The ‘one to five ’ method - A tool for ethical communication in groups among healthcare professionals

Healthcare professionals have expressed a wish for facilitated inter-professional communications about ethical difficulties experienced in clinical practice. The introduction of an easily accessible method for facilitating ethical communication in groups may promote its implementation in everyday clinical practice. The aim of this paper was to draw on previous studies and available knowledge in order to develop and describe a method that enables systematic implementation of inter-professional ethical communication in groups. The ‘one-to-five method ’ for facilitated ethical communication in groups is theoretically inspired by Habermas ’ s theory of communicative actions and base on previous studies that accords with the Helsinki Declaration (2013). The ‘one to five method ’ supports guidance of ethical communication in five steps: telling the story about the situation; reflections and dialogue concerning the emotions involved; formulation of the problem/dilemma; analysis of the situation and the dilemma; and searching for a choice of action or approach. It offers an easily accessible method for teaching healthcare professionals how to facilitate ethics communication groups. Educating facilitators closely connected to clinical work may lead to ethical dialogue becoming a natural part of clinical practice for healthcare professionals.


Introduction
An ethically difficult situation is defined as one in which values, principles and interests' conflict and it is difficult to judge what is right and good in the specific instance (Sarvimäki and Stenbock-Hult, 2008 p73).Working in health care means encountering ethically difficult situations (Jakobsen and Sørlie, 2016).RNs have described ethical difficulties when unable to meet the patients' needs and expectations (Rees et al., 2009;Grönlund et al., 2015), giving bad news and having to act against the patient's will (Rasoal et al., 2016).Physicians have described feeling burdened by having to make difficult medical decisions (Torjuul et al., 2005), or starting, withholding or withdrawing life support treatment for patients at the end of life (Grönlund et al., 2011).
Studies show a perceived lack of inter-professional communication in everyday clinical practice (Torjuul and Sorlie, 2006).RNs and physicians express a wish for more opportunities to communicate various perspectives of ethically difficult situations (Silén et al., 2011), to share the agony (Grönlund et al., 2011) and reach a shared moral understanding (Torjuul and Sorlie, 2006).Communicating about clinical ethical issues can promote good, person-centered care (Dauwerse et al., 2013) and prevent moral distress (Silén et al., 2011).
Various methods for eliciting reflection and communication regarding professional issues are used in healthcare, such as Gibb's reflective cycle of a structured learning model (Husebø et al., 2015), reflective practice groups for nurses (Dawber, 2013) and positive psychology (Howard, 2008).Interest in providing opportunities for reflection and communication on ethically difficult situations in organized forms is also increasing (Pedersen et al., 2009), with guidance from competent facilitators (Söderhamn et al., 2015).Clinical ethics support (CES) is a general term covering various forms of support provided to address ethical issues in health care.In an integrative literature review, Rasoal et al. (2017) identified four approaches used in CES: clinical ethics committes, clinical ethics consultation, moral case deliberation (MCD), and a fourth approach that encompasses ethic rounds, ethic reflection groups and ethic discussion groups, because of their similarities in terms of construction, function and goals.Clinical ethics committees focus on the ethical responsibilities of organizations in order to protect the rights, safety and wellbeing of the patient (Rasoal et al., 2017) and can, for example, participate in healthcare organizational policies, give advice and make recommendations (Pedersen et al., 2009).Clinical ethics consultations can be performed by members of ethics committees, or by others with the requisite knowledge and skills (Rasoal et al., 2017) to provide support and advice concerning clinical ethical issues, and can promote the decision-making process (Førde and Pedersen, 2011).
The MCD approach described by Molewijk. et al. (2008) has been evaluated (e.g.Svantesson et al., 2018).It comprises various forms of ethical communication methods, such as pragmatic and dialogical ethics (Molewijk et al., 2008), and conversation, dilemma and Socratic methods.The various methods are selected according to the purpose and context of the MCD but they all include healthcare professionals meeting to reflect over ethical issues, supported by an ethically skilled facilitator (Dauwerse et al., 2013;Molewijk et al., 2008).
Clinical ethics committees, and clinical ethics consultations are described as top-down approaches, while MCD and ethics rounds/ reflection and discussion groups are labelled bottom-up approaches (Molewijk et al., 2008).Another way of describing this is that clinical ethics committees, and consultations are established organizational structures, while ethics rounds/reflection and discussion groups are not as clearly anchored in the healthcare systems (Rasoal et al., 2017).
There is still a long way to go before facilitated ethical communication is organizationally determined and implemented as an obvious support for professionals in need of it.One way of promoting interprofessional communication about ethical issues experienced in actual care situations is to open up the possibilities for facilitated ethics communication groups and make them a natural part of everyday clinical work.This implies the availability of easily accessible methods to support prospective facilitators.Such support could open up possibilities for healthcare professionals, with training and a specific interest in healthcare ethics, to learn and practice how to facilitate ethical communication in groups and may further promote the implementation of such groups.
This article presents a method with easily accessible instructions about how to facilitate ethical communication in groups for healthcare professionals with knowledge and an interest in healthcare ethics.The 'one to five' method could be used as a tool to promote and ease implementation of ethical communication in groups and thus further stimulate a continuous ongoing ethical dialogue in clinical practice.
Therefore, the aim of this paper is to describe and further discuss, a research-based method developed to enable implementation of interprofessional ethical communication in healthcare organizations.

