Abstract
Background:
Ethics consultation is the traditional way of resolving challenging ethical questions raised about patient care in the United States. Little research has been published on the resolution process used during ethics consultations and on how this experience affects healthcare professionals who participate in them.
Objectives:
The purpose of this qualitative research was to uncover the basic process that occurs in consultation services through study of the perceptions of healthcare professionals.
Design and Method:
The researchers in this study used a constructivist grounded theory approach that represents how one group of professionals experienced ethics consultations in their hospital in the United States.
Results:
The results were sufficient to develop an initial theory that has been named after the core concept: Moving It Along. Three process stages emerged from data interpretation: moral questioning, seeing the big picture, and coming together. It is hoped that this initial work stimulates additional research in describing and understanding the complex social process that occurs for healthcare professionals as they address the difficult moral issues that arise in clinical practice.
Introduction
Clinical ethics consultation, generally overseen by hospital ethics committees, is a significant part of ethics support services in many institutions in the United States. 1,2 Ethics consultations address complex clinical patient care questions that arise in practice.
Consultations are requested by healthcare professionals (nurses, physicians, social workers) or by family, patients, or even an outside observer for assistance in making decisions in a clinical situation. Once a consultation is requested, members of the clinical consultation service evaluate the clinical situation through interviews with healthcare professionals, family, and the patient when possible. 3 The consultation service representatives use a variety of methods to resolve the problems and often call a patient–staff conference to arrive at an ethically sound and realistic resolution of the problem. After a clinical care recommendation has been reached, the consultant representatives follow up at intervals to evaluate outcomes of the consultation.
Although consultations’ goals are primarily for patients and family, healthcare professionals involved in the patient’s care may also benefit from participating in the consultation process. Research on healthcare professionals and the effect of participating in ethics consultations has focused on evaluation of the service, for example, asking healthcare staff about their satisfaction with consultation services or reasons for delays in calling ethical consultations. Only recently have healthcare professionals been studied as participants in ethics consultation services. The studies reported are quantitative and aimed at identifying benefits of healthcare support services participation 4,5 rather than exploring the deeper explanations of the consultation process.
Research on moral case deliberation (MCD), a method of health professional instruction, has recently been reported from European communities. 5 MCD is conducted by a trained facilitator whose purpose is to educate and promote reflection in the healthcare professionals rather than solve clinical problems. 5 Ethical consultation services in the United States differ in that by services address and resolve immediate clinical issues, the outcomes of which are to benefit the patient and family but facilitating care or allowing a good death. The healthcare professionals involved in clinical consultations benefit indirectly from participating in the consultation.
Therefore, research to describe the underlying psychological and social processes of ethical consultation experienced by healthcare professionals will add to an area of research on ethics consultation services as practiced in the United States. A deeper understanding of healthcare professionals’ experiences will inform ethics consultants how to better educate and support professionals as they address complex issues in patient care. The purpose of this qualitative research was to explore experiences of healthcare professionals who had participated in the ethics consultation services to better understand the processes that underlie this event.
Methods
Design
A constructivist grounded theory approach is one in which a matching process is used so that research on the phenomenon of interest can be expedited. 6,7 In this study, the principle investigator and three of the four researchers had worked extensively with hospital ethics committee consultation services in the hospital in which the study was conducted. The researchers bring to the study a background of intimate understanding of consultation services, and through their experience are better able to interpret findings of the research. 6,7
The aim of this research was to construct a view of the social and psychological process ethics consultation process that emerged from healthcare professionals’ perceptions. Constructivist method uncovers each participant’s narrative and assumes that each narrative is shaped through the unique lens of his or her life. Therefore, the researchers’ interpretation of this event cannot be held to be applicable to other settings, but rather how one group of healthcare professionals perceived the process of ethics consultations in a specific setting. 6,7
Sample
Researchers interviewed professionals who worked in a 600-bed academic hospital in a large metropolitan city in the Midwest United States that has an established ethics committee which offers consultation services. The sample of healthcare professionals represented multiple areas of the hospital and consisted of nurses, physicians, and social workers.
Research questions
The interviewer asked participants to respond to the following general statements:
Tell me about your latest experience as a participant in ethics consultation. How did the ethics consult impact you and others involved? How or what did you contribute to the consultation experience? Compared to where you were before the consultation experience, where are you now?
