Ethical conflicts in nursing: An interview study

Abstract

Background:

A growing body of evidence about nurses’ ethical conflicts has been added to nursing science in recent decades, but no research has been done in Estonia. Ethical conflicts are a cultural and context sensitive phenomenon, so the historical, legal, social, economic and political backgrounds and position of nursing have had an impact on ethical conflict experiences.

Aim:

Describe nurses’ experiences of ethical conflicts.

Method:

A qualitative, descriptive study was conducted among nurses (n = 21) in May-October 2018 in Estonia. The data were collected in the form of semi-structured individual interviews and analysed using the inductive content analysis method.

Ethical considerations:

Due to the sensitive nature of the research topic, only individual interviews were carried out.

Findings:

Nurses’ ethical conflicts were related to situations that violated the rights, safety or well-being of the patient or relatives, caused them suffering, were against their will or threatened nurses’ dignity and professionalism through a variety of practices, attitudes and relationships. The insufficiency of patient care and professional collaboration emerged as important sources of nurses’ ethical conflicts and were connected to historical and societal factors.

Conclusions:

In order to achieve good quality of care, nurses need to have appropriate education and organisational support to carry out ethical daily care. More research is needed to understand the multidimensional cultural and contextual knowledge of ethics and nurses’ ethical conflicts.

Keywords

Ethical conflict nurses perceptions nursing patient care professional collaboration qualitative study

Introduction

Ethical contradictions are an integral part of nursing because different parties strive to meet their needs, goals and endeavours in the overall provision of nursing care.^1,2 Therefore, nurses can experience ethical conflicts^3,4 that have an adverse effect on their motivation, job satisfaction, and contribute to their burnout, depression and resignation from the job.^4
–6 Ethical conflicts have been found to be culture and context sensitive, and they reflect differences in culture, societal attitudes and legal principles.^7,8 Unlike other Western countries, Estonia was dominated by a Soviet regime for nearly 50 years, which fundamentally influenced the attitudes and behaviour of people.^9,10 Expectations towards nursing care assumed an effectiveness, speed and technical approach instead of individuality and quality of care.¹¹

Despite rapid development in Estonia since re-independence, the period of occupation has left a historical gap that’s seen in politics, economics, the legal system, the health status of people, societal values and attitudes.^9,10,12 Despite the growing international body of evidence about nurses’ ethical conflicts, no such research has been conducted in Estonia. In order to maintain and improve the performance of nurses at work and reduce their burnout, it’s important to glean knowledge from local nursing practice environments where those context sensitive factors are present.¹¹ The lack of previous research evidence about nurses’ ethical conflicts in Estonia has led to the need for a qualitative approach.

Background

According to Jameton,¹³ ethical conflict in nursing is understood as a moral dilemma, moral uncertainty and moral distress, that arise within nurse and between nurse and different parties.³ In the case of a moral dilemma, separately right or justified but mutually exclusive ethical values and beliefs appear in the same situation. Moral distress is caused by situations in which the morally right action is hindered by other persons or some factors beyond a nurse’s control. The nurse is justifying a morally different behaviour or act, but can’t implement it. In case of moral uncertainty, a nurse is unsure of the right action or behaviour as a nurse.¹³

The most important professional values in nursing are related to patient well-being and caring for patients.^14,15 Abundant ethical conflicts are also related to situations in which nurses can’t protect patients’ rights or do their best for a patient,^6,16

–20 where the autonomy and privacy of the patient is affected, the wishes of the patient are not respected or informing patients and relatives is insufficient.^4,16,19,20 According to nurses, other health professionals behave unequally towards certain patients due to their social background²¹ and are paternalistic in communication with them.²² Important factors include the shortage of human resources^17,19,23 and an excessive workload that prevents nurses from providing care that is compliant with the standards.^21,24 Nurses’ own lack of knowledge and skills is an ethical conflict source.^16,21 Communication within teams is important in relation to ethical conflicts.^23,25,26 The professional opinions of nurses aren’t always respected within teams^23,25,27 and hierarchy has an impact on whether nurses have the courage to express their beliefs and values in the work process.^28,29

