Samvete i vården : att möta det moraliska ansvarets röster

Sammanfattning: The overall aim of this thesis is twofold: first, to develop and validate questionnaires that could be used for investigating relationships between perceptions of conscience, moral sensitivity and burnout and second, to describe patterns of self-comfort used to ease stress and illuminate meanings of living with a troubled conscience. The thesis comprises five studies and is based on both quantitative and qualitative data.In study I, a questionnaire was constructed to assess perceptions of conscience; the Perceptions of Conscience Questionnaire (PCQ). This 15 item-questionnaire was distributed to 444 care providers. Statistical analyses of responses showed sufficient distribution and a stable six factor solution congruent with reviewed literature. The six factors were labelled: ‘the voice of authority’, ‘warning signal’, ‘demanding sensitivity’, ‘asset’, ‘burden’ and ‘depending on culture’. The findings suggest that the PCQ is a valid questionnaire. The aim of study II was further development of an existing questionnaire assessing care providers’ moral sensitivity, enabling its use in various care contexts. The revised nine-item questionnaire, the Moral Sensitivity Questionnaire Revised version (MSQ-R), was distributed to 278 care providers with various professional backgrounds. Statistical analyses of responses showed sufficient distribution and a three-factor solution congruent with reviewed literature. The three factors were labelled: ‘sense of moral burden’, ‘sense of moral strength,’ and ‘sense of moral responsibility.’ The findings suggest that MSQ-R is valid for use in various healthcare contexts. In study III, the PCQ, the MSQ-R and the Maslach Burnout Inventory (MBI) were distributed to a population of psychiatric care providers (n=101) to investigate relationships between perceptions of conscience and moral sensitivity and levels of burnout. The hierarchical cluster analysis shows two clusters with Pearson’s r >.50. Cluster A comprising items such as: being sensitive, interpreting and following the voice of conscience that warns us against hurting other or ourselves and developing as human beings was labelled ‘experiencing a sense of moral integrity’. Cluster B comprising items such as: feeling inadequate, doing more than one has strengths for, feeling always responsible, having difficulties to deal with wearing feelings, perceiving that conscience gives wrong signals and express social values, having to deaden one’ conscience, were all related to scores of the MBI subscales emotional exhaustion (EE) and depersonalisation (DP). Cluster B was labelled ‘experiencing a burdening accountability’. The results show that levels of ‘experiencing a burdening accountability’ are closely related to levels of being at risk of burnout.The aim of study IV was to describe patterns of self-comforting measures used to ease stress. The written accounts of 168 care providers and healthcare students were analysed by means of qualitative content analysis. The findings disclose two dimensions: an ability to use early learned measures to take care of oneself (ingression) and an ability to feel intimately related to life, other human beings and universe or God (transcendence). The findings provide valuable knowledge about self-comfort as a coping strategy. The aim of study V was to illuminate meanings of living with a troubled conscience. Ten psychiatric care providers, respondents of study III with various perceptions of conscience were interviewed. The interviews were interpreted using a phenomenological - hermeneutical method. The findings show that one meaning of living with a troubled conscience is being confronted with inadequacy and struggling to view oneself as ‘good enough.’ The comprehensive understanding indicates that inadequacy, both one’s own and that of organization one represents, infuse feelings of shame rather than feelings of guilt. Shame concerns one’s identity and need of reconciliation.Conclusions: The results reveal two ways of encountering a troubled conscience. One is being unable to interpret the ethical demand from a troubled conscience. This is indicated by connections between levels of moral burden and levels of burnout. The other way is being able to interpret the ethical demand and using one’s troubled conscience to develop practical wisdom. This means facing shame of feeling inadequate, reconciling images of the ideal self and self-contempt, and becoming realistic about what one can do. In this process comfort seems to be a mediator of reconciliation.