Data collection
The study proposal was approved by the Human Subjects Committee and was part of a larger research project to determine beneficial outcomes in HEC consultation services. Healthcare professionals who had been involved in a particular ethics consultation case were recruited to answer an online survey. In total, 31 healthcare professionals completed the questionnaire.
At the end of an online quantitative survey about ethics consultation services, participants were asked to add comments for which a space was provided to respond in narrative. Eight people wrote narratives and these comments were included in the study analysis. Second, the online participants were recruited for a face-to-face interview about their participation in ethics consultations. A total of 11 healthcare professionals gave contact information and were contacted. Three of the 11 never returned phone calls and emails for reasons unknown. Eight of the 11 healthcare professionals consented and completed interviews.
The interviews lasted approximately 30–45 minutes and were held in private locations. Identifying information was not included in the recorded interview or in the transcription of the interview. The interview process began with open statements/questions that guided more directed and clarifying questioning from the interviewer as the interview unfolded. Each interview was transcribed in its entirety. The researcher conducting the interviews used a constant comparison method, informed by previous interviews, and shaping subsequent interviews to illuminate the emerging theoretical concepts. Interpretation and saturation of data occurred quickly, which may be explained, in part, by the researchers’ use of the constructivist grounded theory method that matched expertise in qualitative research and background in ethics consultation services. 7
Interpretation
Data interpretation was conducted by the researcher who interviewed the participants, using the constructivist grounded theory approach consisting of initial open coding, and these initial codes were grounds for focused coding in which the researchers identified most significant codes. 7,8 A core concept was identified and linked to other concepts from which a final emerging theory of healthcare professionals’ experience with consultation services was identified. 8 Both researcher interpreters compared their interpretations, and resolution of the discrepancies resulted in a consensus of the evidence for and presentation of an emerging theory.
Trustworthiness 7,8 was addressed through specific intentional methods to ensure credibility, transferability, and confirmability. Credibility, or how believable data interpretation is, was ensured by promoting the truthfulness of the participants and by having researchers whose interpretation could be trusted. 8 To promote truth-telling in the participants, the researcher conducting the interviews was not an employee of the institution and was not an ethics consultant. This information was disclosed to the healthcare professional when consent was obtained. The researcher who conducted the interviews, although non-participatory in the hospital ethics services, was familiar with the institutional setting and the consultation services provided thus ensuring more objectivity. The HEC committee also provided peer scrutiny of the study and participated at varying stages of the development of the study and in discussion of the results.
Transferability, the ability to transfer knowledge to other settings, is limited. This study used a constructionist view of grounded theory from which the researcher interprets participants’ experiences. 8 Constructivist grounded theory is highly specific and situated in the small group of study participants, thus limiting the ability to transfer these concepts and processes to other healthcare professionals outside of the study participants. However, by the same measure, there is no evidence to support the contrary that this sample is not a fair representation of other samples who are participating in hospital ethics consultation services in other large tertiary teaching institutions. Transferability can be established as further research is conducted on healthcare professionals in other settings.
And finally, confirmability or neutrality of interpretation was addressed through methods employed by researchers to interpret results of the study. 8 The second researcher reviewed all transcripts independently; then comparisons were made and a final interpretation was agreed upon by both researchers. Once a consensus was reached on the core concept and the interpretation by the two researchers, an independent researcher reviewed the audit trail and confirmed the results and conclusions presented herein.
Results
Core concept and theoretical model
Grounded theory is a qualitative research method, the goal of which is to uncover the basic social process through the shared experiences of participants and relationships of participants. 8 With data interpretation, a primary foundational concept for which all the stages of the process relate emerges and is known as the core concept.
Moving It Along emerged as the core concept in this research quickly. Participants viewed hospital services as transitional with the goal of helping patients move through the process of care. From a theoretical perspective, Moving It Along is created by an underlying tension that acts in an instrumental way to motivate healthcare professionals to advance patient care, as expressed by this participant: I’m really trying hard not to so we can keep this patient’s care rolling and moving and so much is about you know like we gotta progress this care and move on so, if I have to take a second, if that’s going to take away from discharge or if that’s going to get in the way of moving on. (Participant 8, nurse)
At the same time, advancing care—moving the patient out of the hospital setting—can be restrained if any decision for care or implementation of care is not morally acceptable. If there is a moral issue that delays progress of the patient through the system, ethics consultation support can be used to resolve the healthcare issue so that moving patients back into the community or to a good death can be completed. Stages of Moving It Along that emerged from this research were moral questioning, seeing the big picture, and coming together (Figure 1), which are more fully discussed in the sections to follow.