In Estonia, previous study on nursing ethics is scarce. In the Soviet time (1944–1991), nursing was viewed as being inferior to medicine with low professional prestige, and nurses were educated in technical schools after the completion of primary school.¹¹ The Estonian Nurses Union was established in 1923 and re-established in 1990,¹¹ and in 1996, the Union adhered to codes of ethics by the International Council of Nurses.³⁰ Since 2002, the patient’s position and rights have been regulated by legislation and international agreements. Patients now have the right to be involved in decisions regarding their own health with informed consent, confidentiality and privacy, as well as a duty to provide information about their health for health professionals.^31,32 In addition, patients have the right to make complaints about malpractice, poor quality care and limited access to care.^12,33 Currently, nurses have the right to work as independent healthcare providers,^11,32 but strong hierarchy is still present in professional collaboration. In previous research, nursing ethics in Estonia was studied in relation to nurses’ autonomy in organisation,³⁴ patient-centredness in acute³⁵ and long-term care.³⁶ However, previous knowledge about ethical conflicts in nursing is absent.

Aim

The aim of this paper is to describe nurses’ experiences of ethical conflicts in Estonia. In order to achieve this, one research question was composed: what kind of ethical conflicts do nurses experience in professional practice?

Method

A hermeneutic-phenomenological methodological approach was used to understand participants’ unique and individual experiences with ethical conflicts at their work.³⁷ A qualitative, descriptive study³⁸was employed for nurses in Estonia from spring to autumn 2018. A semi-structured interview³⁹ guide was developed based on Jameton’s conceptual approach¹³ and previous literature.^6,16,21 The interview guide included two themes and one open-ended question. The first theme focused on participants’ experiences of ethical conflicts. First, they were asked to describe their perceptions of ethical conflicts and then, in line with Jameton’s concepts, they were asked to describe their experiences of moral dilemma, distress and moral uncertainty.¹³ The second theme focused on their feelings and experienced consequences of ethical conflict. At the end, an open-ended question was given for participants to freely add and discuss about the topic. The researcher intervened in the interview process only by asking questions to clarify the participants’ thoughts, where necessary. In this paper, the results based on the first interview theme will be reported.

Recruitment

A purposive sampling was used for recruitment.⁴⁰ In Estonia, there are a total of 8300 nurses.⁴¹ In order to offer an equal opportunity for nurses from different parts of Estonia to participate in this study, participants were recruited through professional nursing organisations. The researcher (GU) contacted all seven Estonian nurses’ associations, unions and trade unions and asked them to share an invitation letter with their members. The invitation letter was also published in an Estonian nursing magazine. The inclusion criteria were that the participant currently worked or had worked as a registered nurse, experienced ethical conflict in professional practice, was able to communicate in Estonian and was willing to share their experience. The invitation letter included information regarding the aim of the study, the voluntary and confidential nature of the participation, the opportunity to withdraw from participating and the researcher’s contact information for enrolment.

Altogether, 21 participants enrolled in the study. All the participants were female and were currently working or had been working in different healthcare institutions in primary healthcare and hospitals all over Estonia. Due to the personal nature of the ethical conflicts, all interviews were individual, face-to-face interviews.³⁹ Interviews were carried out outside of the nurses’ working hours, and the researcher (GU) travelled for the interview to the place and town in Estonia to suit the participant. Before the interview, the researcher sent the participants the preparatory questions based on Jameton’s¹³ concepts of ethical conflicts. The interviews were audio recorded and lasted from 28 to 120 min with the mean duration being 77 min. The participants were informed that they could contact the researcher after the interview if they needed to add or change something. That opportunity wasn’t used. A total of 268 pages of transcripts were composed.

Analyses

The inductive content analyses method was used⁴² concurrently with data collection. Audio-taped interviews were transcribed verbatim and after that, each interview was read several times to get an overview of the entire data. As the participants described their experiences of ethical conflict situations both in relation to specific interview themes and during the whole interview, all the transcribed text was analysed to respond research questions. The data were extracted into meaning units, which were sentences or entire paragraphs that corresponded to Jameton’s¹³ definition of ethical conflicts. Meaning units were condensed and grouped based on their similarities and differences, and abstracted first to sub-categories and again to the main categories. Categories were named inductively based on the data.⁴² One researcher (GU) carried out analysis up to the sub-categories, and the analysis was finalised in collaboration with all the authors (EU, RU, MK) to ensure the coherence of the categories.

