تنش‌های اخلاقی در بخش ارتوپدی بیمارستان امام خمینی: یک مطالعه کیفی.

نوع مقاله : پژوهشی (Original Research)

نویسندگان

1 استادیار گروه هوشبری، دانشکده پیراپزشکی، دانشگاه علوم پزشکی کاشان.

2 دکتری پزشکی، دانشکده پزشکی، دانشگاه علوم پزشکی تهران.

3 مرکز تحقیقات اخلاق و تاریخ پزشکی دانشگاه علوم پزشکی تهران. استادیار گروه اخلاق پزشکی، دانشکده پزشکی، دانشگاه علوم پزشکی تهران.

چکیده

زمینه و هدف: تنش اخلاقی از جمله مسائل گریبانگیر کادر ‌درمان است. تنش ‌اخلاقی به معنی ناتوانی فرد در عمل براساس ارزش‌های درونی و حرفه‌ای به دلایل فشارهای درونی و بیرونی است. متخصصین مراقبت‌های بهداشتی ممکن است با شرایط چالش‌برانگیزی مواجه شوند که از نظر اخلاقی در مورد درست یا غلط‌بودن تصمیمات یا اقدامات درمانی تردید داشته باشند؛ درحالیکه در برابر تغییر شرایطی که آن را غیراخلاقی می‌پندارند، احساس ناتوانی کنند. امروزه تنش ‌اخلاقی به عنوان یکی از علل اصلی سندرم فرسودگی شغلی درمیان کادر درمان شناخته می‌شود. این مطالعه به منظور بررسی تنش‌های اخلاقی کادر درمان بخش ارتوپدی بیمارستان امام خمینی انجام شد.
روش بررسی: مطالعه به صورت کیفی به روش تحلیل محتوا از طریق مصاحبه‌های حضوری نیمه ساختارمند با مشارکت پزشکان، دستیاران و پرستاران بخش ارتوپدی بیمارستان امام خمینی انجام شد. مصاحبه‌ها در نرم‌افزار ورد پیاده‌سازی، کدگذاری و دسته‌بندی گردید. سپس کدهای مشابه در طبقات و زیرطبقات مشابه قرار گرفت.
یافته‌ها: 23 مصاحبه انجام و 18 زیرطبقه،  7 طبقه و 3 درون‌مایه چالش‌های مراقبتی، تنش‌های ارتباطی تیم درمان و چالش‌های آموزشی شکل گرفت.
نتیجه‌گیری: نتایج از وجود چالش‌های مختلف و تنش‌های اخلاقی حکایت می‌کرد که نتایج آن بیمار و کادردرمانی را تحت تاثیر قرار داده و موجب دیسترس، ناامیدی و عدم رضایت می‌شد. مدیریت این چالش‌ها نیاز به تدابیر جدی در تعیین مقررات سیستم درمانی، وظایف شغلی و اصلاح روابط بین‌فردی را مطرح نمود. شناخت تنش‌های اخلاقی در سیستم مراقبتی و درمانی می‌تواند در برنامه‌ریزی و اصلاح ساختار مدیریتی، ارتباطی و در نهایت بهبود کیفیت خدمات و پیامدهای بیماران کمک موثری باشد.