Moving It Along: the process of ethics consultations as experienced by healthcare professionals. Arrows indicate core concept of Moving It Along.
Moral questioning
Varied perceptions
Interdisciplinary and inter-service disparities of perceptions and actions appeared to be one source for generating questions about patient care. Nurses viewed doctors as being distant and insensitive to patient concerns: … she got her leg chopped off, she made it clear that she didn’t want her leg chopped off, so, like, maybe we (the healthcare professional team of physicians) should have consult(ed) ethics beforehand? (Participant 2, nurse)
On the other hand, physicians expressed concern that nurses or social workers were too eager to call consultations and that “the big question” was being sufficiently dealt with through physician-managed care as one physician wrote … ethics consults get ordered before a family meeting or goals of care discussion is even attempted. It seems that the requests most often originate from care providers who don’t feel their primary team will listen to their concerns. (Physician narrative from online questionnaire)
Furthermore, the various services, like oncology, pediatrics, or psychiatry, were reported to be unaware of each other’s input, lacking time to communicate, and hold differing views about what interventions addressed patients’ best interests. One participant indicated that surgical service disagreed with the patient and medical services. The ethics consultation was requested because of this disagreement.
The study participants reported that they felt stuck, and confused about plans of care, at times not even knowing what the big or real question of care was. Emotional frustration, anger, anxiety, fear, and moral distress in healthcare professionals propelled the need for intervention and a call for ethics consultation. Nurses were particularly vulnerable to the sufferings of patients and patient’s significant others, and to the moral distress that resulted: … it’s just hard on the nurse … especially when you formed … a bond … even if she never spoke to me, but I felt like I knew her body really well, like I knew her family … it was a personal case … personally, I would not like to live like that, and so if I knew … that she wouldn’t want to live like that, and that’s how I would feel, I would be really mad at my person making these decisions …. Why are we so aggressive? Why do we keep doing all this stuff? (Participant 2, nurse)
Asking questions
Uncertainty, conflict in decisions, and validation about right choices for patient care prompted healthcare professionals request ethics consultation. Participants reported the reasons for calling a consult and these were grouped into three general types: validation of a decision already made for patient care, clarity in defining the question, and conflict occurred among or between healthcare professionals on the care team, patients, and/or surrogates.
Calling the question
Progress to move a patient along in the healthcare system is stopped and someone on the healthcare team must request a formal ethics consult or ‘call the question’. Apparently, the healthcare professional who actually followed through with asking for an ethics consultation was a significant issue for the healthcare team members. Some of the healthcare professionals interviewed indicated that calling the consult was indicative of failure as a healthcare professional on the care team: I should be able to figure that out myself right now in my own time and move on. (Participant 1, physician)
There may be delays in calling an ethics consultation. This hospital bases care on a model of specialty services or groups of healthcare professionals who provide direction for specialized care. The services are used in addition to the hospital unit care that is responsible for the day-to-day care primarily done by nurses. Some patients require care from multiple services, for example, internal medicine, physical therapy, surgery, or oncology, all might be involved in the care of a single patient. Communication and decision-making for patient care was clearly slowed by the complexity and numbers of healthcare professionals involved. Various services sought out other services to make decisions about calling in a consultation.
One participant used the metaphor of a “bird dog” as the person who is the first to identify a need for a consultation and who diligently follows through with the necessary steps to call the ethics consult, just as a bird dog sees the bird and tracks the bird until the hunter is able to shoot or capture it.
