within the regional ambulance service, namely the head of the department for quality and education, and the team leader of the instructors who run in-house training modules for EMTs and PMs. It was agreed to run a work shop involving all instructors in the region to introduce the research project and to work with the model for structured ethics reflection. At a second workshop HB and LH once more facilitated instructors engagement with the model, followed by a discussion of ways to introduce ethics reflection in training modules. Concerns were raised, that the full-fledged model would not be practicable within the module structure, neither would it be staright forward to engage all employees in this kind of activity. Following on from the workshops, a go-to version of the model was integrated into a three-part training module on rhabdomyolysis. Participants would be devided into three groups and groups would circle the three parts of the module in turn. The part on structured ethics reflection involved an oral case presentation and six discussion cards, each stating one to three questions inspired by the model for structured ethics reflection on the one side, and inspirational suggestions for further discussion on the other. Setting 3: Supervison for peer-supporters Collaboration was also established with two ambulance station managers who are supervising a group of ambulance personnel from the region tasked with offering work related peer-support to colleagues. The station managers suggested that the research project and the model for structured ethics reflection be introduced to the peer-supporters. At their request, a second meeting was agreed on to try out the full-fledged model for structured ethics reflection. Subsequently, the project group collaborated with the supervisors on transforming elements of the model into supportive tools in the day-to-day work of the peer-supporters. The third and final phase of the research project will be concerned with implementing and investigating clinical ethics support in training modules and through the actions of anesthesiologists and peer-supporters. Discussion As ethical challenges are commonly complex and pertain to more than a single person prevented from doing the right thing, individual coping strategies are rarely sufficient [ 12 ]. Structuring the dialogue through ethics reflection groups or moral case deliberation can lead to an experience of mental relief and stress reduction among health professionals [ 12 , 24 , 25 ] These forms of clinical ethics support are, however, ill-suited to the context of the prehospital emergency services for several reasons. First, prehospital emergency personnel spend most of their working hours “in the field” which challenges the practical feasibility of any of these forms of support. Second, the emergency services employ personnel with very diverse backgrounds which makes for different educational exposure to and experiences with “ethics”. Third, all though this is changing, the emergency services still harbour what has been termed a “macho” workplace culture which tends to interfere with the confidence and trust necessary for dialogues on how to manage ethical challenges. Other forms of clinical ethics support need to be developed and tested in the context of the prehospital emergency services to be organizationally viable. The results of the present action research project suggest that developing and testing context sensitive clinical ethics support is best qualified by a bottom up and highly collaborative approach. Conclusion Over time, ethical challenges and the ensuing moral distress can result in burnout with a range of negative consequences for the involved and with personnel leaving the emergency services. Confidence and trust in colleagues, managers, and the organization are prerequisites for sharing experiences of morally distressing events in the workplace. Traditional forms of clinical ethics support (clinical ethics committees, clinical ethics consultation, moral case deliberation, and ethics reflection groups) are ill suited to the organisational setup of the emergency services. This points out a need for organisational support for personnel to address and manage morally distressing situations collectively and productively. Organizationally targeted and context sensitive forms of structured ethics support can address moral distress, prevent burnout, and contribute to the building of a supportive and attractive working environment in the emergency services. Declarations Acknowledgements We acknowledge the engagement and time of the prehospital emergency personnel who took part in this study. We recognise that speaking up on sensitive issues can be challenging and take courage even in organisational contexts where participants feel relatively safe to do so. Author contributions HB, LH and SM decided on the overall methodology and design of the study. LH and HB prepared and conducted the focus groups assisted by LM. Data analysis and manuscript drafting was carried out by LH and HB assisted by DW, LM and SM who contributed with specialist knowledge and revisions. All authors approved the final manuscript before submission. Data availability statement The datasets used and analysed during the current study available from the corresponding author on reasonable request. Additional information The project is registered with the Danish Data Protection Agency (20/63051). According to Danish legislation interview-based studies do not require approval by a research ethics committee, which was confirmed in a mail to HB from The National Committee on Health Research Ethics in Denmark on March 8, 2021 (20202000-205). Research activities were performed in accordance with relevant guidelines and the Declaration of Helsinki. All participants received verbal and written project information, including their right to withdraw at any time. All participants gave their written consent to participation and publication of identifying information in an oline open-access publication. The authors have no competing interests as defined by Nature Research, or other interests that might be perceived to influence the results and/or discussion reported in this paper. References Foster, C., Miola, J., Who´s in charge? The relationship between medical law, medical ethics, and medical morality? . Med Law Rev, 2015. 23 (4): p. 505-30. Cole, R., Stone, M., Ruck K. A., Fritz, Z., Family members, ambulance clinicians and attempting CPR in the community: the ethical and legal imperative to reach collaborative consensus at speed. J Med Ethics, 2021. 47 (10): p. 650-653. Hem, M.H., Molewijk, B., Gjerberg, E., Lillemoen, L., Pedersen, R., The significance of ethics reflection groups in mental health care: a focus group study among health care professionals. BMC Med Ethics, 2018. 19 (1): p. 54. Jimenez-Herrera, M.F., Axelsson, C., Some ethical conflicts in emergency care. Nurs Ethics, 2015. 22 (5): p. 548-60. Forde, R., Vandvik, I. H., Clinical ethics, information, and communication: review of 31 cases from a clinical ethics committee. J Med Ethics, 2005. 31 (2): p. 73-7. Bruun, H., Lystbaek, S.G.., Stenager, E., Huniche, L., Pedersen, R., Ethical challenges assessed in the clinical ethics Committee of Psychiatry in the region of Southern Denmark in 2010-2015: a qualitative content analyses. BMC Med Ethics, 2018. 19 (1): p. 62. Molewijk, B., Hem, M. H., Pedersen, R., Dealing with ethical challenges: a focus group study with professionals in mental health care. Bmc Medical Ethics, 2015. 16 . Pelto-Piri, V., Engström, K., Engström, I., Staffs´ perception of the ethical landscape in psychiatric inpatient care: A qualitative content analysis of ethical diaries. . Clinical Ethics, 2014. 9 . Lillemoen, L. and R. Pedersen, Ethics in Municipal Health Services: Working Systematically with, and Developing Competence in Ethics. Clinical Ethics, 2013. 8 (1): p. 19-28. van der Dam, S., Abma, T. A., Kardol, M. J., Widdershoven, G. A., "Here's my dilemma". Moral case deliberation as a platform for discussing everyday ethics in elderly care. Health Care Anal, 2012. 20 (3): p. 250-67. Hurst, S.A., et al., Ethical difficulties in clinical practice: experiences of European doctors. Journal of medical ethics, 2007. 33 (1): p. 51-57. Kälvemark, S., Höglund, A., Hansson, M., Westerholm, P., Arnetz, B., Living with conflicts-ethical dilemmas and moral distress in the health care system. Social science & medicine, 2004. 58 (6): p. 1075-1084. Burston, A., Tuckett, A., Moral distress in nursing: contributing factors, outcomes and interventions. Nurs Ethics, 2013. 20 (3): p. 312-24. Silverman, H., et al., Ethical decision-making climate, moral distress, and intention to leave among ICU professionals in a tertiary academic hospital center. Bmc Medical Ethics, 2022. 23 (1). Ghazanfari, M.J., et al., Moral distress in nurses: Resources and constraints, consequences, and interventions. Clinical Ethics, 2022. 