The Ethical Standpoints of Rehabilitation in the Nordic Countries- a Theoretical Study About Caring Sciences and Rehabilitation

International Journal of Caring Sciences January-April 2021 Volume 14 | Issue 1| Page 29

Original Article

The Ethical Standpoints of Rehabilitation in the Nordic Countries- A Theoretical Study About Caring Sciences and Rehabilitation

Frilund, Marianne, RN, MnS, PhD Associate Professor, Faculty of Medicine and Health Sciences, NTNU, Department of Health Sciences Aalesund, Larsgårdsvegen 2, 6009 Aalesund Norway Vinje, Marianne Physical therapist, Master of Management Advicor, Organizational Development Ålesund Muncipality, Norway Correspondene: Frilund, Marianne, RN, MnS, PhD, Ass. Professor, Faculty of Medicine and Health Sciences, NTNU, Department of Health Sciences Aalesund, Larsgårdsvegen 2, 6009 Aalesund Norway E- mail: [email protected]

Abstract

Purpose: The study's purpose is to argue from a theoretical perspective, the importance of an ethical foundation or ontology in rehabilitation. The study aims to create a theoretical model where ethics and rehabilitation form a synthesis. Method: The study is theoretical in the fields of rehabilitation and Caring Science. It follows a hermeneutic approach where the text is interpreted and analysed concerning context. Findings: A common opinion, based on our material, is that rehabilitation is a relationship rather than a separate activity area. No professional group can invoke a monopoly on rehabilitation. Who formulates clinical practice goals and determines the patients' needs? How is the rehabilitation process tailored to the theme of "what is right "and "what is best for the patient"? Conclusion: The theoretical model as it describes in this paper has opportunities to guide the ReHabilitering team against excellent ethical rehabilitation independent of clinical context. Keywords: Rehabilitation, caring sciences, ethics, moral .

Introduction and language pathology and other specialities. The team highlights their patients' rights and Rehabilitation or Physical Medicine autonomy by maximising function and Rehabilitation has existed since the early 1900s. optimising their living situations to contribute to Physical Medicine Rehabilitation started in the the community. (Atanelov et al., 2015; Maribo, US in 1921 by President Franklin Delano Nielsen, & Jespersen, 2014) In the Nordic Roosevelt, to help himself and others affected countries, the way of thinking in rehabilitation with polio regain independence in daily life has turned over from malfunction and disease to activities (Atanelov, Stiens, & Young, 2015). human health resources. Rehabilitation Many medical specialities focus on acute emphasises interprofessional co-operation to management and stabilisation of pathologic meet the patients' needs and goals for a specific conditions, but rehabilitation focuses on holistic time. (Järvikoski & Karjalainen, 2014; Rundell et patient-centred care that addresses psychological al., 2015) and social circumstances. Physical Medicine Rehabilitation is also known as the "quality-of- In the field of rehabilitation, a variety of ethical life" medical speciality (Atanelov et al., 2015). and moral issues has emerged (Christensen, Today, rehabilitation is organised as Mogensen, & Prastegaard, 2011; Fiskaa, 2015; multidisciplinary teams that include physical Moe, 2017). Medical ethics provides a set of therapy, occupational therapy, nursing, speech ethical principles that guide medicine's everyday