Some people in the healthcare professional team do not feel empowered to call it themselves, so they must work to persuade people who they perceived as empowered to call the consult. Non-physicians were reluctant to request consults without first seeking validation and agreement from other team members. One of the study participants saw her role as powerless and having less ethical obligation to call a consult in this vivid narrative: I’m not the primary person that’s following this patient along. I’m here for 12 hours … I might not even take care of that person again. So, there is not as much ownership, like, I’d like to advocate for my patient but I’m by no means a main decision maker … I’m just the nurse and whatever you guys do is what you’re gonna do … (Participant 5, nurse)
Another non-physician participant explained thus I believe that only people in places of power would do that (call a consult). I don’t know or I don’t believe that it’s the smaller person who presses that button to have them (ethics consultation service), it may be that it should be but I don’t believe it does … (Participant 7, social worker)
Whether lack of consensus or lack of empowerment, consultation requests from problem identification to calling a consult could be delayed for days to, in one case, weeks. Perhaps the discord and lack of communication is particularly problematic in academic hospital settings in which numbers of services and many professionals are involved. One physician participant insightfully wrote … the nurses are on the floor had one level of (understanding) it (patient situation), the neuro ICU team sees one thing and gets certain information, the palliative care team spends more time with the patient and family and has another aspect of it, the burn surgery team sees the patient in the morning, and maybe has only certain interactions … (Participant 1, physician)
Seeing the big picture
Opening to new ideas
Respondents claimed that they perceived the patient situation and the ethical issues differently once they became engaged in the ethics consultation intervention. These changes in perception are reported to have occurred most often when they participated in the family, healthcare professionals, and consultant/s meetings. The change in perception occurred through a variety of other ways, by reading a written consultation note, by participation in meetings that included the consultant and other healthcare professionals only, and through individual healthcare professionals who had one-on-one conversations with the ethics consultant/s. Healthcare professionals who were interviewed indicated that they experienced a shift from a focus on the problem to one of openness and a receptivity to new ways of perceiving the ethical situation. They had clear sense of duty to move the situation along and that this process may require changes in thinking and communication.
As expressed earlier, there were three general reasons for requesting ethics consultations: validation of a decision already made by the healthcare professionals, clarity in defining the question, and conflict occurred among or between healthcare professionals, patients, and/or surrogates.
If consultations were called to validate a decision already made (for example, discharging a non-compliant patient) as ethical, the response of participants may be different. Participants expressed that they already knew the answer and that the consultation was merely a formality. The participant responses in cases of validation may be less likely to open to new ideas and perception.
However, ethics consultations that were called to clarify the question of care or for conflict resolution may stimulate a greater self-reflection and receptivity to new ways of thinking. From descriptions, participants were struck with seeing other perspectives from team members, family, and the ethical consultant/s, as suggested by this narrative: I as a social worker sometimes think very differently than a surgeon or a medical professional and … it’s nice … being able to talk with someone who has more perspective … to help me wrap my head around what are we really looking at … (Participant 4, social worker)
Consensus building
A second stage of seeing the big picture was interpreted as consensus building in which participants expressed understanding of others’ views and an increasing trust of other professionals.
A participant expressed a new, insightful vision of the teamwork: Nobody wants big brother but if it was your family member in the hospital you would definitely want, you would love to know that there is a third eye on the situation (because) there’s so many specialists that come in for your liver, your heart, that you would want somebody that’s really got the big picture in mind and looking for the end result and the … goal; what are these wishes (patient) and what are these wishes (staff) and how can we make them meet? (Participant 8, social worker)
Coming together
In all cases, decisions were ultimately made and a plan to move care for the patient forward. Resolution was achieved; if not the most ideal, it was as realistic and ethically acceptable. Most, if not all, healthcare professionals were perceived as coming together at some level on the care decisions and actions.
Working on the same page
The participants described a variety of interventions used by the ethics consultant team that included an extensive interview, a consultation write up, and meeting to resolve the problem with staff and patients/family, or just staff. Study participants generally reported a sense of unity as a result of the experience: improved communication and respect, a greater sense of common commitment, improved knowledge from the experience, and the best resolution of the problem in view of the limitations of the situation.