17 (3): p. 265-271. Trautmann, J., Epstein, E., Rovnyak, V., Snyder, A., Relationships among moral distress, level of practice independence, and intent to leave of nurse practitioners in emergency departments: results from a national survey. Advanced Emergency Nursing Journal, 2015. 37 (2): p. 134-145. Jameton, A., What Moral Distress in Nursing History Could Suggest about the Future of Health Care. AMA J Ethics, 2017. 19 (6): p. 617-628. Quek, C.W.N., et al., Systematic scoping review on moral distress among physicians. BMJ Open, 2022. 12 (9): p. e064029. Morley, G., Ives, J., Bradbury-Jones, C., Irvine, F., What is ‘moral distress’? A narrative synthesis of the literature. Nursing ethics, 2019. 26 (3): p. 646-662. Crico, C., Sanchini, V., Casali, Paolo G., Pravettoni, P., Evaluating the effectiveness of clinical ethics committees: a systematic review. Med Health Care Philos, 2021. 24 (1): p. 135-151. Forde, R., Pedersen, R., Clinical ethics committees in Norway: what do they do, and does it make a difference? Camb Q Healthc Ethics, 2011. 20 (3): p. 389-95. Bell, J.A.H., et al., Clinical ethics consultations: a scoping review of reported outcomes. BMC Med Ethics, 2022. 23 (1): p. 99. Reiter-Theil, S., Ethics consultation on demand: concepts, practical experiences and a case study. Journal of Medical Ethics, 2000. 26 (3): p. 198-203. Haan, M.M., van Gurp, J. L. P., Naber, N. M., Groenewoud, A. S., Impact of moral case deliberation in healthcare settings: a literature review. BMC Med Ethics, 2018. 19 (1): p. 85. Kok, N., et al., Effect of Structural Moral Case Deliberation on Burnout Symptoms, Moral Distress, and Team Climate in ICU Professionals: A Parallel Cluster Randomized Trial. Critical Care Medicine, 2023: p. 10.1097/CCM.0000000000005940. Lillemoen, L., Pedersen, R., Ethics reflection groups in community health services: an evaluation study. Bmc Medical Ethics, 2015. 16 . Bruun, H., Huniche, L., Stenager, E., Mogensen, C. B.., Pedersen, R., Hospital ethics reflection groups: a learning and development resource for clinical practice. BMC Med Ethics, 2019. 20 (1): p. 75. Rasoal, D., Skovdahl, K., Gifford, M., Kihlgren, A., Clinical ethics support for healthcare personnel: an integrative literature review. Hec Forum, 2017. 29 : p. 313-346. McCormack, B., Action research for the implementation of complex interventions , in Complex interventions in health . 2015, Routledge. p. 326-337. Malterud, K., Action research--a strategy for evaluation of medical interventions. Fam Pract, 1995. 12 (4): p. 476-81. Mikkelsen, S., Lassen, A.M., The Danish prehospital system. European Journal of Emergency Medicine, 2020. 27 (6): p. 394-395. Mikkelsen, S., et al., Termination of prehospital resuscitative efforts: a study of documentation on ethical considerations at the scene. Scand J Trauma Resusc Emerg Med, 2017. 25 (1): p. 35. Bruun, H., Milling, L., Mikkelsen, S., Huniche, L., Author Correction: Ethical challenges experienced by prehospital emergency personnel: a practice-based model of analysis. BMC Med Ethics, 2022. 23 (1): p. 120. Halkier, B., Focus groups as social enactments: integrating interaction and content in the analysis of focus group data. Qualitative research, 2010. 10 (1): p. 71-89. Halkier, B., Practice theoretically inspired focus groups: Socially recognizable performativity? A New Era in Focus Group Research: Challenges, Innovation and Practice, 2017: p. 389-410. Malterud, K., Systematic text condensation: a strategy for qualitative analysis. Scand J Public Health, 2012. 40 (8): p. 795-805. Bruun, H., Milling, L., Wittrock, D., Mikkelsen, S., Huniche, L., How prehospital emergency personnel manage ethical challenges: the importance of confidence, trust, and safety. BMC Med Ethics, 2024. 25 (1): p. 58. Vetlesen, A.J., The Perseption of the Moral , in Perception, empathy, and judgment: An inquiry into the preconditions of moral performance . 2012, Penn State Press. Additional Declarations No competing interests reported. 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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-4653025","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":328878294,"identity":"2fa48c82-1707-48ad-adfe-78f710314f28","order_by":0,"name":"Lotte Huniche","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYBACPgkgkcBwgIEfxHgAZIC4DDwHcGthg2mRnAFiJBCrhQGoxeAG0Vqke8wePKi5I2d8u/ngh8Qfdxjk23MMGN6cwaNF5oy5QcKxZ8Zmd44lSyQkPGMwOPPGgHHODXwOyzGTSGw4nLjtRo4BUMthBgOJHANmng+EtdRvnpH/+QdIi/wMIrUkAA1nA9vCcAOkBa/D0sokEo4dNpxxI83MIiHtMI/BmWcFB+fg8T6/RPI2yR81h+X5ZyQ/vvHB5rCcfHvyxgdvjuHWggF4QMQBEjSMglEwCkbBKMACAPwLWKovqZr5AAAAAElFTkSuQmCC","orcid":"","institution":"University of Southern Denmark","correspondingAuthor":true,"prefix":"","firstName":"Lotte","middleName":"","lastName":"Huniche","suffix":""},{"id":328878296,"identity":"217ca424-6fb5-49fd-a966-7a0d57ae849b","order_by":1,"name":"Louise Milling","email":"","orcid":"","institution":"Odense University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Louise","middleName":"","lastName":"Milling","suffix":""},{"id":328878297,"identity":"41aa8431-9c7c-4f02-852d-3dcadc7501fb","order_by":2,"name":"Daniel Wittrock","email":"","orcid":"","institution":"The Ambulance Services in the Region of Southern Denmark","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Wittrock","suffix":""},{"id":328878299,"identity":"ea789aa1-1af5-40bc-8f49-09bc4f2bf0ce","order_by":3,"name":"Søren Mikkelsen","email":"","orcid":"","institution":"Odense University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Søren","middleName":"","lastName":"Mikkelsen","suffix":""},{"id":328878301,"identity":"d3257068-993b-4ddc-a85b-6fccd40415d7","order_by":4,"name":"Henriette Bruun","email":"","orcid":"","institution":"Mental Health Services in the Resion of Southern Denmark","correspondingAuthor":false,"prefix":"","firstName":"Henriette","middleName":"","lastName":"Bruun","suffix":""}],"badges":[],"createdAt":"2024-06-28 07:52:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4653025/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4653025/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-024-83507-z","type":"published","date":"2024-12-30T15:57:41+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":73093998,"identity":"61144047-cdff-4c2d-9043-9f421ba5ea51","added_by":"auto","created_at":"2025-01-06 16:23:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":424763,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4653025/v1/61783e5e-0dbd-4cc6-98ab-0add062bc492.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Preventing burnout from moral distress amongst prehospital emergency personnel: action research to develop and test organizationally targeted clinical ethics support","fulltext":[{"header":"Background","content":"\u003cp\u003eIn clinical practice, health care professionals are faced with medical, legal, and value-related considerations\u0026nbsp;[1, 2], that are deeply entangled with specific priorities regarding each patient and their relatives. Ethical challenges are thus unavoidably part of clinical decision-making and have been conceptualised as \u0026ldquo;a situation where there is doubt, uncertainty, or disagreement about what is morally good or right.\u0026rdquo;\u0026nbsp;[3]. Ethical challenges have been researched in different clinical settings such as somatic medicine\u0026nbsp;[4, 5], mental health\u0026nbsp;[6-8], community health\u0026nbsp;[9, 10]\u0026nbsp;and among all types of health care professionals\u0026nbsp;[11, 12]. Only few studies have focused on ethical challenges in the\u0026nbsp;prehospital emergency services,\u0026nbsp;where decision-making takes place in civil society settings, under time pressure, with limited access to information about the patient, and few possibilities for consulting with a colleague. Even if the ethical challenges are similar to those faced by clinicians in other areas of health care, the organizational framework for managing challenges differs fundamentally.\u003c/p\u003e\n\u003cp\u003eEthical challenges are associated with moral distress.\u0026nbsp;Moral distress is recognised as a serious problem among nurses, physicians, and other health care professionals as it negatively affects their wellbeing, their relations with patients, relatives, colleagues, and external collaborators\u0026nbsp;[13]. Further, moral distress is associated with burnout and the inclination to discontinue employment in health care\u0026nbsp;[14-16].\u0026nbsp;In 1984\u0026nbsp;moral distress was defined in nursing as resulting from situations \u0026ldquo;when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.\u0026rdquo;\u0026nbsp;[17]. Other studies have demonstrated that moral distress applies to a range of other health care professionals\u0026nbsp;[18]\u0026nbsp;and a\u0026nbsp;narrative synthesis of the\u0026nbsp;literature\u0026nbsp;points to the causal relationship between the experience of a moral event and psychological distress\u0026nbsp;[19]. Psychological distress is expressed as psychological and/or physical reactions. Psychological reactions may vary, but include anxiety, frustration, guilt, anger, sadness, psychological exhaustion, helplessness, and depression. Likewise, physical symptoms may include insomnia, nausea, migraines, abdominal pain, a tendency to cry, and physical exhaustion.