Studies show that healthcare professionals need inter-professional clinical ethics support (CES) in order to communicate and reflect on ethically difficult care situations that they experience in their clinical practice. Internationally, various CES interventions have been performed, but the communication processes and organisation of these interventions are rarely described in detail. The aim of this study was to explore communicative and organisational conditions of a CES intervention with the intention of promoting inter-professional communication about ethically difficult care situations. Eight audio- and video-recorded inter-professional CES sessions, inspired by Habermas' theory of communicative actions, were conducted. The observations were transcribed, sorted, and analysed using concept- and data-driven content analysis methods. The findings show three approaches to promoting communicative agreement, which include the CES facilitators' and participants' approaches to promoting a permissive communication, extended views, and mutual understanding. The CES sessions had organizational aspects for facilitating communicative agreement with both a given structure and openness for variation. The dynamic structure of the organization, promoted both safety and stability as well as a creativity and responsiveness, which in turn opened up for a free and dynamic inter-professional dialogue concerning ethically difficult care situations. The findings constitute a step towards a theory-based CES method inspired by Habermas' theory of communicative action. Further research is needed in order to fully develop the method and obtain increased knowledge about how to promote an inter-professional dialogue about ethically difficulties.

BACKGROUND:: An ethical climate has been described as a working climate embracing shared perceptions about morally correct behaviour concerning ethical issues. Various ethical climate questionnaires have been developed and validated for different contexts, but no questionnaire has been found concerning the ethical climate from an inter-professional perspective in a healthcare context. The Swedish Ethical Climate Questionnaire, based on Habermas' four requirements for a democratic dialogue, attempts to assess and measure the ethical climate at various inter-professional workplaces. This study aimed to present the construction of and to test the psychometric properties of the Swedish Ethical Climate Questionnaire.

METHOD:: An expert group of six researchers, skilled in ethics, evaluated the content validity. The questionnaire was tested among 355 healthcare workers at three hospitals in Sweden. A parallel analysis (PA), an exploratory factor analysis and confirmatory factor analysis were performed.

ETHICAL CONSIDERATIONS:: The participants included in the psychometric analysis were informed about the study, asked to participate in person and informed that they could withdraw at any time without giving any reason. They were also assured of confidentiality in the reporting of the results.

FINDINGS:: The parallel analysis (PA) recommended one factor as a solution. The initial exploratory factor analysis with a four-factor solution showed low concordance with a four-factor model. Cronbach's alpha varied from 0.75 to 0.82; however, since two factors only consisted of one item, alpha could not be reported. Cronbach's alpha for the entire scale showed good homogeneity (α = 0.86). A confirmatory factory analysis was carried out based on the four requirements and showed a goodness-of-fit after deleting two items. After deletion of these items, Cronbach's alpha was 0.82.

DISCUSSION:: Based on the exploratory factor analysis, we suggest that the scale should be treated as a one-factor model. The result indicates that the instrument is unidimensional and assesses ethical climate as a whole.

CONCLUSION:: After testing the Swedish Ethical Climate Questionnaire, we found support for the validity and reliability of the instrument. We found the 10-item version of Swedish Ethical Climate Questionnaire satisfactory. However, we found no support for measuring different dimensions and, therefore, this instrument should be seen as assessing ethical climate as of whole.

Several studies show that healthcare professionals need to communicate inter-professionally in order to manage ethical difficulties. A model of clinical ethics support (CES) inspired by Habermas' theory of discourse ethics has been developed by our research group. In this version of CES sessions healthcare professionals meet inter-professionally to communicate and reflect on ethical difficulties in a cooperative manner with the aim of reaching communicative agreement or reflective consensus. In order to understand the course of action during CES, the aim of this study was to describe the communication of value conflicts during a series of inter-professional CES sessions. Ten audio- and video-recorded CES sessions were conducted over eight months and were analyzed by using the video analysis tool Transana and qualitative content analysis. The results showed that during the CES sessions the professionals as a group moved through the following five phases: a value conflict expressed as feelings of frustration, sharing disempowerment and helplessness, the revelation of the value conflict, enhancing realistic expectations, seeing opportunities to change the situation instead of obstacles. In the course of CES, the professionals moved from an individual interpretation of the situation to a common, new understanding and then to a change in approach. An open and permissive communication climate meant that the professionals dared to expose themselves, share their feelings, face their own emotions, and eventually arrive at a mutual shared reality. The value conflict was not only revealed but also resolved.

BACKGROUND: Providing nursing care for patients with end-stage renal disease entails dealing with existential issues which may sometimes lead not only to ethical problems but also conflicts within the team. A previous study shows that physicians felt irresolute, torn and unconfirmed when ethical dilemmas arose.

RESEARCH QUESTION: This study, conducted in the same dialysis care unit, aimed to illuminate registered nurses' experiences of being in ethically difficult situations that give rise to a troubled conscience.

RESEARCH DESIGN: This study has a phenomenological hermeneutic approach.

PARTICIPANTS: Narrative interviews were carried out with 10 registered nurses working in dialysis care.