کلیدواژه‌ها

موضوعات

  1. Ameri M, Safavi Bayat Z, Ashktorab T, Kavoosi A, Vaezi A. Moral distress: evaluating nurses’ experiences. ijme. 2013; 6 (1) :64-73. [Persian].
  2. Arnetz B B. Psychosocial challenges facing physicians of Social science & medicine, 2001. 52(2): p. 203-213. https://doi.org/10.1016/s0277-9536(00)00220-3.
  3. van der Arend AJ, Remmers-van den Hurk CH. Moral problems among Dutch nurses: a survey. Nurs Ethics. 1999 Nov;6(6):468-82. doi: 10.1177/096973309900600603. PMID: 10696193.
  4. Corley MC, Elswick RK, Gorman M, Clor T. Development and evaluation of a moral distress scale. Journal of advanced nursing. 2001; 33(2): 250-256. https://doi.org/10.1046/j.1365-2648.2001.01658.x
  5. Raines ML. Ethical decision making in nurses: relationships among moral reasoning, coping style, and ethics stress. JONA'S healthcare law, ethics and regulation. 2000; 2(1): 29-41.
  6. Fumis RRL, Junqueira Amarante GA, de Fátima Nascimento A, Vieira Junior JM. Moral distress and its contribution to the development of burnout syndrome among critical care providers. Ann Intensive Care. 2017;7(1):71. https://doi: 10.1186/s13613-017-0293-2. Epub 2017 Jun 21. PMID: 28639161; PMCID: PMC5479870.
  7. Jameton A. Nursing practice: the ethical issues. 1984; Englewood Cliffs: Prentice-Hall.
  8. Hamric AB, Blackhall LJ. Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. Critical care medicine. 2007; 35(2): 422-429. https://doi.org/10.1097/01.ccm.0000254722.50608.2d.
  9. Henrich NJ, Dodek PM, Gladstone E, Alden L, Keenan SP, Reynolds S, Rodney P. Consequences of Moral Distress in the Intensive Care Unit: A Qualitative Study. Am J Crit Care. 2017;26(4):e48-e57. https://doi: 10.4037/ajcc2017786. PMID: 28668926.
  10. Storch J L, Rodney P,  Starzomsk R C. Toward a moral horizon: Nursing ethics for leadership and practice.Toronto: Pearson; 2013; 160-187.
  11. Pauly B, Varcoe C, Storch J, Newton L. Registered nurses' perceptions of moral distress and ethical climate. Nurs Ethics. 2009;16(5):561-73. https://doi: 10.1177/0969733009106649.
  12. Walsh BC, Karia R, Egol K, Zuckerman JD, Phillips D. Teaching Professionalism in Orthopaedic Residency: Efficacy of the American Academy of Orthopaedic Surgeons Ethics Modules. J Am Acad Orthop Surg. 2018; 26(14):507-514. https://doi: 10.5435/JAAOS-D-16-00386.86.
  13. Rise MB, Pellerud A, Rygg LØ, Steinsbekk A., Making and maintaining lifestyle changes after participating in group based type 2 diabetes self-management educations: a qualitative study. PLoS one, 2013; (5)8: e64009. https://doi.org/10.1371/journal.pone.0064009.
  14. van Esch S C, Heideman W H, Cleijne W, Cornel M C, Snoe FJ. Health care providers’ perspective on using family history in the prevention of type 2 diabetes: a qualitative study including different disciplines. BMC Fam Pract. 2013; 14 (31). https://doi.org/10.1186/1471-2296-14-31.
  15. Noor Abdulhadi N, Al-Shafaee M, Wahlström R, Hjelm K. Doctors’ and nurses’ views on patient care for type 2 diabetes: An interview study in primary health care in Oman. Primary Health Care Research & Development. 2013; 14(3): 258-269. https://doi:10.1017/S146342361200062X Burnard, P.
  16. Philip Burnard, A method of analysing interview transcripts in qualitative research. Nurse Education Today. 1991; 11 (6): 461-466. https://doi.org/10.1016/0260-6917(91)90009-Y.
  17. Hsieh H F, Shannon S E. Three approaches to qualitative content analysis. Qualitative health research. 2005; 15(9): 1277-1288. https://doi.org/10.1177%2F1049732305276687.
  18. McCain G C. Content analysis: a method for studying clinical nursing problems. Applied nursing research: ANR. 1988; 1(3): 146. https://doi.org/10.1016/s0897-1897(88)80029-6.
  19. Dey I. Qualitative data analysis: A user friendly guide for social scientists. 1st ed: Routled; 2003.
  20. Robson C. Real world research: A resource for social scientists and practitioner-researchers. Vol. 2. 2002; Blackwell Oxford.
  21. Burnard P. Teaching the analysis of textual data: an experiential approach. Nurse education today. 1996; 16(4): 278-281. https://doi.org/10.1016/s0260-6917(96)80115-8.
  22. Polit D.F, Beck C T, Hungler B. Essentials of nursing research: methods.appraisal`s and utilization. 5th Lippincott Williams & Wilkins; 2004. Translated by Dehghan Nayyeri N and Asadi Nooghabi A A. Andishe Rafiee, Tehran. 2004. P. 254-258. ISBN: 964-8154-18-x.
  23. Shoorideh FA, Ashktorab T, Yaghmaei F, Alavi Majd H. Relationship between ICU nurses’ moral distress with burnout and anticipated turnover. Nursing Ethics. 2014; 22(1): 64-76. https://doi.org/10.1177/0969733014534874.
  24. Larson CP, Dryden-Palmer KD, Gibbons C, Parshuram CS. Moral Distress in PICU and Neonatal ICU Practitioners: A Cross-Sectional Evaluation. Pediatr Crit Care Med. 2017 ;18(8): e318-e326. https://doi: 10.1097/PCC.0000000000001219. PMID: 28598947.
  25. Rizo CA, Jadad A R, Enkin M J B B M J. What's a good doctor and how do you make one?: Doctors should be good companions for people. BMJ. 2002; 325(7366): 711. PMCID:
  26. Coulter A. Patients' views of the good doctor. BMJ. 2002; 325(7366):668-9. https://doi: 10.1136/bmj.325.7366.668.
  27. Korsch B M, Harding C. The intelligent patient's guide to the doctor-patient relationship: learning how to talk so your doctor will listen. Oxford University Pres; 1998.
  28. Shaw A, Ibrahim S, Reid F, Ussher M, Rowlands G. Patients’ perspectives of the doctor–patient relationship and information giving across a range of literacy levels. Patient Educ Couns. 2009; 75 (1): 114-120. https://doi.org/10.1016/j.pec.2008.09.026.
  29. Lefaivre KA, Macadam SA, Davidson DJ, Gandhi R, Chan H, Broekhuyse HM. Length of stay, mortality, morbidity and delay to surgery in hip fractures. J Bone Joint Surg Br. 2009; 91(7): 922-7. https://doi: 10.1302/0301-620X.91B7.22446.
  30. Johnson J, Rogers W. Joint issues – conflicts of interest, the ASR hip and suggestions for managing surgical conflicts of interest. BMC Medical Ethics. 2014; 15: 63. http://www.biomedcentral.com/1472-6939/15/63.
  31. Bernheim K F, Switalski T J P S. Mental health staff and patient's relatives: How they view each other. Hosp Community Psychiatry. 1988; 39(1): 63-68. https://doi.org/10.1176/ps.39.1.63.
  32. Dolatyari A, Sharififar S T, Zareiyan A, Tadrisi S D. Family satisfaction with care in the intensive care unit: Results of a multiple center study in selected military hospitals. MCS. 2014; 1 (1): 18-26. [Persian]. http://mcs.ajaums.ac.ir/article-1-44-en.html.
  33. Kalroozi F., Dadgari F., Zareiyan A. Patients’ satisfaction from health care group in patient’s bill of right observance. J Mil Med. 2010; 12 (3): 143-148. [persian]
    http://militarymedj.ir/article-1-697-en.html.
  34. Sexton J B, Thomas E J, Helmreich R L J B. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000; 320 (7237): 745-749. https://doi.org/10.1136/bmj.320.7237.745.
  35. Ogulata S N. Erol R J J o M S. A hierarchical multiple criteria mathematical programming approach for scheduling general surgery operations in large hospitals. J Med Syst. 2003; 27(3): 259-270. https://doi.org/10.1023/a:1022575412017.