Professionals on the care team valued ethics consultations because of the improved communication and respect. They believed that their questions were heard, and that their point of view was taken seriously. One participant recounted what the attending said to her about how the ethics consult affected him. In this case, the attending felt empowered by the unity: I (the attending) would have never made this decision on my own. I would’ve done what the family said so I wasn’t sued, and, … you know … (if I were) the patient, that’s what I would have wanted. (Participant 1, physician)
Education, learning new information, was clearly experienced by some participants. The healthcare professionals interviewed gained new knowledge about the patient situation and learned more about decision-making principles and how to arrive at a good decision. In addition, some expressed that what they had learned was clinically applicable, for example, how to better express themselves to patients and other team members: I really learned a lot from people giving me different ways to say things, and kind of make that into your own so you’re more comfortable with those situations, so yeah, I thought that it was really (helpful). (Participant 2, nurse)
Resolving and reflecting
Once decisions were made, participants expressed relief at resolution and a belief that the decision made and actions resulting from that decision were the best possible for the patient and family under the circumstances. However, there were instances of disagreement with a final formal decision. In some instances, the cases are not dealt with as expressed in this intensive care unit (ICU) nurse’s statement describing what happened if ethical issues were not resolved: The patient moves on, they, on this unit, they either move on to another floor or they move on to home or they move on to death … (Participant 5, nurse)
Participants also more uncommonly reported negative experiences of dissatisfaction with the decisions and action plan for the patient, as this example illustrates: No introductions were made … the meeting just started without them. I sat through the entire meeting not knowing who the ethics committee member was. To this day, I have no idea what the person’s name was. (Participant from questionnaire narrative response, physician)
There were unmet expectations expressed by some healthcare professionals. Against the background of moving it along, the professionals in this study expected to have the solution to the patient concerns and a clear specific plan. When the consultation did not meet expectations, study participants expressed dissatisfaction in the process and outcome of a consultation as an unhelpful formality: I often find it frustrating as I do not usually see specific recommendations within the documentation. I think that would be great to include more clearly in notes as well as references to the ethics handbook and/or other cases to help providers understand the recs (requirements) as well as increase their understanding so they are empowered earlier in patient cases to ask ethical questions if they are present instead of waiting for the “event” (consultation meeting). (Participant from questionnaire narrative response, physician)
Other study participants expressed more realistic understandings of the complexity and the individuality of ethical problems, seeing that even decisions made and outcomes from the consultation may remain partially unanswered and partially resolved: I think that sometimes it’s hard to resolve with the consult because it’s information that’s valuable and it shows a different perspective of what aspects we need to be looking at, but it really wasn’t any clear cut “this is what you should do,” and I think that is probably how most of the consults are. (Participant 3, social worker)
Discussion
The researchers’ purpose in conducting this research was to explore experiences of healthcare professionals who have participated in patient cases of ethics consults to better understand the deeper processes that underlie this event. A three-stage grounded theory emerged and was named Moving it Along: An Emerging Theory of Healthcare Professionals’ Experience with Ethics Consultations. Four points for discussion about this research have significant clinical relevance.
Consultation service as a social process
The study findings emphasize that ethics consultation services are social processes through which participants navigate. Consultation services’ primary focus is on ethical questions that arise in care situations but underlying what the surface issues are the workings and networks of healthcare professionals and the many complexities that arise between and among them. The ethics consultation is metaphorically an iceberg with much of what surrounds the process occurring undetected, such that the consultant can bring to surface information and attitudes that were previously misunderstood or undetected. Over the decades, the literature of the consultant role has been developing and redirected from one of moral authority who imposes decisions to one of facilitator who guides consensus building. 1,2,9
More recent literature reflects a broader view of consultation services, with greater attention to non-cognitive elements of consultation, like interpersonal relationships among consultation participants, 10 emotional support, 11 –13 cultural differences, 14 communication, 15 and the consultation process itself. 15
The findings of this study suggest that greater attention to the social processes occurring with healthcare professionals who participate in ethics consultation services and a greater focus on social aspects of the participants, like communication, conflict resolution, and demonstrating respect, may make these services more effective. Consultants may be more effective when they develop a greater expertise in social skills that has traditionally been viewed as less central to the ultimate purpose of ethics consultation services, that of addressing ethical questions. More attention to social aspects will help participants to attend to the unique features of a situation, the parties involved, and the culture of the institution. 12,15
Calling the consult
From accounts of these participants, requesting consultation services was delayed and perhaps underused. The findings of this study suggest some reasons for why these services are delayed. In a large survey of 600 hospitals by Fox et al., 16 95% of the hospitals participating in the study indicated that ethics consultation in their hospitals could be requested by family, any provider of care, or interested party. Yet, in the facility in which this study was conducted, healthcare professionals continued to view calling a consult as privileged and a responsibility of the physicians in charge of the patient. Patients or family may be ignorant of the process and viewed as information sources rather than equal partners for collaboration and deliberations for care.
These study findings suggest that in this group of provider participants, little may have changed since findings by Kelly et al. 17 and Gacki-Smith and Gordon 18 reported that physicians were the gatekeepers of ethics consultation services and that formal and informal power structures create tension between providers, especially nurses and physicians. 18 Researchers also recommended that providers who are non-physician team members have a less threatening way to request consults.
Other researchers have addressed and reported on the reluctance of physicians and residents to call consultations finding that there are a variety of psychological reasons. 18,19 Gaudine et al. 20 found an array of barriers for consultation services that were classified as lack of knowledge, experience, reactions from others, issues of responsibility, lack of support, and lack of faith in the process. The findings of this study supported much of work done by previous researchers 17 –20 through expressed healthcare professionals’ accounts of their experiences.
