Within this section of the chapter I will discuss how solution focused questioning can assist the CEC using the ASCS approach to succeed in their task to support and assist the clinician with the case or issue brought to the group.
Clarification of the issues.
The concern is identified by the clinician, (A asking the clinician to begin the story). The group then acts as a curious enquirer, to encourage the clinician to reflect upon the dilemma. There are a number of techniques that team members could utilise within their questioning (S seeking out perspectives including the patient’s). The group questions and explores the situation in a way that helps the person with the issue to identify answers from their own personal perspective. This questioning style could be learned by the CEC members via a short training course (2 days), and confidence in the questioning technique could be improved through
retrospective case reviews conducted by the CEC.
The group then questions and explores the dilemma using the solution-focused approach. The focus here is to avoid leading or putting answers or suggestions into the mouth of the clinician, but instead facilitate effective reflection. Clarification of the issues in the case is made easier through the use of reflective questioning. Examples of questioning styles include the following:
So what did it take to do that?
What helped you achieve that?
How do you do that?
How did you get through that difficulty?
Curious enquirers within the CEC need to become more confident in phrasing questions that are non-directive, and purely about the clinician and his/her
responses and actions in a given situation. By focusing the questions in this way, the group minimises the risk of introducing their own subjective thoughts, and of leading the clinician towards a decision by covert persuasion. This can then all aid reaching decisions about possible (S) solutions.
Triantafillou (1997 pp321-2) when discussing elements of solution-focused
supervision identifies the following fundamental elements that underpin the review process - establishing an atmosphere of competence, search for client based solutions, and feedback and follow up. Through education and practice, the group would become familiar with the questioning techniques used in the solution-
focused model, such as scaling questions, exception-seeking questions, questions about coping, and looking at surrounding day-to-day clinical activities where
problems do not exist, in order to place the issue into perspective (Appendix 2). Fundamental to the success of the CEC case deliberations, is the ability to offer supportive and empathic communication. The dialogue between the case bringer and the CEC must acknowledge that situations including conflicts are shaped by interpretation and context, which in turn shape and alter contexts so that the situation is a constantly fluid and moving one.
As Ragan et al (2008 p17) state:
“All forms of human communication can be seen fundamentally as stories, as interpretations of aspects of the world occurring in time and shaped by history, culture, and character (Fisher 1989). Illness, like narrative, occurs
within context at the same time that it reshapes context, within relationships at the same time that it reshapes them, and within a persons’ life at the same time that it reshapes that life”.
By acknowledging and welcoming this and not trying to ignore or filter out this important element of the ethical concern, the CEC can offer the clinician the best opportunity to make a judgement based on their own philosophy and shaped by the context. The supportive questioning and reflection facilitated by this approach, offers the best chance of yielding a practical and appropriate answer to the
situation from practice and within practice, and will stimulate the moral growth of those involved, especially the practitioner by providing them with skills and confidence to utilise in the workplace and apply within their own teams. As Cusveller (2012 p440) states “ethics education needs to be more practical” and “many of the competencies needed to participate in an ethics committee are, to an important degree, a continuation (and intensification) of the competencies needed to participate in a team of nurses delivering daily patient care in the first place”. This can be applied not only to nurses but to all members of the healthcare team, across the spectrum of disciplines. This approach can be seen to have
foundations in the teachings of Habermas. Fisher (1989 p92, cited in Ragan et al 2008 p18) asserts:
“Habermas posits persons as arguers; I see them, including arguers, as storytellers...His [Habermas’s] concept of the end of communication is understanding; my concept of the end of communication is practical wisdom and humane action”.
Key elements of the approach are reflected by the philosophy of “petite ethique” identified by Ricoeur (Potvin 2010). Potvin describes a client-focused philosophy
with an underpinning ethic of action, where the aim is a good life with and for others, in an institution that is just. She summarises the aim of the clinician in bringing the case to the ethics consultation, and the aim of the response from the clinical ethics group as follows:
“The laudable intention of these professionals is to somehow, and according to the very difficult human and institutional circumstances of the clinical setting, provide means for a better life with and for the patient/family. In responding to a request for an ethics consultation, the health care team not only provides a means to act in the best interests of their patient, but also provides a means to act in a responsible manner towards their colleagues’ best interests (e.g., by providing an opportunity to share their concerns)” (Potvin 2010 p316).
The ethic of ‘I-You-It’ reflects the clinician’s aim in bringing the issue to the CEC: ‘I want to make the right choices and I am capable of making the right choices.’ The motivation is to support the ‘you’, both the patient and, from the CEC perspective, everyone involved in the situation. The CEC sits well into the framework of ‘it’, in that Potvin describes the role of the organisation as that of a ‘neutral mediator’, a phrase that accurately describes what the CEC would be, if it were to use the ASCS model and solution-focused questioning.