36.   Sepehrmanesh Z, Ahmadvand A. Prevalence of Burnout in the Residents of Kashan and Isfahan Universities of Medical Sciences in 2012. RME. 2015; 7 (1) :27-34. [Persian]. http://rme.gums.ac.ir/article-1-155-en.htm.

  1. Khaghanizade M, Malaki H, Abbasi M, Abbaspour A, Mohamadi E. Faculty-Related Challenges in Medical Ethics Education: A Qualitative Study. Iranian Journal of Medical Education. 2012; 11 (8) :903-916. [Persian] http://ijme.mui.ac.ir/article-1-1434-en.html.

38.   Ziaeddin Tabei S ,  Afshar L . Patient's rights in university teaching hospitals and Ethical challenges. Journal of Medical Ethics, Volume:4 Issue: 13, 2011 [Persian].

39.   Malek M, Mohammadi S, Attarchi M. Occupational stress and influencing factors, in medical residents of one of the educational hospitals of Tehran University of Medical Sciences. RJMS. 2011; 18 (87): 24-35. [Persian] http://rjms.iums.ac.ir/article-1-1830-en.html.

40.   Soleymanha M, Heidarzadeh A, Haghighi M, Khoshrang H, Akbari M. Assessment of Job-Education Satisfaction in Residents of Guilan University of Medical Sciences. RME. 2013; 5 (1) :45-51. [Persian] http://rme.gums.ac.ir/article-1-150-en.html.

