Moral shielding: A grounded theory of integrity maintenance in multidisciplinary teams

Using a classic grounded theory methodology (CGT), this study explores the phenomenon of moral shielding within mental health multidisciplinary teams (MDTS). The study was located within three catchment areas engaged in acute mental health service practice. The main concern identified was the maintenance of a sense of personal integrity during situational binds. Through theoretical sampling thirty two practitioners, including; doctors, nurses, social workers, occupational therapists, counsellors and psychologists, where interviewed face to face. In addition, emergent concepts were identified through observation of MDTs in clinical and research practice. Following a classic grounded theory methodology, data collection and analysis occurred simultaneously. A constant comparative approach was adopted and resulted in the immergence of three sub- core categories; moral abdication, moral hinting and pseudo-compliance. Moral abdication seeks to re-position within an event in order to avoid or deflect the initial obligation to act, it is a strategy used to remove or reduce moral ownership. Moral gauging represents the monitoring of an event with the goal of judging the congruence of personal principles and commitments with that of other practitioners. This strategy is enacted in a bid to seek allies for the support of a given moral position. Pseudo-compliance represents behaviour that hides desired principles and commitments in order to shield them from challenge. This strategy portrays agreement with the dominant position within the MDT, whilst holding a contrary position. It seeks to preserve a reservoir of emotional energy required to maintain a sense of personal integrity. Practitioners who were successful in enacting moral shielding were found to not experience significant emotional distress associated with the phenomenon of moral distress; suggesting that these practitioners had found mechanisms to manage situational binds that threatened their sense of personal integrity.

Salutogenesis: a new paradigm for pervasive computing in healthcare environments?

Salutogenesis is now accepted as a part of the contemporary model of disease: an individual is not only affected by pathogenic factors in the environment, but those that promote well-being or salutogenesis. Given that "environment" extends to include the built environment, promotion of salutogenesis has become part of the architectural brief for contemporary healthcare facilities, drawing on an increasing evidence-base. Salutogenesis is inextricably linked with the notion of person-environment "fit". MyRoom is a proposal for an integrated architectural and pervasive computing model, which enhances psychosocial congruence by using real-time data indicative of the individual's physical status to enable the environment of his/her room (colour, light, temperature) to adapt on an on-going basis in response to bio-signals. This work is part of the PRTLI-IV funded programme NEMBES, investigating the use of embedded technologies in the built environment. Different care contexts require variations in the model, and iterative prototyping investigating use in different contexts will progressively lead to the development of a fully-integrated adaptive salutogenic single-room prototype.

Designing an adaptive salutogenic care environment

Humans are profoundly affected by the surroundings which they inhabit. Environmental psychologists have produced numerous credible theories describing optimal human environments, based on the concept of congruence or “fit” (1, 2). Lack of person/environment fit can lead to stress-related illness and lack of psychosocial well-being (3). Conversely, appropriately designed environments can promote wellness (4) or “salutogenesis” (5). Increasingly, research in the area of Evidence-Based Design, largely concentrated in the area of healthcare architecture, has tended to bear out these theories (6). Patients and long-term care residents, because of injury, illness or physical/ cognitive impairment, are less likely to be able to intervene to modify their immediate environment, unless this is designed specifically to facilitate their particular needs. In the context of care settings, detailed design of personal space therefore takes on enormous significance. MyRoom conceptualises a personalisable room, utilising sensoring and networked computing to enable the environment to respond directly and continuously to the occupant. Bio-signals collected and relayed to the system will actuate application(s) intended to positively influence user well-being. Drawing on the evidence base in relation to therapeutic design interventions (7), real-time changes in ambient lighting, colour, image, etc. respond continuously to the user’s physiological state, optimising congruence. Based on research evidence, consideration is also given to development of an application which uses natural images (8). It is envisaged that actuation will require machine-learning based on interpretation of data gathered by sensors; sensoring arrangements may vary depending on context and end-user. Such interventions aim to reduce inappropriate stress/ provide stimulation, supporting both instrumental and cognitive tasks.