Theoretical framework
The 'one-to-five method' for facilitated ethical communication in groups is theoretically inspired by Habermas's theory of communicative actions.The ideal situation for communicative actions has four requirements, namely: equality, openness, review (Habermas, 1990 p 65-66) and an intention to reach a communicative agreement (Benhabib, 1990 p 336).Equality means taking a respectful approach that allows all participants to communicate freely.Openness means inviting all participants to express their views and make statements that are valid, truthful, sincere and comprehensible.Review refers to promoting an open dialogue where assumptions, statements and ideals are freely expressed and which continues until a common understanding about the situation is achieved (Habermas et al., 1996 p 303, 100-113).The concept of communicative agreement may, according to Benhabib (1990 p 336), raise awareness of the different aspects that might find expression in the moral dialogue and that can be accepted by those involved.

Further development
The 'one to five method for ethical communication in groups is based Fig. 1.The 'one-to-five method' as a practical tool for facilitating ethical communication in groups.
C. Fischer-Grönlund et al. on previous research (Grönlund et al., 2016;Grönlund et al., 2018 ;Brännström et al., 2019).In previous studies, clinical intervention with 10 inter-professional communication sessions about ethical issues where performed, audio-and video-recorded and analyzed.One study focused on the communication of value conflicts (Grönlund et al., 2016); a second on the organization of the sessions (Grönlund et al., 2018); and in a third professionals were interviewed about their experiences of having participated in inter-professional ethical communication groups (Brännström et al., 2019).The results from the three studies were analyzed as a whole from the perspective of how to present a method that could be used both for educating facilitators and as a tool for enabling the inter-professional communication process in group sessions among healthcare professionals.Literature describing various concepts and methods for ethical support was searched for and studied during the entire development process (Dauwerse et al., 2013;Hartman et al., 2018;MacRae et al., 2005;Molewijk et al., 2008;Nesbit et al., 2018;Reiter-Theil et al., 2011;Stolper et al., 2015).

Method description and reflections
The 'one-to-five method' for ethical communication in groups concerns inter-professional meetings, open to all healthcare professionals at the same care unit, to communicate about actual, ethically difficult situations or dilemmas that they are currently experiencing in their clinical work.The core approach is to sustain a trusting atmosphere where all participants have an equal right to express their viewpoints C. Fischer-Grönlund et al. and to be listened to (Grönlund et al., 2018).The purpose of ethical communication in groups is to encourage healthcare professionals to take up ethical issues from their practical experience.Through open inter-professional communication that moves towards a common understanding of the value conflict, the professionals are encouraged to seek out well-grounded action options that benefit patient care (cf Grönlund et al., 2016).

Organization
The ethical communication sessions are open to all from the various professional groups, including the head of department.The size of the group should be limited to approximately ten participants to allow a democratic approach to the dialogue.If more professionals from the department wish to participate it is preferable to arrange two separate sessions.The sessions start and end at the appointed time and the door is closed to latecomers to avoid interruption of the dialogue and to make the participants feel safe.The pattern of organization for each session includes an introduction and presentation of an ethically difficult situation of concern, an open dialogue among the participants, and concluding remarks.The goal is to work through all five steps: telling the story of the situation; reflections and dialogue about the emotions involved; formulation of the value conflicts; ethical analysis; and lastly choice of action or approach.If it is not possible to work through all five steps, the process may be continued in the next session.Emotions that are expressed and reflected upon during the session should not be talked about afterwards, to ensure confidence among the participants.However, the ethical issues revealed are meant to be openly discussed among all the professionals in the unit in order to promote an ethical dialogue even between sessions.Ethical issues of concern and core reflections during the sessions can be shared by making written documentation available for all to read, see (Fig. 1).