\u003c/p\u003e\n\u003cp\u003eSupporting prehospital emergency personnel in managing ethical challenges can thus prevent moral distress turning into burnout. In turn, this can prevent spillover effects for patients, relatives, colleagues, external collaborators and may prevent personnel from resigning. Clinical ethics support can assist health care professionals in managing ethical challenges, and include clinical ethics committees [20, 21], clinical ethics consultation [22, 23], moral case deliberations [24, 25], and ethics reflection groups [26, 27]. The organisation of these support initiatives vary (table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1: Three organisational forms of clinical ethics support\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.641744548286605%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.439252336448597%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical ethics committees\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.037383177570092%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical ethics consultation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.881619937694705%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMoral case deliberation Ethics reflection groups\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.641744548286605%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow does it work?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.439252336448597%\" valign=\"top\"\u003e\n \u003cp\u003eA permanent committee discusses specific cases or general questions raised by hospital management, administration, clinicians, patients, or relatives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.037383177570092%\" valign=\"top\"\u003e\n \u003cp\u003eA professional ethicist (or small team of ethicists) meets with clinicians routinely or on request to discuss ethical challenges experienced by clinicians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.881619937694705%\" valign=\"top\"\u003e\n \u003cp\u003eA group of colleagues meet to discuss ethical challenges in clinical practice. A facilitator structures the process\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.641744548286605%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow is it organised?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.439252336448597%\" valign=\"top\"\u003e\n \u003cp\u003eBy one or several hospitals in a region\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.037383177570092%\" valign=\"top\"\u003e\n \u003cp\u003eBy an ethicist employed at the hospital or as part of the services of a clinical ethics committee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.881619937694705%\" valign=\"top\"\u003e\n \u003cp\u003eWithin or across clinical units and departments\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.641744548286605%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWho facilitates?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.439252336448597%\" valign=\"top\"\u003e\n \u003cp\u003eAn ethicist or clinician trained as an ethics facilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.037383177570092%\" valign=\"top\"\u003e\n \u003cp\u003eAn ethicist or a clinician trained as an ethics facilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.881619937694705%\" valign=\"top\"\u003e\n \u003cp\u003eAn ethicist or a clinician trained as an ethics facilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"14.641744548286605%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWho parti-cipates?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.439252336448597%\" valign=\"top\"\u003e\n \u003cp\u003eMultidisciplinary clinicians, ethicists, priests, municipality representatives, lawyers, at times patients, relatives, or their representatives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.037383177570092%\" valign=\"top\"\u003e\n \u003cp\u003eMultidisciplinary clinicians from a clinical unit or department\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.881619937694705%\" valign=\"top\"\u003e\n \u003cp\u003eMultidisciplinary clinicians from a clinical unit or department\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eClinical ethics committees take a top-down approach and commonly provide advice or recommendations [28]. Bottom-up approaches, such as moral case deliberation and ethics reflection groups, engage and stimulate reflection among clinicians about ethical challenges in their day-to-day work. Clinical ethics consultation is commonly led by professional ethicists and combines a top-down with a bottom-up approach. All of these forms of clinical ethics support are, for different reasons, ill-suited to the context of the prehospital emergency services. Thus, the aim of our study was to investigate ethical challenges and management strategies in prehospital settings and on that basis to develop and test organisationally targeted forms of ethics support to prevent moral distress turning into burnout or cause personnel to leave the emergency services.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eBased on action research [29, 30] a core research group was established whose members (the authors of this paper) planned and coordinated the collaborative efforts aimed to investigate ethical challenges and management strategies (phase one: a focus group study), and to develop and test clinical ethics support targeted at core settings of the emergency services in the Region of Southern Denmark (phase two).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe prehospital emergency services in Denmark\u003c/p\u003e\n\u003cp\u003eThe research project was based in the prehospital research unit in the Region of Southern Denmark, one of five health regions in Denmark. It covers an area of 12.191 km\u0026sup2; with a population of 1.2 million. The Danish welfare state provides all citizens with access to free healthcare including the prehospital medical services, which are three-tiered. When a caller contacts the emergency dispatch center, the healthcare dispatcher takes the call and dispatches one or more of the following units: 1) An ambulance manned with two emergency medical technicians (EMTs) or paramedics (PMs) [31], 2) An ambulance and a rapid response paramedic unit, 3) An ambulance and an anesthesiologist-manned mobile emergency care unit (MECU) or helicopter (HEMS). Three in four missions are carried out by EMTs or paramedics alone, either as an ambulance or an ambulance supplemented by a paramedic-manned rapid response vehicle. MECUs or HEMS are dispatched in approximately one in four missions along with an ambulance according to a rendezvous model [32]. The dispatchers\u0026rsquo; choice of ground-based or helicopter-based supplementary unit is dependent upon the geographical location of the incident, the medical needs of the patient, the estimated response times, and subsequent transport times to hospital.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDesign of the focus group study\u003c/p\u003e\n\u003cp\u003eTo provide a knowledge base for developing and testing organisationally targeted forms of clinical ethics support a focus group study including three focus groups was conducted [33]. \u0026nbsp;Focus groups were chosen to elicit narrative descriptions based on social interaction amongst participants [34, 35]. The purpose was to gain insight into ethically challenging situations along with clinical reasoning and social negotiations concerning the best course of action for the patient and others involved in the specific circumstances. The participants were recruited through an internal prehospital information network. The majority of the ambulance crew participants were full-time employees and commonly teamed up with the same colleague during most shifts. Likewise, most of the anaesthesiologists had been manning the local MECUs since the inception in 2006. On average their prehospital workload was between two and five monthly 24-hour shifts, supplementing their in-hospital work. In total, 15 EMTs, PMs, and MECU physicians participated in the three focus groups [33] (table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2: Focus group participants\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.49586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrehospital emergency personnel\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.75206611570248%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMECU physicians\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.75206611570248%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEMTs and PMs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.49586776859504%\" valign=\"top\"\u003e\n \u003cp\u003eFocus group 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.75206611570248%\" valign=\"top\"\u003e\n \u003cp\u003e2 male, 0 female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.75206611570248%\" valign=\"top\"\u003e\n \u003cp\u003e2 male, 0 female\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.49586776859504%\" valign=\"top\"\u003e\n \u003cp\u003eFocus group 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.75206611570248%\" valign=\"top\"\u003e\n \u003cp\u003e1 male,1 female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.75206611570248%\" valign=\"top\"\u003e\n \u003cp\u003e4 male, 0 female\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.49586776859504%\" valign=\"top\"\u003e\n \u003cp\u003eFocus group 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.75206611570248%\" valign=\"top\"\u003e\n \u003cp\u003e1 male, 1 female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.75206611570248%\" valign=\"top\"\u003e\n \u003cp\u003e2 male, 1 female\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.49586776859504%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.75206611570248%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e4 male, 2 female\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.75206611570248%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e8 male, 1 female\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEach focus group lasted two hours and was conducted\u0026nbsp;in a meeting room at an ambulance station. Authors LH and HB facilitated all three focus groups while LM collected written consent forms and audio recorded the sessions. During focus groups notes were written on a flip chart in plain view for all to comment. Authors SM and DW did not participate in the focus groups in any capacity due to their respective positions as lead consultant of the MECU and head of the department for quality and education in the regional ambulance services.\u003c/p\u003e\n\u003cp\u003eAudio files were transcribed verbatim. During transcription and further processing of data, any names of persons and places mentioned during the focus groups were pseudonymised. Audio files, interview transcripts, and photographs of the flip charts were stored on a secure server.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData analyses\u003c/p\u003e\n\u003cp\u003eData were transferred to and systematised in NVivo (QSR International, Burlington, Massachusetts, USA). The analytic procedure was guided by systematic text condensation [36]. First, all transcripts were read to gain an overall impression of the content. As data proved rich in descriptions of both experiences with and management of ethical challenges, the research team decided to focus on each separately. The first round of analysis focused on the ethical challenges experienced from the first-person perspectives of the prehospital emergency personnel in their clinical day-to-day work [33]. The second round focussed on ways of managing ethical challenges [37].\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e Prehospital emergency personnel conveyed that from their first-person perspective ethical challenges arise in day-to-day work when clinical guidelines, legal requirements, and clinicians\u0026rsquo; professional and personal value systems are in conflict and complicate decision-making processes. Ethical challenges arise in contexts of 1) caring for patients, 2) managing organizational demands, 3) collaborating.\u003c/p\u003e \u003cp\u003eIn the context of caring for patients\u003c/p\u003e \u003cp\u003eEthical challenges arise during incidents when the patients\u0026rsquo; autonomous decision-making capacity is reduced or absent. For example, in unconscious or semi-conscious patients with cardiac arrest or severe trauma, and in patients with impaired cognitive functioning due to organ malfunctioning, head injury, anxiety, pain, shock, or substance abuse. Reduced or absent decision-making capacity renders it difficult or impossible for the prehospital emergency personnel to honor the patients\u0026rsquo; right to participate in decisions related to their health. In such situations, the personnel has no choice but to determine the best course of action for the patient without their input or clearly statet consent.\u003c/p\u003e \u003cp\u003eExamples involve patients with cardiac arrest where experienced EMTs and PMs find it ethically challenging if they have to put legal requirements to start resuscitation before what they consider to be in the best interest of a patient. In cases involving intoxicated and incapacitated patients a typical ethical challenge concerns the patient refusing what the personnel consider necessary medical attention in a hospital. In other cases the personnel are ethically challenged when they are not able to treat or refer patients to appropriate professional assistance. For example, in cases where patients suffer from mental health issues or long term substance abuse. With no alternative treatment option spending time caring for such patients means withholding vital ambulance resources.\u003c/p\u003e \u003cp\u003eOther kinds of ethically challenging situations arise when the patient is a child or an adolescent. Several examples of infants dying at home or in the ambulance were mentioned during the focus groups. Such events shift the focus from caring for the patient to caring for parents, siblings, and others present at the scene, including colleagues. In the prehospital setting, no procedure is available for sufficiently addressing the emotional needs of those present at a child\u0026rsquo;s death. In other cases, the ethical challenge is about deciding if a child without any signs of severe disease should be taken to hospital for further examination to calm extremely worried and insecure parents. Conversely, the personnel can face a difficult decision about whether or not to report potential threaths to the health and safety of children. Despite their extended legal obligation to notify the social services, the clinicians find these situations ethically challenging and morally distressing. Unless there are obvious signs of abuse or physical danger the clinicians\u0026rsquo; decision rests on a snapshot of the child\u0026rsquo;s circumstances. They must form an immediate opinion without having any say in what happens next and with no means of knowing whether a notification to the authorities will turn out to be helpful or might ultimately cause more harm than good to the child and the family.\u003c/p\u003e \u003cp\u003eEthical challenges are also related to taking the considerations of relatives into account when evaluating what is in the best interest of an adult patient. Sometimes relatives or others who are involved in the life and care of a patient can constitute an invaluable source of information regarding a patient\u0026rsquo;s medical history, cultural traditions, and personal preferences. On the other hand, relatives can get in the way or even obstruct the efforts of the personnel if intoxicated, emotionally distressed, or suffering from mental health issues. Some relatives actively injure or cause harm to patients, some are vulnerable and potentially in need of care themselves. Relatives do on occasion insist on treatment and procedures that are not medically indicated, nor in the best interest of the patient: \u0026ldquo;If the relatives expect that [non-indicated] treatment will be initiated, one can \u0026lsquo;hurry slowly\u0026rsquo;, give a little oxygen on a face mask and a probe on the finger, then it looks as if something is being done anyway.\u0026rdquo;\u003c/p\u003e \u003cp\u003eSometimes personnel are confronted with patient values grounded in unfamiliar religious or cultural traditions and may either not know, not understand, or downright disagree with them. Thus, personnel can be ethically challenged and morally distressed by patient choices that go against their professional judgement or personal values.\u003c/p\u003e \u003cp\u003eIn the context of managing organizational demands\u003c/p\u003e \u003cp\u003ePrehospital emergency personnel can be ethically challenged when balancing their professional and legal duties towards the patient with safeguarding themselves, colleagues, and others. One example is the transportation of very sick patients at high-speed using lights and sirens versus the safety of ambulance passengers and bystanders. Another example is treating patients while handling angry and violent relatives posing a threat to personnel or others. One further example is weighing out the risks of entering premises that expose personnel to physical danger such as fire, explosives, or structural collapse versus getting to patients requiring immediate care.