Interventions designed to facilitate consultation requests may be explored and evaluated. Education can improve knowledge of ethical process, and change perceptions of consultation requests as restricted to medical professionals to one of open access in which requests for consultation can be initiated by any interested party. Open access may improve delay and underutilization of services. Also, raising healthcare professionals’ awareness of expectations inter-professionally, for example, the role of other team members, and the role of the institution to support practice that adheres to standards, may improve access and use of ethics consultation services. 10
Benefits
Participants in this research reported that they experienced improved education, support from others, elevated sense of unity of purpose, improved communication, and the ability to understand others’ view points. Dialogue among healthcare professionals was described as essential in resolving the ethical issues experienced by study participants. The literature suggests that mediation rather than consultation may be a more correct terminology for ethics support services. 21
Moving It Along as a conflict of interest
The core concept of “Moving It Along” prima facie appears to decontextualize and depersonalize patients. Yet, the institutional system, and healthcare in general, manages patients with the goal of quickly returning them to self-sufficiency and to the community.
Study participants expressed a commitment to provide care economically and in a timely manner, but a more fundamental commitment to provide healthcare that meets expectations of society, respective professions, and patients themselves. 10 Like narrative ethics, the human experience as experience is the primary focus of qualitative research and explores the stories of the participants. 22,23 These responses suggested that healthcare professionals interviewed, although perhaps not aware of the conflict, balanced the need to move patients along with a moral imperative to do the right thing.
Conflict of interest (COI) was evident in the institutional imperative to move patients out of the system and the professional fiduciary commitment to the patient. Although situations in which COL arise are not by themselves unethical, they may affect judgment of healthcare professionals, so that professionals should be vigilant of situations in which COI. 24 COI can also create difficult spaces for healthcare professionals that can result in moral distress. 19,25 Participants’ stories indicated that there were instances of COI that resulted in moral conflict and distress.
Although ethics consultants were not the population of interest in this research, COI occurs and ethics consultants are called to raise awareness of its influence in their practice. Meyers 26 stressed that consultants should consider the structure of consultation services and ways to change the structure to eliminate COI. If COI cannot realistically be eliminated (which Meyers claimed is often unlikely), then COI is disclosed and managed. In addition to raising awareness in the consultant and managing through greater independence of function, Meyers 26 suggests empowering other participants in the consultation process thereby checking and diminishing the consultant’s role in decision-making.
Implications
The aim of qualitative research is to understand human experiences and the meaning that these experiences have for them. 7,8 The study participants gave an account of their experiences with ethics consultations and a beginning theory of the social processes that underlie the healthcare professionals’ experience emerged. Further research is needed to support findings in this research and to address additional intriguing questions that are worthy of further research.
Additional work to further clarify the complex social relationships, of the institution, the disciplines, services, and the consultants, should be explored. Second, improving usefulness of consultation services, studies of why consultation services are not used would be helpful. Timeliness of consulting may be significance in not only reducing costs but also reducing suffering and pain in patients, families, and healthcare professionals.
Further theoretical and conceptual development of the psychological and social processes may further enlighten those who provide ethics services to improve ethics consultation that better benefit patients and healthcare professionals. If providers have greater awareness of professional and personal gains from ethics consultation services, they may use ethics consultation services more readily thus improving patient care.
Limitations
The specific setting is representative, and the small number of participants to saturate data may be of concern. Since the researchers were involved themselves in consultation services, as is appropriate for constructivist grounded theory method, the process facilitated a quicker saturation of data. Researchers had insight into how to ask questions and obtained richer data than might be gained or researchers been outsiders to the phenomenon of interest.
Consultation services varied greatly in the United States, making it difficult to make conclusions that are representative and applicable to other settings in which consultation services are offered. The researchers’ interpretation of this event cannot be held to be a truth claim, but rather how one group of individuals has perceived the event in a specific setting. 6,7
Conclusion
This study identified the social and personal experiences of healthcare professionals who participated in consultation services. The grounded theory identified three stages: moral questioning, seeing the big picture, and coming together. It is hoped that this theory is the beginning of additional work in describing and understanding the complex social process that occurs for healthcare professionals as they navigate the healthcare system to address moral issues that arise in clinical practice.
Footnotes
Conflict of interest
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding was obtained through the Department of Philosophy, Kansas University Medical Center for transcription.