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practice. Different healthcare providers have reality, and a moral imperative. When caregivers their guidelines for moral and ethics. (Hunter, act ethically, human dependence, power, 2013) Christensen et al.( 2011), highlight four vulnerability, dignity, and courage are brought to basic principles with relevance for professional life. (Eriksson, 2007, 2009; Eriksson & caregivers and multi-professional teams. These Lindström, 2009; Førland & Alvsvåg, 2018) An principles are 1) autonomy 2) doing well, 3) not ethically aware caregiver strives to "do good", damage and 4) equal value of all people. "do right "and" take responsibility " (Frilund, 2013, 2018). The WHO conference in 2017 Questions asked in previous research were showed a need for increased awareness and whether rehabilitation settings have standard support for the rehabilitation field. The action ontologically rules for excellent and humanistic program presented has been central to the manners in the rehabilitation practice. political discussion in the Nordic countries. (Chandratilake, 2014, Christensen et al., 2011) (WHO, 2017) Chandratilake states that ethics and moral help us discover when we, as professionals in "the name The purpose of the study of the good", are on the verge of overthrowing The study's purpose is to argue from a theoretical the clients' autonomy and integrity. perspective, the importance of an ethical Researches show that ethical discussions and foundation or ontology in rehabilitation. The reflections make the professionals aware of what study aims to create a theoretical model where they see are desired and possible in ethics and rehabilitation form a synthesis. rehabilitation. (Christensen et al., 2011; Frilund, The study aims to provide answers to the 2013; Moe, 2017). The literature describes two following issues: different paradigms within the rehabilitation context. The first paradigm has a liberating a) What is the main idea of rehabilitation in the perspective, highlighting the users` rights to Nordic countries? participate in the rehabilitation process. The b) Which ethical and moral principles govern other paradigm emphasises economy, Nordic countries' rehabilitation activities? technological development, and efficiency. Such services are provided through standardised c) Synthesis: A theoretical model describing the "clinical pathways", "patient pathways", synthesis between caring ethics and rehabilitation standardised programs, "best practice" Methods: The study is theoretical in the fields of descriptions and other clinical guidelines. The rehabilitation and Caring Science. It follows a two paradigms can conflict with each other, hermeneutic approach where the text is which result in ethical challenges and dilemmas. interpreted and analysed. (Howell, 2013) The (Christensen et al., 2011, Frilund, 2013) study is described from an organisational Being aware of the patient's potential or perspective based on Nordic countries' national resources is an essential part of rehabilitation. In documents such as legislation and treatment, the individual is often perceived as an recommendations and relevant previous research. object to be treated. When care and rehabilitation Data material and analyse: We have obtained professionals see the individual as a subject, they the data through manual search and a "snowball can take responsibility for his/her health strategy". By using keywords like promotion processes. The ontological basis for "rehabilitation", phrases like "what is caring is to see patients as subjects or "gentlemen rehabilitation", "definitions of rehabilitation", we in their own lives". The multidisciplinary team found public reports, recommendations, and has opportunities to create a trustful relationship legislation with relevance for rehabilitation area. and confidence with the patient. The patient's The first step in the data collection started by needs, wishes and expectations are linked to the studying the various countries' official websites: group's intention, and the rehabilitation is carried Ministry of Social Affairs and Health out to care. Caring Science is universal science (https://stm.fi/sv/framsida) and The Finnish (Eriksson, 2009) and Froland and Alvsvåg Institute for Health Welfare. (https://thl.fi). THL (2018) emphasise that caring science as a is a Finnish expert agency that provides reliable discipline covers most health and social information on health and welfare for decision- professions. Researches regard Caring as a making and activities in the field. (https://thl.fi). fundamental condition of life, interpersonal The Norwegian Directorate of Health, whose