\u003c/p\u003e \u003cp\u003eOther ethically challenging balancing acts involve values related to the responsible use of prehospital resources. For example EMTs and PMs sometimes struggle when patients are assigned to an ambulance, if the patient has no clinically indicated need for emergency transportation:\u003c/p\u003e \u003cp\u003eIt\u0026rsquo;ll take an hour and a half to transport this patient to the hospital, who in principle should drive himself. That is an hour and a half where we are not available [for other tasks], where an ambulance is taken out of service to transport this broken finger.\u003c/p\u003e \u003cp\u003eConversely, personnel are relatively frequently challenged to the point of moral distress when leaving a bereaved relative, a mentally ill patient, or others whose needs do not explicitly fall within the remit of emergency care in order to ensure sufficient capacity for other incidents. A particular challenge is when EMTs and PMs are repeatedly called out to patients with mental health issues:\u003c/p\u003e \u003cp\u003eMany of our patients are \u0026lsquo;regulars\u0026rsquo;. Recently we had a patient where I was kind of shocked that he wasn\u0026rsquo;t admitted to a place with only a handle on the outside of the door [a psychiatric ward]. He sits and stabs himself deeply in the stomach with a knife. We transport [the patient] to [the emergency department]... He is stitched up and discharged with a \u0026ldquo;have a nice day\u0026rdquo;.\u003c/p\u003e \u003cp\u003eEqually, for some personnel it is ethically challenging to witness how patients with a long history of abuse do not really benefit from emergency interventions or hospital-based treatment, but to have nowhere else to refer these patients to.\u003c/p\u003e \u003cp\u003eIn the context of collaborating\u003c/p\u003e \u003cp\u003eIn day-to-day collaboration within the emergency services a common ethical challenge for EMTs and PMs is being tasked with or expected to accept courses of action that they do not believe are right. A value conflict can follow between loyalty towards a decision made at the dispatch center or by a superior versus loyalty to one\u0026rsquo;s own conviction regarding \u0026lsquo;best treatment\u0026rsquo;. In such situations potential benefits from attempting to change a course of action is weighed against the risks for the patient of a delay (however short) and of causing anxiety and mistrust in both patients and relatives as this may undermine their confidence in the actions of the whole team. Occasionally conflicts regarding the best course of action to treat a patient also arise among EMTs and PMs. This is a reason why most prefer to team up with the same few colleagues who they know and trust to share similar values.\u003c/p\u003e \u003cp\u003ePrehospital emergency personnel also interact or collaborate with a wide range of professionals from other services on a daily basis. These include nursing homes, emergency departments, psychiatric units, shelters for the homeless, the police, the fire brigade, etc.\u003c/p\u003e \u003cp\u003eA common ethical challenge relates to collaboration around end-of-life decisions in nursing homes. Particularly during evening and night shifts care assistants may be temporarily employed with no or limited medical training, and may call on the emergency services in situations when emergency intervention is not necessarily in the best interest of an old, fragile resident with serious comorbidities. In cases where an advance directive exists, care assistants might not know where it is kept or cannot access it. Prehospital emergency personnel agree that dying peacefully and with dignity is preferable to dying during futile interventions or while being rushed to a hospital.\u003c/p\u003e \u003cp\u003eSometimes, when we are dispatched to patients who are perhaps very old or physiologically in a miserable state, then, if you apply a certain ethical approach, you can say that it might be better not to move heaven and earth rushing [the patient] to hospital for them to die in a strange place. Instead, why don\u0026rsquo;t we call the next of kin.\u003c/p\u003e \u003cp\u003eHowever, even if advance directives are available they do not always solve the ethical challenge of securing a dignified death. Often, advance directives are incomplete or outdated. In these cases, EMTs and PMs are legally obliged to initiate resuscitation and continue until a physician has decided to terminate treatment.\u003c/p\u003e \u003cp\u003eEthically challenging situations also arise in relation to collaboration with police authorities. In cases where a person dies unwitnessed the police is required to investigate. Consequently, personnel and police officers attend the scene for different reasons and have different tasks. The clinicians are tasked with confirming death and attending to the body while the police are tasked with assessing whether the death is the result of a criminal act. These different roles and tasks may result in opposing approaches to the situation, the deceased, and in particular, to any relatives present at the scene.\u003c/p\u003e \u003cp\u003eStrategies for managing ethical challenges\u003c/p\u003e \u003cp\u003eActions based on ethical considerations can be coined as \u003cem\u003emoral conduct\u003c/em\u003e [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. In this definition moral conduct is broken down into a three-part sequence initiated by \u003cem\u003emoral perception\u003c/em\u003e, followed by \u003cem\u003emoral judgment\u003c/em\u003e, leading to \u003cem\u003emoral action\u003c/em\u003e. Moral perception is a precondition for moral judgement and involves the individual being receptive to the events taking place. Moral judgement encompasses the interpretation, understanding, and balancing of the welfare, interests, and rights of the concerned parties. The ability to perceive what is morally significant and to feel affected by a situation that affects the well-being of others is furthermore an expression of the individual\u0026rsquo;s capacity for empathy. Empathy is thus an important aspect of moral conduct.\u003c/p\u003e \u003cp\u003eMoral perception\u003c/p\u003e \u003cp\u003eIn health care morally relevant perception pertains to any signs that indicate the patient\u0026rsquo;s state of health or can otherwise contribute to an understanding of the patient\u0026rsquo;s situation. A typical strategy reported by prehospital emergency personnel is gathering as much information about the patient as possible to aid the decision-making further down the line, including decisions that may prove ethically challenging. Examples are picking up on signs around the home, e.g. assistive devises, daily medication, a hospital bed, a pre-packed box of palliative medication, etc.\u003c/p\u003e \u003cp\u003eWell, [we try to] understand what the medical history is, along with what [we] find in the patient [\u0026hellip;], are there any medical records or papers, is there anything [that can inform us about the patient\u0026rsquo;s condition]. What kind of medication is given, if any. It can be very informative, and also, has the patient been declared terminally ill? Okay then we know, then someone has decided [the level of treatment], and we more or less know where we are in the process.\u003c/p\u003e \u003cp\u003eMoral judgement\u003c/p\u003e \u003cp\u003eMoral judgement is guided by various resources. Some physicians refer to bioethical principles such as utilitarianism, e.g. to arrive at the greatest good for the greatest number. Other principles mentioned are paternalism and autonomy, e.g. when considering when and how a patient should be consulted and have a say in decisions relevant to their health and welfare:\u003c/p\u003e \u003cp\u003eThe fact is that you, as a physician, at least to some extent, think in that slightly paternalistic way; we are trained like that a bit, and may have to make some decisions on behalf of others [who are incapacitated]. But that autonomy thing, it doesn\u0026rsquo;t apply to them [most prehospital patients]. I\u0026rsquo;m trained in making decisions and things like that, but I\u0026rsquo;m not always sure that it\u0026rsquo;s the right one [\u0026hellip;] Maybe the patient is admitted [to hospital], and then, you know what, no complaints. I can go home at nine o\u0026rsquo;clock tomorrow morning, and I won\u0026rsquo;t hear any more of it. On the other hand, if you dare to stick out your neck a little and maybe do the right thing by letting them [the patients] stay at home, you might\u0026hellip; [get into trouble].\u003c/p\u003e \u003cp\u003eSome personnel also referred to a non-specific \u0026ldquo;gut feeling\u0026rdquo; as a basis for moral judgement. A PM explained how he relied on his gut feeling to guide his classification of patients as conscious and competent or not, and from that decided on relevant action. One physician drew attention to the ethical challenges arising from his negative moral judgement of particular patients such as rapists or violent offenders. In the light of selective negative moral judgement it can be a challenge to empathise with and treat all patients equally. Further, experienced personnel reported that generally their moral judgment had changed over time and with increased experience.