Trustworthiness

In term of trustworthiness, the research context, sampling, principles of recruitment, data collection and process of analyses are described precisely.⁴³ All interviews started with a warm-up question about understanding ethical conflict. This ensured that the participants shared a similar understanding of ethical conflicts with researchers. In order to retain the quality of analyses and objectivity of conclusions,^43,44 authentic quotes have been used and the results supported by a table. For credibility, the analysis process was finalised in collaboration with all the authors to verify the coherence between the categories and the data.⁴² The data were found to be saturated during the 18th interview, but to ensure that no more information emerged,⁴⁴ three more interviews were carried out.

Ethical considerations

Research ethics approval was obtained from the Research Ethics Committee of the University of Tartu (Protocol number 281/T-3 from 16.04.2018). Prior to the interview, the participants were informed about the purpose and method of the study, the terms of participation, interruption and measures used to ensure confidentiality, and signed an informed consent form. Due to the sensitive nature of the research topic, only individual interviews were carried out. In order to ensure anonymity and guarantee the confidentiality of the participants, no sociodemographic or organisational background information was collected or reported. All personal and institutional data, as well as other details that could help to identify the participants or particular situations were excluded from the transcripts. In addition, interviews were coded by numbering them randomly according to the order of interviews and quotations were used in the results section. The study focused on delicate, ethically complicated issue, potentially causing discomfort for the participants. Several participants mentioned after the interview that relaying their experiences was liberating.

Results

The nurses described ethical conflict as an internal value conflict and conflict between people. A value conflict was described as a situation, attitude, behaviour or act that was contrary to some of their ethical values, beliefs, existing norms, rules, principles or good practice. This emerged when someone else’s behaviour was seen as morally wrong and, in turn, as an obligation to act contrary to their own principles or uncertainty about the appropriateness of their own behaviour. Conflict between people was described as a disagreement, fight or power struggle about ethical principles between nurses and parties with whom they collaborate. Based on analyses, a total of 32 sub-categories and 6 main categories of ethical conflicts were found (Table 1).

Table 1.

The focus of nurses’ ethical conflicts.

Main categories	Sub-categories
Dehumanising patients	• Treating patient as an object • Insufficient involving of patient and/or family • Endangering patient’s privacy • Unequal attitude due to patient’s social background • Carelessness towards patient suffering • Paternalistic behaviour towards patient • Labelling patient • Forcing helplessness or inactivity of patient • Talking publicly about patient
Disagreement with treatment decisions	• Questionable harm/benefit ratio of treatment or care • Insufficient treatment or care • Aggressive treatment at the end of life instead of palliative treatment
Nurse’s profession perceived not valued and respected in society	• The salary doesn’t match with the job contribution • Hierarchy within the team • Lack of involvement in the decision-making process • Limitations in informing patients and relatives • Inappropriate behaviour of patients and relatives
Perceived insufficiency in professional competence	• Lack of competence on following patient’s actual will • Lack of competence in giving appropriate end of life care • Lack of competence in giving appropriate support to relatives of patient • Uncertainty about impact of own action or disregard for other’s life and death • Professional image perceived as a burden
Unprofessional relationships within the healthcare team	• Disrespectful behaviour towards nurses • Team members dealing with personal matters during work • Team members play out their tensions on others • Fighting in front of the patient • Bullying within the team
Unsupportive working environment	• Institutional values conflicting with nursing values • Lack of support from managers • Working organisation preventing provision of good care • Unclear or excessive rules and demands • Lack of cooperation within healthcare system

Dehumanising patients

Nurses values were conflicted when team members didn’t treat patients with respect and dignity but rather as objects or ill body parts. It was against nurses’ values when the preferences of patients were not prioritised because of disagreements between patients and relatives or patients and health professionals. Patients and their relatives weren’t sufficiently informed and involved in the treatment and decision-making:

The surgeon said loudly within earshot of the patient: ‘This kidney cancer is going for surgery; start to prepare her!’ (2)

It happened often that a patient would be hospitalised without knowing why. (4)

Ethical conflicts were caused by a threat to the privacy of the patient, such as due to the spatial design of healthcare establishments, arrangements in the provision of services or the tradition of informing family members about patients’ health without their consent. It happened that the patient could be a well-known public figure or someone who the nurse and her relatives knew personally, and the nurse’s relatives didn’t understand the restrictions that come with a nurse’s professional role by asking delicate information:

Does a woman need to know that her husband’s cholesterol is 7? On the one hand, the woman makes all his meals and should know. On the other hand, a man has the right to make his own choices. (3)

And then I have to say that it’s a patient; I can’t speak about it. They (nurses’ family members) didn’t understand and I felt like I temporarily lost people on whom I hoped to rely. (1)

Nurses experienced ethical conflicts because of inequality towards patients due to their social background. More authoritative patients like public persons, their relatives or health professionals received more attention, care and better access to services than patients without such background. Prejudices towards patients showing signs of alcohol consumption were noticed, and this had an impact on the quality of care provided to them. Other health professionals’ carelessness towards the needs and suffering of patients or relatives, exploitation of a health professional’s authority, arguing in front of other people, paternalistic behaviour, labelling, depreciating and talking about patients publicly was also a source of nurses’ ethical conflicts. For nurses, it was against the value of patients’ autonomy if patients were forced to be helpless and inactive for the convenience of staff. For example, restless patients with disturbed consciousness were bandaged recklessly or patients weren’t helped according to their preferences:

When a patient rang the bell at night to ask for help in going to the toilet, the care assistant snapped at him: ‘You have nappies, do it in your pants! I’m not taking you anywhere at night!’ (10)

Disagreement with treatment decisions

The sources of nurses’ ethical conflicts included situations in which the treatment and care decisions violated the value of beneficence and caused harm for patients. Some decisions were not taken according to the patients’ needs or will, but rather in order to give physicians an opportunity to practice. According to the nurses, the treatment could be inadequate, insufficient or too excessive, causing unnecessary suffering and pain, like aggressive treatment at the end of patients’ life instead of good palliative care:

The patient with do not resuscitate (DNR) decision basically couldn’t swallow, but Hjertemagnyl (Aspirin) was prescribed to him to avoid future complications. I asked the doctor: ‘There is DNR; what kind of distant complications are we talking about?’ (9)

Nursing profession perceived as not valued and respected in society

Nurses perceived their profession and themselves as not being valued in society. It was against their values and a sign of disrespect, that their salary didn’t match their contribution to work. Hierarchy within the team was perceived as something strong and fundamental. Nurses experienced ethical conflicts when they were rejected from the decision-making process related to treatment, working conditions and organisational issues. Nurses felt that their rights of informing patients were unclear and limited due to legislation on the protection of personal data and the unclear responsibilities within team:

We have very strong subordination relations here. (Physician): ‘I’m a physician, I’m always above you. You are an insignificant nurse and you are just a caregiver’. (4)

The patient wants me to explain what the physicians just said to him and I’m not allowed to. It doesn’t seem right not to give the patient what he needs and maybe gets only from me. (6)

Nurses experienced ethical conflicts due to inappropriate behaviour by patients and their relatives in the therapeutic process. They perceived dissatisfaction, excessive demands and aggression towards them as disrespectfulness and distrust towards their profession. On the other hand, from the nurses’ point of view gifts from patients and relatives were also inappropriate in a professional relationship:

I was also given chocolate today. / --- / I don’t want to accept it, but I can’t give it back because refusing would cause offence; it’s so visible. (3)

Perceived insufficiency of professional competence

Nurses had doubts about themselves and the decisions they made; the veracity of their actions and their responsibilities were a source of ethical conflict. They described ethical conflicts stemming from difficulties in understanding the will of the patient, and instances of dissent between a patient and relatives. Nurses perceived helplessness if they were unable to properly alleviate the suffering of patient and ensure a dignified death. Relatives of severely ill or dying patients also needed nurses’ presence and support, but nurses often felt the scarce of time and competence for that, which, at the same time, was against their values:

I hear him (patient) coughing. He has a constant silent bleeding. He has panic attacks at night, he can’t breathe, he’s in pain. And I can’t do anything. (9)

Young nurses can sometimes be really insecure. They don’t know what to say and are afraid of doing something wrong. So, they won’t say a word and instead stay away. (8)

Nurses experienced uncertainty about the impact of their own actions or omissions on the life and death of others. They pondered whether they had indirectly participated in the process of euthanasia by giving a particular medicine, neglecting certain procedures or deciding not to start resuscitation in the emergency room:

My goal is to help the patient. But if he refuses to eat, should I force him? If he doesn’t want to live any more, should I help him die? Am I then participating in passive euthanasia? (5)

Recognising that the image of nursing had to be constantly worn outside of working hours and imposed restrictions on one’s personal life was ethically conflicting when nurses perceived lack of competence about how to separate work and private life.