مراجع

  1. Ameri M, Safavi Bayat Z, Ashktorab T, Kavoosi A, Vaezi A. Moral distress: evaluating nurses’ experiences. ijme. 2013; 6 (1) :64-73. [Persian].
  2. Arnetz B B. Psychosocial challenges facing physicians of Social science & medicine, 2001. 52(2): p. 203-213. https://doi.org/10.1016/s0277-9536(00)00220-3.
  3. van der Arend AJ, Remmers-van den Hurk CH. Moral problems among Dutch nurses: a survey. Nurs Ethics. 1999 Nov;6(6):468-82. doi: 10.1177/096973309900600603. PMID: 10696193.
  4. Corley MC, Elswick RK, Gorman M, Clor T. Development and evaluation of a moral distress scale. Journal of advanced nursing. 2001; 33(2): 250-256. https://doi.org/10.1046/j.1365-2648.2001.01658.x
  5. Raines ML. Ethical decision making in nurses: relationships among moral reasoning, coping style, and ethics stress. JONA'S healthcare law, ethics and regulation. 2000; 2(1): 29-41.
  6. Fumis RRL, Junqueira Amarante GA, de Fátima Nascimento A, Vieira Junior JM. Moral distress and its contribution to the development of burnout syndrome among critical care providers. Ann Intensive Care. 2017;7(1):71. https://doi: 10.1186/s13613-017-0293-2. Epub 2017 Jun 21. PMID: 28639161; PMCID: PMC5479870.
  7. Jameton A. Nursing practice: the ethical issues. 1984; Englewood Cliffs: Prentice-Hall.
  8. Hamric AB, Blackhall LJ. Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. Critical care medicine. 2007; 35(2): 422-429. https://doi.org/10.1097/01.ccm.0000254722.50608.2d.
  9. Henrich NJ, Dodek PM, Gladstone E, Alden L, Keenan SP, Reynolds S, Rodney P. Consequences of Moral Distress in the Intensive Care Unit: A Qualitative Study. Am J Crit Care. 2017;26(4):e48-e57. https://doi: 10.4037/ajcc2017786. PMID: 28668926.
  10. Storch J L, Rodney P,  Starzomsk R C. Toward a moral horizon: Nursing ethics for leadership and practice.Toronto: Pearson; 2013; 160-187.
  11. Pauly B, Varcoe C, Storch J, Newton L. Registered nurses' perceptions of moral distress and ethical climate. Nurs Ethics. 2009;16(5):561-73. https://doi: 10.1177/0969733009106649.
  12. Walsh BC, Karia R, Egol K, Zuckerman JD, Phillips D. Teaching Professionalism in Orthopaedic Residency: Efficacy of the American Academy of Orthopaedic Surgeons Ethics Modules. J Am Acad Orthop Surg. 2018; 26(14):507-514. https://doi: 10.5435/JAAOS-D-16-00386.86.
  13. Rise MB, Pellerud A, Rygg LØ, Steinsbekk A., Making and maintaining lifestyle changes after participating in group based type 2 diabetes self-management educations: a qualitative study. PLoS one, 2013; (5)8: e64009. https://doi.org/10.1371/journal.pone.0064009.
  14. van Esch S C, Heideman W H, Cleijne W, Cornel M C, Snoe FJ. Health care providers’ perspective on using family history in the prevention of type 2 diabetes: a qualitative study including different disciplines. BMC Fam Pract. 2013; 14 (31). https://doi.org/10.1186/1471-2296-14-31.
  15. Noor Abdulhadi N, Al-Shafaee M, Wahlström R, Hjelm K. Doctors’ and nurses’ views on patient care for type 2 diabetes: An interview study in primary health care in Oman. Primary Health Care Research & Development. 2013; 14(3): 258-269. https://doi:10.1017/S146342361200062X Burnard, P.
  16. Philip Burnard, A method of analysing interview transcripts in qualitative research. Nurse Education Today. 1991; 11 (6): 461-466. https://doi.org/10.1016/0260-6917(91)90009-Y.
  17. Hsieh H F, Shannon S E. Three approaches to qualitative content analysis. Qualitative health research. 2005; 15(9): 1277-1288. https://doi.org/10.1177%2F1049732305276687.
  18. McCain G C. Content analysis: a method for studying clinical nursing problems. Applied nursing research: ANR. 1988; 1(3): 146. https://doi.org/10.1016/s0897-1897(88)80029-6.
  19. Dey I. Qualitative data analysis: A user friendly guide for social scientists. 1st ed: Routled; 2003.
  20. Robson C. Real world research: A resource for social scientists and practitioner-researchers. Vol. 2. 2002; Blackwell Oxford.
  21. Burnard P. Teaching the analysis of textual data: an experiential approach. Nurse education today. 1996; 16(4): 278-281. https://doi.org/10.1016/s0260-6917(96)80115-8.
  22. Polit D.F, Beck C T, Hungler B. Essentials of nursing research: methods.appraisal`s and utilization. 5th Lippincott Williams & Wilkins; 2004. Translated by Dehghan Nayyeri N and Asadi Nooghabi A A. Andishe Rafiee, Tehran. 2004. P. 254-258. ISBN: 964-8154-18-x.
  23. Shoorideh FA, Ashktorab T, Yaghmaei F, Alavi Majd H. Relationship between ICU nurses’ moral distress with burnout and anticipated turnover. Nursing Ethics. 2014; 22(1): 64-76. https://doi.org/10.1177/0969733014534874.
  24. Larson CP, Dryden-Palmer KD, Gibbons C, Parshuram CS. Moral Distress in PICU and Neonatal ICU Practitioners: A Cross-Sectional Evaluation. Pediatr Crit Care Med. 2017 ;18(8): e318-e326. https://doi: 10.1097/PCC.0000000000001219. PMID: 28598947.
  25. Rizo CA, Jadad A R, Enkin M J B B M J. What's a good doctor and how do you make one?: Doctors should be good companions for people. BMJ. 2002; 325(7366): 711. PMCID:
  26. Coulter A. Patients' views of the good doctor. BMJ. 2002; 325(7366):668-9. https://doi: 10.1136/bmj.325.7366.668.
  27. Korsch B M, Harding C. The intelligent patient's guide to the doctor-patient relationship: learning how to talk so your doctor will listen. Oxford University Pres; 1998.
  28. Shaw A, Ibrahim S, Reid F, Ussher M, Rowlands G. Patients’ perspectives of the doctor–patient relationship and information giving across a range of literacy levels. Patient Educ Couns. 2009; 75 (1): 114-120. https://doi.org/10.1016/j.pec.2008.09.026.
  29. Lefaivre KA, Macadam SA, Davidson DJ, Gandhi R, Chan H, Broekhuyse HM. Length of stay, mortality, morbidity and delay to surgery in hip fractures. J Bone Joint Surg Br. 2009; 91(7): 922-7. https://doi: 10.1302/0301-620X.91B7.22446.
  30. Johnson J, Rogers W. Joint issues – conflicts of interest, the ASR hip and suggestions for managing surgical conflicts of interest. BMC Medical Ethics. 2014; 15: 63. http://www.biomedcentral.com/1472-6939/15/63.
  31. Bernheim K F, Switalski T J P S. Mental health staff and patient's relatives: How they view each other. Hosp Community Psychiatry. 1988; 39(1): 63-68. https://doi.org/10.1176/ps.39.1.63.
  32. Dolatyari A, Sharififar S T, Zareiyan A, Tadrisi S D. Family satisfaction with care in the intensive care unit: Results of a multiple center study in selected military hospitals. MCS. 2014; 1 (1): 18-26. [Persian]. http://mcs.ajaums.ac.ir/article-1-44-en.html.
  33. Kalroozi F., Dadgari F., Zareiyan A. Patients’ satisfaction from health care group in patient’s bill of right observance. J Mil Med. 2010; 12 (3): 143-148. [persian]
    http://militarymedj.ir/article-1-697-en.html.
  34. Sexton J B, Thomas E J, Helmreich R L J B. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000; 320 (7237): 745-749. https://doi.org/10.1136/bmj.320.7237.745.
  35. Ogulata S N. Erol R J J o M S. A hierarchical multiple criteria mathematical programming approach for scheduling general surgery operations in large hospitals. J Med Syst. 2003; 27(3): 259-270. https://doi.org/10.1023/a:1022575412017.