\u003c/p\u003e \u003cp\u003eMoral action\u003c/p\u003e \u003cp\u003eEMTs, PMs, and physicians have different scopes for moral action, as their tasks and responsibilities differ. For the most part EMTs and PMs work independently at the scene and engage in moral perception, judgement, and action without the presence of a physician. However, most EMTs and PMs regularly request support from a physician for example if they need their \u0026ldquo;backs covered\u0026rdquo;, look for \u0026ldquo;an assessment of available options\u0026rdquo;, or want \u0026ldquo;help to settle a disagreement\u0026rdquo;. Whether physicians are present or not, it is important to the EMTs and PMs that they have confidence in the physicians\u0026rsquo; medical competences as a basis for decision-making and moral action, whether they agree with them or not. However, sometimes the EMTs and PMs feel overruled by physicians, for example if they do not make their reasons explicit or do not take the considerations of the EMTs or PMs into account when deciding on a course of action. EMTs and PMs employ various strategies to influence physicians to take the kinds of actions that they would prefer, such as trying to point out alternatives or using sarcasm. On occasions, an EMT or PM disagrees with a physician to an extent where they see not other option than to withdraw from the situation altogether. For example by turning to legitimate practical tasks unrelated to the treatment of the patient, such as preparing the ambulance for leaving the scene.\u003c/p\u003e \u003cp\u003eThe physicians stage their professional competencies as the starting point for assessing the optimal action in a specific situation. In addition, the physicians\u0026rsquo; actions are guided by legal requirements. The physicians are aware that what is legally warranted may not always be in the best interest of the patient or relatives, and the risk of a complaint sometimes plays a role in decision-making:\u003c/p\u003e \u003cp\u003eSo if you just, well, if you\u0026rsquo;re a doctor, for example, and you admit everyone, you\u0026rsquo;ll never get your ass on the line. There will never be any formal complaints. [\u0026hellip;] There are no relatives who complain that their relative has been admitted to hospital. Isn\u0026rsquo;t it just fantastic? But they don\u0026rsquo;t understand what it means to be admitted to the hospital when you are 90 years old, confused, demented.\u003c/p\u003e \u003cp\u003eAlthough the considerations of the EMTs and PMs are generally not the physicians\u0026rsquo; top priority, some are conscious of actively involving EMTs and PMs in the decision-making process. The physicians are aware that their decisions and actions, including their personal conduct, have an impact on how an incident is managed overall. If a physician is considered as acting in an unprofessional, unreasonable, or ethically questionable manner, it can affect the entire team and their actions.\u003c/p\u003e \u003cp\u003eOrganisational support of moral conduct\u003c/p\u003e \u003cp\u003eIn the present study the EMTs, PMs, and physicians all stress that medically and morally sound patient care depend on mutually respectful and supportive working relations. Further, they point out that sharing thoughts on ethical challenges is important not just for qualifying patient care and for maintaining good working relations, but also for long-term mental health and work satisfaction among personnel. At the time of the investigation the emergency services in the region of Southern Denmark have debriefing and defusing procedures in place, but no clinical ethics support. Personnel address ethical challenges and value conflicts in \u003cem\u003einformal settings\u003c/em\u003e, such as en route in the ambulance or rapid response vehicle, at the ambulance station between assignments, and occasionally outside work with colleagues, or a family member or friend with a background in health care:\u003c/p\u003e \u003cp\u003eThe biggest challenge in the ambulance is that it obviously depends a lot on who you are driving with. [\u0026hellip;] I would be more inclined to have a defusing session or a conversation about certain matters with a colleague I already know and trust, than someone I only just met on\u0026hellip; [this particular shift].\u003c/p\u003e \u003cp\u003ePhysicians have the opportunity to introduce and discuss ethically challenging issues at mandatory monthly meetings for physicians only. This forum is described as providing a legitimate and safe space for sharing and discussing actions taken.\u003c/p\u003e \u003cp\u003eIn general sharing and discussing ethical challenges presupposes confidence inspired by medical skills and experience, trust that conversational partners will respond caringly and with integrity, and last but not least, organisational safety, i.e. to be able to rest assured that conveying difficulties or uncertainty does not entail repercussions.\u003c/p\u003e \u003cp\u003eDeveloping and testing clinical ethics support\u003c/p\u003e \u003cp\u003eBased on the investigation of ethical challenges and management strategies, and on insider knowledge of organisational structures, the members of the project group agreed to anchor the development of targeted clinical ethics support in a particular model for structured ethics reflection [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Three settings within the prehospital emergency services in the region of Southern Denmark were targeted for the development and testing phase.\u003c/p\u003e \u003cp\u003eSetting 1: Prehospital anaesthesiologists\u0026rsquo; monthly meetings\u003c/p\u003e \u003cp\u003e The research project and the model was introduced to the prehospital anaesthesiologists and structured ethics reflection was facilitated by HB and LH at three concecutive meetings. This was followed up by an evaluation and discussion of how to proceed with ethics reflection among the anesthesiologists themselves and how anesthesiologists might support ethics reflection in relevant contexts of day-to-day clinical practice with other personnel.\u003c/p\u003e \u003cp\u003eSetting 2: Regional training modules for EMTs and PMs\u003c/p\u003e \u003cp\u003eCollaboration was established with two key employees within the regional ambulance service, namely the head of the department for quality and education, and the team leader of the instructors who run in-house training modules for EMTs and PMs. It was agreed to run a work shop involving all instructors in the region to introduce the research project and to work with the model for structured ethics reflection. At a second workshop HB and LH once more facilitated instructors engagement with the model, followed by a discussion of ways to introduce ethics reflection in training modules. Concerns were raised, that the full-fledged model would not be practicable within the module structure, neither would it be staright forward to engage all employees in this kind of activity. Following on from the workshops, a go-to version of the model was integrated into a three-part training module on rhabdomyolysis. Participants would be devided into three groups and groups would circle the three parts of the module in turn. The part on structured ethics reflection involved an oral case presentation and six discussion cards, each stating one to three questions inspired by the model for structured ethics reflection on the one side, and inspirational suggestions for further discussion on the other.\u003c/p\u003e \u003cp\u003eSetting 3: Supervison for peer-supporters\u003c/p\u003e \u003cp\u003eCollaboration was also established with two ambulance station managers who are supervising a group of ambulance personnel from the region tasked with offering work related peer-support to colleagues. The station managers suggested that the research project and the model for structured ethics reflection be introduced to the peer-supporters. At their request, a second meeting was agreed on to try out the full-fledged model for structured ethics reflection. Subsequently, the project group collaborated with the supervisors on transforming elements of the model into supportive tools in the day-to-day work of the peer-supporters.\u003c/p\u003e \u003cp\u003eThe third and final phase of the research project will be concerned with implementing and investigating clinical ethics support in training modules and through the actions of anesthesiologists and peer-supporters.