Potvin (2010 p317) reflects the imbalance of power inherent in the relationship between the professional and the patient:
“The asymmetrical relationship between the expert professional and the vulnerable patient/family is a place of potential abuse. This relationship therefore necessitates mediation, often in the form of rules or norms that
make possible a fair collaboration between the patient/family and health professionals. The duty not to abandon the patient, the obligation of confidentiality, and expectations regarding patient’s participation in their care planning are some examples of these imperatives.”
Even if we accept a plurality of ethical views within the situation, there are cultural norms and healthcare rules against which these differing views can be considered, and thus reasonable options for action can be identified.
Some of the potential benefits for the clinician ascribed to considering issues using a reflective, solution-focused approach, include the following: reflection on practice versus reflection in practice and the exploration of the benefits of an action; the opportunity to stand back from the situation; being able to look at others’ viewpoints; finding out new legal and empirical details; testing out options; becoming more aware of the support available; and ethical self-awareness. This can contribute towards building confidence in relation to clinical ethical matters, can facilitate good practice and can help to avoid conflict, both between clinician and patient and between clinician and clinician. Using the approach within the CEC offers an opportunity for the CEC and the clinician bringing the case to consider the power the latter holds within the clinical situation and how they can use that power skillfully and with respect. Through an environment of trust, an ethic underpinned by trust is built.
Wiggins et al (2005) also discuss the asymmetry of the patient’s dependence and the physician’s power, and clearly articulate the latter as follows:
“Because the patient is ill or injured and cannot heal him- or herself, he or she has become dependent on the knowledge, skills and sympathy of
health care professionals. Therefore, health care professionals have a power, the power to help, on which the patient has become dependent. This renders the patient vulnerable to misuses of such power…..The issue of trust goes beyond simply trusting the physician’s medical expertise; it also involves trusting the moral character of the human being wielding that expertise” (p82-83).
Another benefit to the clinician can be that through the discussion around the dilemma, and use of sensitive questioning, the CEC can help direct clinicians to further relevant support, such as legal advice, if required. Through the
development of the processes inherent in the solution-focused approach, the CEC can demonstrate skills that are also important to building a strong, trusting
clinician/patient relationship such as transparency, a willingness to be questioned, the courage to review, flexibility and the willingness to listen and learn. These groups can become role models for good communication and anti-discriminatory practice.
Simply the opportunity to consider ethical concerns in a confidential and
supportive forum can be seen as a benefit for the clinician. Reflection within the CEC around the nature of an ethical issue or issues, within a less pressured, non- clinical environment, can facilitate a considered and supported review of initial value judgements and the issues that have triggered them. Such informal
discussions, held outside the heat of battle, can offer the clinician an opportunity to consider their responses or actions in the clinical situation and whether these are based upon appropriate assumptions about the case.
An opportunity to consider initial value judgements could be useful, as they may be based on incomplete information or be heavily biased by a particular
experience, belief or prejudice. Thus, leaving them unquestioned or unexplored may influence the subsequent behaviour of the clinician and potentially lead to unwise decisions in similar circumstances in the future. As Musschenga (2009 p 598) states:
“Moral judgments are, to a large extent, intuitive and automatic responses to challenges, elicited without awareness of underlying mental
processes…Intuitive moral judgments stem from an ancient, automatic, very fast affective part of the human brain, while moral reasoning takes place within the phylogenetically newer, slower, motivationally weaker cognitive system”.
Therefore, offering an opportunity to take these responses and explore them in a more measured environment, could begin to introduce a more conscious and rational process, which may increase the clinician’s moral awareness. This may change the course of the clinician’s decision and subsequent future decisions. Wells (2005) identifies a number of situations in which commonly held
assumptions, leading to an initial value judgement about a particular behaviour, can be seen to be erroneous upon further reflection. One such area, she argues, is autonomy and individual rights. She also talks about the issue of patient independence. Wells states that the healthcare commonly promotes an active approach to involvement in care for the patient and would make a judgement that active involvement to achieve physical independence was agreed to be a laudable goal. But, some cultures, e.g. Asian and Hispanic believe it is their duty to care for their sick. The sick person’s role is viewed as passive and even dependant as the person is seen as ill as a result of sins committed by the family. It is the
judgement about such a patient must reflect the cultural norms for that person not the assumptions held by the ethics committee.
For many teams, day-to-day decision making, including reflection on the ethical aspects of cases, can be achieved through multi-disciplinary discussion, which is increasingly being built into the day-to-day practice in healthcare through multi- disciplinary healthcare reviews. This approach recognises the decision-making challenges that practitioners face. Wells (2005) reflects that doing the right thing in clinical practice is challenging especially when the patients and care givers come from very different cultural backgrounds. The MDT is required to develop the skills in practice to enable them to be able to, on a daily basis, elicit the meanings those they care for ascribe to events and how this will influence the decisions they make about their own health. Understanding these meanings and perceptions is vital in order to offer truly patient centred care. Because of this no evaluation within the CEC should take place without active steps to elicit the patient perspective.