36.   Sepehrmanesh Z, Ahmadvand A. Prevalence of Burnout in the Residents of Kashan and Isfahan Universities of Medical Sciences in 2012. RME. 2015; 7 (1) :27-34. [Persian]. http://rme.gums.ac.ir/article-1-155-en.htm.

  1. Khaghanizade M, Malaki H, Abbasi M, Abbaspour A, Mohamadi E. Faculty-Related Challenges in Medical Ethics Education: A Qualitative Study. Iranian Journal of Medical Education. 2012; 11 (8) :903-916. [Persian] http://ijme.mui.ac.ir/article-1-1434-en.html.

38.   Ziaeddin Tabei S ,  Afshar L . Patient's rights in university teaching hospitals and Ethical challenges. Journal of Medical Ethics, Volume:4 Issue: 13, 2011 [Persian].

39.   Malek M, Mohammadi S, Attarchi M. Occupational stress and influencing factors, in medical residents of one of the educational hospitals of Tehran University of Medical Sciences. RJMS. 2011; 18 (87): 24-35. [Persian] http://rjms.iums.ac.ir/article-1-1830-en.html.

40.   Soleymanha M, Heidarzadeh A, Haghighi M, Khoshrang H, Akbari M. Assessment of Job-Education Satisfaction in Residents of Guilan University of Medical Sciences. RME. 2013; 5 (1) :45-51. [Persian] http://rme.gums.ac.ir/article-1-150-en.html.

طب و تزکیه
دوره 31، شماره 3
آذر 1401
صفحه 198-185

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