People will not take you just as another person; they always look upon you as a nurse. It’s as if you constantly have a role to fulfil. (3)

Unprofessional relationships within the healthcare team

Nurses experienced ethical conflicts in relation to the disrespectful behaviour of their team members. It went against their values that team members dealt with personal issues during working hours and played out their personal tensions on colleagues. As part of the communication within the team, nurses described insults, humiliation, disrespect and vulgar behaviour:

I was on my way home and she (physician) came into the dressing room and yelled at me: ‘You’re an inept, sloppy and lazy shit! Why did you come to work here at all! We’d be better off without you!’ (4)

Bullying for indistinct reasons or due to religious beliefs or different linguistic and cultural background was against the value of equality in the team. Power struggles between team members prevented nurses from performing their job and compromised their working principles according to patient safety:

They (colleagues with different nationality) push you away; they don’t want to get on with you…You’re an Estonian; let’s see how you’ll handle it. (17)

Unsupportive working environment

Nurses valued quality and made their decisions based on patients’ needs. However, they sometimes felt that institutional values conflicted with the professional values of nursing and that cost-saving, cost effectiveness and other values in the work environment were more important. Ethical conflicts were perceived as not valued due to insufficient organisational support. Excessive workload and disorganisation of work prevented nurses from realising their ideal of how a nurse should behave and act, as they couldn’t perform all of the planned activities or perform them as well as they wanted. Due to poorly organised work or staff shortages, nurses were required to perform tasks that were below or above their competence level:

There is more and more computer work and everything has to be written on the computer. What should I write there? Things I didn’t do with the patient because of the computer work? (9)

I was in the operation room with the anaesthesiologist, who had two operation rooms going at the same time…so, I was left alone in the operation room, responsible for the patient under narcosis and with artificial respiration. (4)

Some rules and guidelines that frame the organisation of the health service were impractical and contradictory according to nurses’ values and didn’t allow them to help patients. Therefore, conflicting rules and a lack of cooperation between state agencies caused ethical conflicts:

The rescue agency says you shouldn’t have any locks in front of the patient rooms…And the county government demands that we must put the locks on because the patient needs privacy. So, what do we do? (5)

Discussion

This study was the first study on nurses’ ethical conflicts across different nursing specialties in Estonia. The ethical conflicts focused on dehumanising patients, disagreement with treatment decisions, the nursing profession perceived not valued and respected in society, perceived insufficiency of professional competence, the unprofessional relationships within the healthcare team and an unsupportive working environment.

Based on the results, patients’ rights were the core value that nurses experienced in causing ethical conflicts in patients’ daily care. The results are in line with previous studies, where it was identified that patients’ rights are violated when healthcare workers go against presented or pre-determined will of patients.^6,16

–20 It’s noteworthy that in Estonia patients’ rights for informed consent, involvement in care and confidentiality are protected by law. In addition, the nursing profession has committed to its codes of ethics.⁴⁵ However, the protection of patients’ rights in Estonia is still rather weak, especially among more vulnerable groups.¹² This may still reflect the paternalistic, historical attitudes,²² in which healthcare professionals have power of knowledge over patients. In future, more attention needs to be paid to nurses’ ethical competences regarding the autonomy of patients to create a care culture, where autonomy is understood and accepted as a basic value of nursing and patients are seen as a subject in their own care.

Ethical conflicts in patients’ rights were highlighted in relation to informing patients, which in this study was remarkably unclear or limited. Ethical conflicts related to the informing process^17,24,27 have been addressed by nurses previously, but the focus of these conflicts has included components of patients’ and relatives’ individual resources and coping mechanisms.²⁷ In this study, the focus was mainly on nurses’ rights to inform and take part in decision-making. Nurses felt ethical conflict between patients’ rights for information and the expected duty of nurses to refrain from giving this information. This type of ethical conflict has found to be caused by long-established traditions, attitudes and hierarchical relations in healthcare teams.^28,29 However, in the Estonian context, patients have an ethical and legal right to be informed, and this should also be reflected in nursing care in order to better address the diverse needs of patients.