ETHICAL CONSIDERATIONS: The study was approved by the Ethics Committee of the Faculty of Medicine, Umeå University.

RESULTS: One theme, 'Calling for a deliberative dialogue', and six sub-themes emerged: 'Dealing with patients' ambiguity', 'Responding to patients' reluctance', 'Acting against patients' will', 'Acting against one's moral convictions', 'Lacking involvement with patients and relatives' and 'Being trapped in feelings of guilt'.

DISCUSSION: In ethically difficult situations, the registered nurses tried, but failed, to open up a dialogue with the physicians about ethical concerns and their uncertainty. They felt alone, uncertain and sometimes had to act against their conscience.

CONCLUSION: In ethical dilemmas, personal and professional integrity is at stake. Mistrusting their own moral integrity may turn professionals from moral actors into victims of circumstances. To counteract such a risk, professionals and patients need to continuously deliberate on their feelings, views and experiences, in an atmosphere of togetherness and trust.

Aim: The aim of this study was to describe how comforters of one dying child were comforted, described by the child's mother and nurse.

Background: The death of a child is one of the greatest losses parents can sustain and a stressful experience for nurses. Those who provide comfort may also need comfort, yet little is known about how comforters are comforted.

Method: The interviews with mother and nurse were analysed using content analysis. Persons and activities mentioned as comforting were outlined in a sociogram.

Findings: The findings show that the mother received comfort from her child and family, the nurse, extended family and others close to the family. She found comfort in being involved in the care and sharing worries with the nurse and in self-comfort. She described that siblings found comfort in each other, in living everyday life, in music and in expressing their feelings in drawings. The nurse gained comfort from sharing hardships with colleagues and a relative and from making a difference to the child.

Conclusion: The findings provide a picture of interacting comforting social networks surrounding one dying child.

Children with progressive cancer often suffer during treatment and at the end of their life, and they need comfort. This study's aim was to describe a child's experiences of being cared for until death, with a focus on discomfort and comfort. Conversations, field notes, drawings, and interviews with the child and his mother and nurse were content analyzed. The themes enduring unbearable situations, expressing emotional suffering, and finding comfort were constructed. The children's parents and other family members are often a significant source of help for the children to endure discomfort and find comfort. Emotional suffering can be expressed in drawing and crying, but sometimes, a child is inconsolable and must endure discomfort. Comfort for a dying child is enhanced by having the family close, experiencing normal daily activities such as drawing and playing, and feeling at home in life despite approaching death.

The aim of the study was to describe parents' narratives concerning what they find comforting when they have a child suffering from cancer. Interviews were conducted with 9 parents--8 mothers and 1 father--of children aged 3 to 9 years who were admitted to a pediatric oncology ward and had undergone their first treatment. The findings showed that the parents derived comfort from being close to their child, perceiving the child's strength, feeling at home in the ward, being a family and being at home, and receiving support from their social network. Comfort experienced in communion with the child and others became important and helped the parents build a new normality perceived as being at home in life despite all their difficulties. Within the frame of communion, the parents seemed to experience moments of hope for their child's recovery and survival.

The aim of this study is to illuminate the meaning of encounters with a troubled conscience among psychiatric therapists. Psychiatric care involves ethical dilemmas which may affect conscience. Conscience relates to keeping or losing a sense of personal integrity when making judgments about one's actions. Ten psychiatric therapists were interviewed in June 2006. The interviews were tape-recorded, transcribed verbatim and interpreted using a phenomenological-hermeneutic method. Two themes 'Facing inadequacy' and 'Struggling to view oneself as being 'good enough'' are presented. In the therapists interviewed, awareness of their use of power, a sense of powerlessness and a sense of blame gave rise to feelings of betrayals and shameful inadequacy. By sharing their inadequacy with co-workers, they managed to endure the sense of their inadequacy which otherwise would have threatened to paralyse them. Finding consolation in sharing wearing feelings, becoming realistic and attesting their worthiness, they reached reconciliation and found confirmation of being good enough. The findings are interpreted in light of Lögstrup's ethics of trust, according to which conscience alerts us to silent but radical ethical demand and the risk of self-deception.

Stress among healthcare students is a growing problem. As self-comfort is assumed to be a way of coping with stressful emotions, the aim of this study was to describe the patterns of self-comforting actions that healthcare students usually use in distress. One hundred and sixty-eight healthcare students volunteered to write down accounts of what they do when they comfort themselves. Their accounts were analysed using qualitative content analysis. The findings reveal two themes: Ingressing and Transcending. Ingressing comprises the sub-themes Unloading, Distracting, Nurturing oneself, Withdrawing and Reassuring. Transcending comprises the sub-themes Opening up and Finding new perspectives. These findings are in line with some stress-reducing strategies described in the literature on stress management. Winnicott's theory about the phenomenon of transition is used to interpret the findings. In the light of Winnicott's theory, self-comforting measures can be comprehended as the ability to transfer early childhood experiences of being nurtured and comforted into well-adapted strategies to effect relaxation and gain strength.