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAs ethical challenges are commonly complex and pertain to more than a single person prevented from doing the right thing, individual coping strategies are rarely sufficient [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Structuring the dialogue through ethics reflection groups or moral case deliberation can lead to an experience of mental relief and stress reduction among health professionals [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThese forms of clinical ethics support are, however, ill-suited to the context of the prehospital emergency services for several reasons. First, prehospital emergency personnel spend most of their working hours \u0026ldquo;in the field\u0026rdquo; which challenges the practical feasibility of any of these forms of support. Second, the emergency services employ personnel with very diverse backgrounds which makes for different educational exposure to and experiences with \u0026ldquo;ethics\u0026rdquo;. Third, all though this is changing, the emergency services still harbour what has been termed a \u0026ldquo;macho\u0026rdquo; workplace culture which tends to interfere with the confidence and trust necessary for dialogues on how to manage ethical challenges. Other forms of clinical ethics support need to be developed and tested in the context of the prehospital emergency services to be organizationally viable. The results of the present action research project suggest that developing and testing context sensitive clinical ethics support is best qualified by a bottom up and highly collaborative approach.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOver time, ethical challenges and the ensuing moral distress can result in burnout with a range of negative consequences for the involved and with personnel leaving the emergency services. Confidence and trust in colleagues, managers, and the organization are prerequisites for sharing experiences of morally distressing events in the workplace. Traditional forms of clinical ethics support (clinical ethics committees, clinical ethics consultation, moral case deliberation, and ethics reflection groups) are ill suited to the organisational setup of the emergency services. This points out a need for organisational support for personnel to address and manage morally distressing situations collectively and productively. Organizationally targeted and context sensitive forms of structured ethics support can address moral distress, prevent burnout, and contribute to the building of a supportive and attractive working environment in the emergency services.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe acknowledge the engagement and time of the prehospital emergency personnel who took part in this study. We recognise that speaking up on sensitive issues can be challenging and take courage even in organisational contexts where participants feel relatively safe to do so.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthor contributions\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;HB, LH and SM decided on the overall methodology and design of the study. LH and HB prepared and conducted the focus groups assisted by LM. Data analysis and manuscript drafting was carried out by LH and HB assisted by DW, LM and SM who contributed with specialist knowledge and revisions. All authors approved the final manuscript before submission.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData availability statement\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdditional information\u003c/p\u003e\n\u003cp\u003eThe project is registered with the Danish Data Protection Agency (20/63051). According to Danish legislation interview-based studies do not require approval by a research ethics committee, which was confirmed in a mail to HB from The National Committee on Health Research Ethics in Denmark on March 8, 2021 (20202000-205). Research activities were performed in accordance with relevant guidelines and the Declaration of Helsinki. All participants received verbal and written project information, including their right to withdraw at any time. All participants gave their written consent to participation and publication of identifying information in an oline open-access publication. The authors have no competing interests as defined by Nature Research, or other interests that might be perceived to influence the results and/or discussion reported in this paper.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFoster, C., Miola, J., \u003cem\u003eWho\u0026acute;s in charge? The relationship between medical law, medical ethics, and medical morality? .\u003c/em\u003e Med Law Rev, 2015. \u003cstrong\u003e23\u003c/strong\u003e(4): p. 505-30.\u003c/li\u003e\n\u003cli\u003eCole, R., Stone, M., Ruck K. A., Fritz, Z., \u003cem\u003eFamily members, ambulance clinicians and attempting CPR in the community: the ethical and legal imperative to reach collaborative consensus at speed.\u003c/em\u003e J Med Ethics, 2021. \u003cstrong\u003e47\u003c/strong\u003e(10): p. 650-653.\u003c/li\u003e\n\u003cli\u003eHem, M.H., Molewijk, B., Gjerberg, E., Lillemoen, L., Pedersen, R., \u003cem\u003eThe significance of ethics reflection groups in mental health care: a focus group study among health care professionals.\u003c/em\u003e BMC Med Ethics, 2018. \u003cstrong\u003e19\u003c/strong\u003e(1): p. 54.\u003c/li\u003e\n\u003cli\u003eJimenez-Herrera, M.F., Axelsson, C., \u003cem\u003eSome ethical conflicts in emergency care.\u003c/em\u003e Nurs Ethics, 2015. \u003cstrong\u003e22\u003c/strong\u003e(5): p. 548-60.\u003c/li\u003e\n\u003cli\u003eForde, R., Vandvik, I. H., \u003cem\u003eClinical ethics, information, and communication: review of 31 cases from a clinical ethics committee.\u003c/em\u003e J Med Ethics, 2005. \u003cstrong\u003e31\u003c/strong\u003e(2): p. 73-7.\u003c/li\u003e\n\u003cli\u003eBruun, H., Lystbaek, S.G.., Stenager, E., Huniche, L., Pedersen, R., \u003cem\u003eEthical challenges assessed in the clinical ethics Committee of Psychiatry in the region of Southern Denmark in 2010-2015: a qualitative content analyses.\u003c/em\u003e BMC Med Ethics, 2018. \u003cstrong\u003e19\u003c/strong\u003e(1): p. 62.\u003c/li\u003e\n\u003cli\u003eMolewijk, B., Hem, M. H., Pedersen, R., \u003cem\u003eDealing with ethical challenges: a focus group study with professionals in mental health care.\u003c/em\u003e Bmc Medical Ethics, 2015. \u003cstrong\u003e16\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003ePelto-Piri, V., Engstr\u0026ouml;m, K., Engstr\u0026ouml;m, I., \u003cem\u003eStaffs\u0026acute; perception of the ethical landscape in psychiatric inpatient care: A qualitative content analysis of ethical diaries. .\u003c/em\u003e Clinical Ethics, 2014. \u003cstrong\u003e9\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003eLillemoen, L. and R. Pedersen, \u003cem\u003eEthics in Municipal Health Services: Working Systematically with, and Developing Competence in Ethics.\u003c/em\u003e Clinical Ethics, 2013. \u003cstrong\u003e8\u003c/strong\u003e(1): p. 19-28.\u003c/li\u003e\n\u003cli\u003evan der Dam, S., Abma, T. A., Kardol, M. J., Widdershoven, G. A., \u003cem\u003e\u0026quot;Here\u0026apos;s my dilemma\u0026quot;. Moral case deliberation as a platform for discussing everyday ethics in elderly care.\u003c/em\u003e Health Care Anal, 2012. \u003cstrong\u003e20\u003c/strong\u003e(3): p. 250-67.\u003c/li\u003e\n\u003cli\u003eHurst, S.A., et al., \u003cem\u003eEthical difficulties in clinical practice: experiences of European doctors.\u003c/em\u003e Journal of medical ethics, 2007. \u003cstrong\u003e33\u003c/strong\u003e(1): p. 51-57.\u003c/li\u003e\n\u003cli\u003eK\u0026auml;lvemark, S., H\u0026ouml;glund, A., Hansson, M., Westerholm, P., Arnetz, B., \u003cem\u003eLiving with conflicts-ethical dilemmas and moral distress in the health care system.\u003c/em\u003e Social science \u0026amp; medicine, 2004. \u003cstrong\u003e58\u003c/strong\u003e(6): p. 1075-1084.\u003c/li\u003e\n\u003cli\u003eBurston, A., Tuckett, A., \u003cem\u003eMoral distress in nursing: contributing factors, outcomes and interventions.\u003c/em\u003e Nurs Ethics, 2013. \u003cstrong\u003e20\u003c/strong\u003e(3): p. 312-24.\u003c/li\u003e\n\u003cli\u003eSilverman, H., et al., \u003cem\u003eEthical decision-making climate, moral distress, and intention to leave among ICU professionals in a tertiary academic hospital center.\u003c/em\u003e Bmc Medical Ethics, 2022. \u003cstrong\u003e23\u003c/strong\u003e(1).\u003c/li\u003e\n\u003cli\u003eGhazanfari, M.J., et al., \u003cem\u003eMoral distress in nurses: Resources and constraints, consequences, and interventions.\u003c/em\u003e Clinical Ethics, 2022. \u003cstrong\u003e17\u003c/strong\u003e(3): p. 265-271.\u003c/li\u003e\n\u003cli\u003eTrautmann, J., Epstein, E., Rovnyak, V., Snyder, A., \u003cem\u003eRelationships among moral distress, level of practice independence, and intent to leave of nurse practitioners in emergency departments: results from a national survey.\u003c/em\u003e Advanced Emergency Nursing Journal, 2015. \u003cstrong\u003e37\u003c/strong\u003e(2): p. 134-145.\u003c/li\u003e\n\u003cli\u003eJameton, A., \u003cem\u003eWhat Moral Distress in Nursing History Could Suggest about the Future of Health Care.\u003c/em\u003e AMA J Ethics, 2017. \u003cstrong\u003e19\u003c/strong\u003e(6): p. 617-628.\u003c/li\u003e\n\u003cli\u003eQuek, C.W.N., et al., \u003cem\u003eSystematic scoping review on moral distress among physicians.