The results highlighted ethical conflicts in relation to equality and privacy, when the patients’ socio-economic status influenced the quality of care they received. This result is in line with previous studies,^19,21 but the particular characteristic of a small country such as Estonia is that a patient’s privacy can inadvertently be threatened by the nurse. Similarly, in previous studies has noted,²¹ that different socio-economical background of patients can favour or discriminate against them. Thus, as described in this study, negative attitudes and prejudices among health professionals towards population groups with low social status have been found to endanger patient equality. In Estonia, the misuse of alcohol is a significant social burden,¹² which results in stigmatising and poorer care quality for patients. From this point of view, two aspects should be recognised in future. First, nursing practices should ensure that patients could remain as private persons, despite the size of a country or organisation. This is needed both for nurses and in order to protect patients’ privacy and ensure equality of care among patients. Second, attention should be paid to nurses’ awareness of their individual attitudes. Nurses have a right to their personal worldview including their individual concepts, values and attitudes, but as nurses they have a duty to follow the shared values of professional ethics.⁴⁶ In future, nurses should receive more support to be explicitly aware and reflect the relationship between their individual ethics and professional ethics. That would strengthen their ability to identify the content of ethical conflicts in nursing care. Currently, ethics has fragmentally been included in the nursing curriculum in Estonia, but it would be purposeful to discuss how to better integrate it into future education.

It’s noteworthy that the ethical conflicts regarding patients’ rights, equality and privacy are closely connected to the patient-centredness, which is seen as a core value in contemporary nursing care.^47,48 In Estonia, patient-centredness has been declared a guiding, national principle in healthcare.^12,49,50 It represents a long-term target of value reform in healthcare, where the emphasis moves from professional driven to patient-focused values.⁵⁰ This will mean that families will be brought into the care process instead of having an individual approach. However, in line with previous studies, nurses reported ethical conflicts when encountering families.^{4,8,16,18,23,24} As in previous studies, nurses found the sharing of information with families to be challenging,^17,27 but in this study, a cultural tradition emerged of offering gifts to health professionals for their services. In the Soviet time, it was a way for patients to ensure they received a better service, but nowadays it’s unnecessary, according to nurses. Nurses need to get a clearer understanding of the components of patient-centredness, along with the ethical role of families, as well as managerial and organisational support to put patient-centred principles into everyday practice.

Nurses in this study described different ethical conflicts in which their dignity and professionalism were threatened in society but also in relation to inter-professional teamwork. They felt that teamwork was based on strict hierarchy and disrespect, which led to the insufficient autonomy of nursing care and unprofessional relationships within teams. Nurses are excluded from the decision-making process and can’t express their professional opinions as outlined in previous research.^25,27,28 The findings highlight the need to pay more attention to inter-professional relationships. In Estonia, the immature working methods in the inter-professional teams can be seen as a reflection of the short history of the current form of healthcare. A hierarchical medicine-centred approach is inconsistent with the principles of patient-centredness. While facing a serious shortage of nurses and raising demographical demands,^12,51,52 it’s crucial not only to strive to increase the number of nurses but also to improve the inter-professional environment in which nursing is performed.

Limitations of the study

The study had some limitations that need to be pointed out. The participants were solely female, but this corresponds to the gender distribution in Estonia, where 97% of nurses are female.⁴¹ Despite the methodological advantages, focus group interviews were not used for reasons of confidentiality, so the positive impact of group dynamics is missing from this study. Nurses’ ethical conflict experiences are multi-layered and overlapping, maximum effort was made by the researchers to present the most central content from the participants’ point of view.

Conclusion

The topic of nurses’ ethical conflicts remains unexplored in Estonia. In this study, nurses’ ethical conflicts have focused on dehumanising or even neglect of patients and on collaboration within and between professions. In patient care, ethical conflicts are related to patients’ fundamental rights for information, involvement and equality. These shared health care values are protected by ethics and legislation. Their violation rises a question of nurses and health care professionals ethical competence and professionalism, but also leadership to carry out interprofessional care. The shortcomings of patient care, nursing autonomy and inter-professional collaboration partially reflect the historical and societal context. In order to achieve good quality of care, nurses need to have appropriate education and organisational support to carry out ethical daily care. In future, more research is needed in the contextual knowledge of ethical conflicts, in order to plan interventions for practice development and quality improvement.

Footnotes

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Gerli Usberg

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