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propose is to improve health service quality and integration. (https://www.norden.org/sv/info- promote factors that bring good health to the norden/rehabilitering; Fiskaa, 2015; 2009; population. (https://www.helsedirektoratet.no/). Järvikoski & Karjalainen, 2014; Vik, 2018). The National Board of Health Denmark Rehabilitation is characterised by coordinated, (https://www.sst.dk/) and National Board of coherent and knowledge-based activities. Health and Welfare in Sweden. (https://www (https://helsedirektoratet.no, 2020; The socialsryrelsen.se) has a wide range of activities Norwegian Directorate of Health, STM, SST, and many different duties within social services, and National Board of Health and Welfare ) health and medical services, patient safety and Rehabilitation aims to promote patients or users epidemiology. opportunities to achieve the best possible The materials are subjective choices by the functional and coping skills, independence, authors, but we judge the material as the participation in education and working life, and representative for our research questions. We managing society and socially. (Meld. St. Nr. 47, used a form of thematical analyses to analyse the Norwegian health care coordination reform, data. (Braun & Clarke, 2006) The analyse 2009, NOU 2011:11Innovasjon in omsorg, 2011; process gave answers to questions one and two, The Norwegian Directorate of Health, 2012). All which provided input for model development. the Nordic Countries highlight rehabilitation as a The Consensus of the study "the theoretical community-oriented activity focusing on model of synthesis between ethic and promoting the population's functional ability and rehabilitation" results from logical social survival from a holistic view on the human argumentation, inspired by the theoretical model being, independent of physical, mental cognitive developed by Frilund (2013, 2018), adapted to or social limitations. the rehabilitation context. The result is seen as "User participation" is a statutory right. User probable and credible based on the selected participation can contribute to increased accuracy premises on which the study is based. in the design and implementation of both general Preunderstanding and ethical principles: The and individual offers of rehabilitation services. article's authors represent two different (https://helsedirektoratet.no/folkehelse/psykisk- professions: physical therapy and health sciences helse-og-rus/brukermedvirkning). User (nursing - caring sciences). We hypothesised that participation has an intrinsic value, including the rehabilitation in the Nordic countries have a person seeking help wants to control one's own robust ethical standpoint, but it is not life and receive help on their term (Moe, 2017; unambiguous, or explicit. We also hypothesised Pettersson & Iwarsson, 2015; Ojdgard, 2018). that a direct value basis in rehabilitation, both at The same is described in Finland and Sweden as the individual and organisational level, is a patient-centred versus client-centred care and prerequisite for the patient/user to have real highlights values as autonomy, integrity, and possibilities to ethically proper rehabilitation. A respect. rehabilitation that initiated health processes Conclusion: However, the user's role as the relieves suffering towards life meaning and expert of their lives is not apparent (Solbjor, quality of life despite illness and disability. Ljunggren and Kleiven, 2017). It is not clear, Results who formulates clinical practice goals and determines the patients' needs. What is the main idea of rehabilitation in the Nordic countries? Rehabilitation is seen as part How is the rehabilitation process tailored to the of its welfare services. theme of "what is right "and "what is best for the (https://www.norden.org/sv/info- patient"? A common opinion, based on our norden/rehabilitering) Moreover, it is defined as material, is that rehabilitation is a relationship both an individual and community-oriented rather than a separate activity area. No activities based on the client's clear goals. The professional group can invoke a monopoly on rehabilitation goals are to promote the rehabilitation. individual's functional ability, well-being, and Which ethical and moral principles govern the employment rate. The rehabilitation activities rehabilitation activities in the Nordic intend to support the rehabilitation patient and countries. Ethics refers to considerations, what safeguard his / her resources, promote an is "right or good to do”, and what norms and independent life, work capacity and social