\u003c/em\u003e BMJ Open, 2022. \u003cstrong\u003e12\u003c/strong\u003e(9): p. e064029.\u003c/li\u003e\n\u003cli\u003eMorley, G., Ives, J., Bradbury-Jones, C., Irvine, F., \u003cem\u003eWhat is \u0026lsquo;moral distress\u0026rsquo;? A narrative synthesis of the literature.\u003c/em\u003e Nursing ethics, 2019. \u003cstrong\u003e26\u003c/strong\u003e(3): p. 646-662.\u003c/li\u003e\n\u003cli\u003eCrico, C., Sanchini, V., Casali, Paolo G., Pravettoni, P., \u003cem\u003eEvaluating the effectiveness of clinical ethics committees: a systematic review.\u003c/em\u003e Med Health Care Philos, 2021. \u003cstrong\u003e24\u003c/strong\u003e(1): p. 135-151.\u003c/li\u003e\n\u003cli\u003eForde, R., Pedersen, R., \u003cem\u003eClinical ethics committees in Norway: what do they do, and does it make a difference?\u003c/em\u003e Camb Q Healthc Ethics, 2011. \u003cstrong\u003e20\u003c/strong\u003e(3): p. 389-95.\u003c/li\u003e\n\u003cli\u003eBell, J.A.H., et al., \u003cem\u003eClinical ethics consultations: a scoping review of reported outcomes.\u003c/em\u003e BMC Med Ethics, 2022. \u003cstrong\u003e23\u003c/strong\u003e(1): p. 99.\u003c/li\u003e\n\u003cli\u003eReiter-Theil, S., \u003cem\u003eEthics consultation on demand: concepts, practical experiences and a case study.\u003c/em\u003e Journal of Medical Ethics, 2000. \u003cstrong\u003e26\u003c/strong\u003e(3): p. 198-203.\u003c/li\u003e\n\u003cli\u003eHaan, M.M., van Gurp, J. L. P., Naber, N. M., Groenewoud, A. S., \u003cem\u003eImpact of moral case deliberation in healthcare settings: a literature review.\u003c/em\u003e BMC Med Ethics, 2018. \u003cstrong\u003e19\u003c/strong\u003e(1): p. 85.\u003c/li\u003e\n\u003cli\u003eKok, N., et al., \u003cem\u003eEffect of Structural Moral Case Deliberation on Burnout Symptoms, Moral Distress, and Team Climate in ICU Professionals: A Parallel Cluster Randomized Trial.\u003c/em\u003e Critical Care Medicine, 2023: p. 10.1097/CCM.0000000000005940.\u003c/li\u003e\n\u003cli\u003eLillemoen, L., Pedersen, R., \u003cem\u003eEthics reflection groups in community health services: an evaluation study.\u003c/em\u003e Bmc Medical Ethics, 2015. \u003cstrong\u003e16\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003eBruun, H., Huniche, L., Stenager, E., Mogensen, C. B.., Pedersen, R., \u003cem\u003eHospital ethics reflection groups: a learning and development resource for clinical practice.\u003c/em\u003e BMC Med Ethics, 2019. \u003cstrong\u003e20\u003c/strong\u003e(1): p. 75.\u003c/li\u003e\n\u003cli\u003eRasoal, D., Skovdahl, K., Gifford, M., Kihlgren, A., \u003cem\u003eClinical ethics support for healthcare personnel: an integrative literature review.\u003c/em\u003e Hec Forum, 2017. \u003cstrong\u003e29\u003c/strong\u003e: p. 313-346.\u003c/li\u003e\n\u003cli\u003eMcCormack, B., \u003cem\u003eAction research for the implementation of complex interventions\u003c/em\u003e, in \u003cem\u003eComplex interventions in health\u003c/em\u003e. 2015, Routledge. p. 326-337.\u003c/li\u003e\n\u003cli\u003eMalterud, K., \u003cem\u003eAction research--a strategy for evaluation of medical interventions.\u003c/em\u003e Fam Pract, 1995. \u003cstrong\u003e12\u003c/strong\u003e(4): p. 476-81.\u003c/li\u003e\n\u003cli\u003eMikkelsen, S., Lassen, A.M., \u003cem\u003eThe Danish prehospital system.\u003c/em\u003e European Journal of Emergency Medicine, 2020. \u003cstrong\u003e27\u003c/strong\u003e(6): p. 394-395.\u003c/li\u003e\n\u003cli\u003eMikkelsen, S., et al., \u003cem\u003eTermination of prehospital resuscitative efforts: a study of documentation on ethical considerations at the scene.\u003c/em\u003e Scand J Trauma Resusc Emerg Med, 2017. \u003cstrong\u003e25\u003c/strong\u003e(1): p. 35.\u003c/li\u003e\n\u003cli\u003eBruun, H., Milling, L., Mikkelsen, S., Huniche, L., \u003cem\u003eAuthor Correction: Ethical challenges experienced by prehospital emergency personnel: a practice-based model of analysis.\u003c/em\u003e BMC Med Ethics, 2022. \u003cstrong\u003e23\u003c/strong\u003e(1): p. 120.\u003c/li\u003e\n\u003cli\u003eHalkier, B., \u003cem\u003eFocus groups as social enactments: integrating interaction and content in the analysis of focus group data.\u003c/em\u003e Qualitative research, 2010. \u003cstrong\u003e10\u003c/strong\u003e(1): p. 71-89.\u003c/li\u003e\n\u003cli\u003eHalkier, B., \u003cem\u003ePractice theoretically inspired focus groups: Socially recognizable performativity?\u003c/em\u003e A New Era in Focus Group Research: Challenges, Innovation and Practice, 2017: p. 389-410.\u003c/li\u003e\n\u003cli\u003eMalterud, K., \u003cem\u003eSystematic text condensation: a strategy for qualitative analysis.\u003c/em\u003e Scand J Public Health, 2012. \u003cstrong\u003e40\u003c/strong\u003e(8): p. 795-805.\u003c/li\u003e\n\u003cli\u003eBruun, H., Milling, L., Wittrock, D., Mikkelsen, S., Huniche, L., \u003cem\u003eHow prehospital emergency personnel manage ethical challenges: the importance of confidence, trust, and safety.\u003c/em\u003e BMC Med Ethics, 2024. \u003cstrong\u003e25\u003c/strong\u003e(1): p. 58.\u003c/li\u003e\n\u003cli\u003eVetlesen, A.J., \u003cem\u003eThe Perseption of the Moral\u003c/em\u003e, in \u003cem\u003ePerception, empathy, and judgment: An inquiry into the preconditions of moral performance\u003c/em\u003e. 2012, Penn State Press.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Prehospital emergency services, The Region of Southern Denmark, ethical challenges, moral distress, burnout, clinical ethics support","lastPublishedDoi":"10.21203/rs.3.rs-4653025/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4653025/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eEthical challenges are integral to health care and are associated with moral distress among health professionals. Moral distress can turn into burnout with a range of negative effects for professionals, patients, relatives, collaborators, and the organisation. Based on action research a focus group study was conducted inclucing prehospital personnel from the emergency services in the Region of Southern Denmark. Results showed that ethical challenges arise in contexts of 1) caring for patients, 2) managing organizational demands, 3) collaborating. Ethical challenges are addressed informally by personnel in emergency vehicles, at ambulance stations, outside working hours, and ocationally involve family or friends with a background in health care. Further, prehospital physicians address ethically sensitive issues during monthly meetings. Voicing ethical challenges presupposes confidence, trust, and safety in relation to colleagues, management, and the organisation. Existing forms of clinical ethics support are ill suited to the prehospital emergency services. Targeted clinical ethics support initiatives are needed to address moral distress, prevent burnout, and build a supportive working environment. Initiatives must be developed collaboratively with personnel and tested bottom-up to identify and eliminate barriers for implementation.\u003c/p\u003e","manuscriptTitle":"Preventing burnout from moral distress amongst prehospital emergency personnel: action research to develop and test organizationally targeted clinical ethics support","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-25 07:44:26","doi":"10.21203/rs.3.rs-4653025/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-21T05:21:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-11T13:17:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-05T09:09:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"121520398229333681166961360199468589837","date":"2024-10-04T08:21:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"208330179214856871144189991004751807958","date":"2024-10-04T06:38:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-01T21:40:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-27T23:07:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-07-03T22:38:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-03T03:23:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-06-28T07:50:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c3c5dfdf-dc11-461c-adbd-3d14f514568a","owner":[],"postedDate":"July 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":34813597,"name":"Biological sciences/Psychology"},{"id":34813598,"name":"Health sciences/Health care"},{"id":34813599,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2025-01-06T16:21:12+00:00","versionOfRecord":{"articleIdentity":"rs-4653025","link":"https://doi.org/10.1038/s41598-024-83507-z","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2024-12-30 15:57:41","publishedOnDateReadable":"December 30th, 2024"},"versionCreatedAt":"2024-07-25 07:44:26","video":"","vorDoi":"10.1038/s41598-024-83507-z","vorDoiUrl":"https://doi.org/10.1038/s41598-024-83507-z","workflowStages":[]},"version":"v1","identity":"rs-4653025","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4653025","identity":"rs-4653025","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}