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rules should be followed. Common ethical values member's values and basic attitude. (Christensen, and rules highlight the level of “the good" Mogensen, & Prastegaard, 2011; Frilund , 2013; rehabilitation practices. Moe (2017) highlights a Moe, 2017). Ethics is more about wisdom and conflict of interest between the desire to offer judgment than about calculations and citizens better services and create a better unquestionable answers. (Fiskaa, 2015). Fiskaas economy in the municipalities. This conflict of study shows that knowledge of ethical theory can interest is visible in the tensions between help clarify the dilemmas, and further create professions, norms, values and instrumental reflection beyond the purely personal level. Is it innovation. That was reflected in research as relevant to highlight caring sciences as a communication problems, barriers, counter- reference for ethical discussion and rehabilitation verses and instability. (Moe, 2017) The conflict reflection? The physiotherapists in Fiskars study of interests has led the foundation for further call for more knowledge and guidance in ethical reflection, Moe (2017) state. Frilund (2013, discussions and ethical reflections. It is not only 2018) found a clear discrepancy between ethical physiotherapists who experience ethical ideals and realistic possibilities to act morally dilemmas in their daily work. It is a common within elderly care. The discrepancy between problem among all caregivers (Frilund, 2018). willingness and perceived realistic possibilities A "synthesis between ethics and morality in increases the risk of negative effects on work the rehabilitation field" takes shape. The quality. Still, the discrepancy also shows the risk study's main intention was to argue for a of emotional burnout among care professionals. synthesis between caring ethics and the field of When ethical ideals are put concerning moral rehabilitation. The model outlined in Figure 1 practices, ethical dilemmas and feeds are can be described from four cornerstones: 1) The revealed. (Frilund, 2013; Fiskaa, 2015; Moe, ethical values and ontology of rehabilitation, 2) 2017). The view of the user as an active Person-centred approach in rehabilitation 3) participant in the rehabilitation process can Morally defensible rehabilitation practice and 4) contribute to positive effects of rehabilitation, Ethical leadership and coordination . which can reinforce the helplessness that many patients/users expire. The first cornerstone, "The ethical values and Two paradigms have been discussed earlier in ontology of rehabilitation", can be described with entities such as ethical ideals, dignity, autonomy, the paper. One paradigm takes for granted an integrity security and community (Frilund, 2018; increased focus on the individual's treatment and Fiskaa, 2015; Moe, 2017) Ethical ideals from our co-determination in their treatment. The second actions and decisions. Ethical ideas are implicitly paradigm takes for granted a development that emphasises economy, productivity and found in the documents about rehabilitation. The patient's position and the client in Norway, efficiency, with a standardised range of services. Sweden and Finland are based on dignity, In Norway, we can see the effects of paradigm autonomy, security (Act on Patient and User two in all recent developed packages and Rights LOV-1999-07-02-63, Act on the patient's programs. (Moe, 2017) These two paradigms have two different ontological standpoints, which position and rights 17.8.1992 / 785, the Patient Act, 2014: 821). Our ethos and ontology reflect quickly comes into conflict with each other. our ethically manners. The relationship between When Political intentions and staff' intentions ontology (ideal) and moral practice (ethical come into conflict, the gap between Caring ethics possibilities) need not necessarily be linear. and financial values is beginning to create a However, moral acts are influenced by the reality divergence in rehabilitation practices. (Moe, in which the activity is exercised and those who 2017). practice rehabilitation. The rehabilitation Our mind includes our attitudes and culture and patient's needs, goals and expectations have to be may need changes emphasising coping in met, but the level of needs satisfaction are everyday life and close cross-professional and dependent on the limitations or resources cross-governmental collaboration. What ethical allocated to the rehabilitation area. (Christensen value or ontology would be ideal in rehabilitation et al., 2011; Frilund, 2013; Moe, 2017; Hjortbak practice to rice the rehabilitation intentions? et al., 2011). When ethical ideals and patients Conclusion: The rehabilitation practice goal is ’’needs” are not met, ethical dilemmas and unambiguous, but the path, way of thinking and challenges arise, reflecting ethos of the attitudes are far from the individual team rehabilitation team.

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Figure 1 Synthesis between ethical ideals and rehabilitation modified by the authors ( The model was initially developed by Frilund in 2013 and modified by Frilund in 2018).

Moral manners in practice reflect the the rehabilitation activities, based on a professional worker's ontological values, which comprehensive survey of various actors involved is far influenced by the professional ethics the in rehabilitation in Finland. (STM, 2017). In person represents. To achieve “qualitative ethical Denmark, the starting point was the rehabilitation rehabilitation”, the team should reach a patients' experiences of rehabilitation, the users' consensus about ethical values and ethical stories. ( Marselisborg-Center, 2004; Feiring & manners acceptable for the team. We must ask, Solvang, 2013) In Norway, the Ministry of how the patient's autonomy, integrity and dignity Health and Care Services highlighted a psycho- are preserved in the rehabilitation process social model for rehabilitation, emphasising (Gutenbrunner & Nugraha, 2018; Rundell et al., interdisciplinary efforts and co-operation (Meld. 2015; Angel et al., 2011; Fiskaa, 2015; Frilund, St. No. 21 1998-99). Meld. St. No. 21 outlines a 2013; Moe, 2017) sustainable model for the welfare society based on prevention, early intervention, rehabilitation Ethical leadership and coordination are the fourth and coping. These should improve the cornerstone. One of the essential tasks for leaders individual's ability to function and reduce the is developing an organisational culture. A need for costly treatment in the specialist health rehabilitation that safeguards the user's service (The coordination reform of Norwegian autonomy, security, dignity participation is not a health care, 2012, Meld. St. No. 14; Meld. St No. matter of course, even though it is stated in 26) documents and legislation. A leader with courage, visions, ethical spirit has a crucial role However, research shows the needs for analyse-, in the content of ethical discussions and the discuss-, develop-, and implement ethical decision-making process. (Frilund, 2015) theories to guide functional rehabilitation. Research highlights a focus on opportunities and Summary and Discussion: In Finland, a not limitations. (Chandratilake, 2014; working group was appointed in 2016 to map out

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