The facilitator
The facilitator's core assignment is to organize and guide the ethical dialogue and to make sure that all steps in the communication process are dealt with thoroughly.The facilitators are external healthcare professionals with a special interest, education and experience in healthcare ethics.They need to have completed a three-part educational program, covering both theory and practice.The first part is theoretical, comprising audio-and video-recorded lectures concerning healthcare ethics, communicative ethics and the theoretical framework for the method of ethical communication in groups.The second part is practical, in the form of practicing facilitating ethical communication.This entails firstly participating in ethical communication groups led by experienced facilitators and subsequently themselves facilitating ethical communication in groups, supported by experienced facilitators.The third part entails putting reflections in writing, sharing feedback about the process of the ethical dialogue and receiving support from experienced facilitators.Facilitators are recommended not to facilitate ethical communication groups in their home departments as, if they are personally involved in the case or issue of concern, they risk losing their focus on the events in the group, which reduces their ability to guide the dialogue.

Communication process
The facilitator opens the way for a permissive communication approach by asking the participants to show respect for each other and make it feel safe to talk.During the sessions, the facilitator guides the communication by repeatedly asking reflective questions and summarizing the essence of what has been said.Finally, at the end of each session, the facilitator summarizes issues of concern, proposals for actions and strategies and makes some concluding remarks.The facilitator ends the session by asking if everyone felt allowed to speak, if anyone felt uneasy or harassed, and by thanking the participants for taking part.The context of ethical communication in groups is understood as an ethical free zone which is achieved in the five steps described below and in Fig. 2.
Step 1. Story about the situation Actual, ethically difficult situations or dilemmas from the participant's clinical experience are the focus for the ethical communication sessions.The situations can be: 1) described during the session by the participants; 2) decided in advance and conveyed to the facilitator; or 3) one that was the focus of discussion in previous sessions but which the participants wish to continue talking about.
1) The facilitator may initiate the session by asking the participants to narrate an ethically difficult situation or dilemma that they have experienced and that they wish to talk about.
2) The facilitator informs the participants about the ethically difficult situation or dilemma that was decided in advance.
3) The facilitator asks if the participants need to revisit an ethically difficult situation that was focused on in a previous session and report what has happened since.
The facilitator, having asked the participants if they all agree to communicate concerning the suggested situation, then opens an ethical dialogue by asking them, one by one, to share their story and experience of the situation.Those not wishing to do so may decline.Once the participants have shared their stories, the group embarks on an open dialogue.The facilitator invites the participants to join in the ethical dialogue by asking open or specific questions such as: "What do you experience as difficult?"or "Please can you tell us more about it".

Reflection
By asking each participant to tell their story everyone, even those who find it difficult to express themselves, is given space in which to talk about their experience (Grönlund et al., 2018).The facilitator encourages the participants to share their stories by maintaining a permissive communication approach, with engagement and active listening (Grönlund et al., 2018).An active listening approach means giving full attention to and showing genuine interest in what the participants have to say.Such an approach helps the facilitator to establish an empathic response which further promotes a trusting relationship (Cassedy, 2010 p 86-87).The permissive communication and active listening approach can signal a sense of trust intended to make the participants feel confident about voicing their experiences (Brännström et al., 2019).
For the dialogue to be democratic, the position of the facilitator needs to be equal to that of the participants; the encounter has to be between competent professionals who feel free to express themselves without being judged (cf Guvå and Hylander, 2012 p 62).In order to allow everyone to give their view on the situation, the facilitator has to be aware of the dialogue and give space to all the participants who want to speak.Sometimes it is necessary to interrupt people who talk too much but this should be done in a positive way to avoid the participant feeling bad (Grönlund et al., 2018).Silences allow time for thought and further reflection, however, the facilitator needs to judge when there should be silence and how long it should last (Cassedy, 2010 p 96-97).The facilitator needs to take note if an important discussion topic is interrupted, and to pick it up again at a suitable point (Grönlund et al., 2018).

Step 2. Reflections and dialogue about emotions involved
During ethical communication personal experiences of ethically difficult situations are shared.Feelings of frustration, uncertainty, helplessness and lack of knowledge may be expressed.It is important to take the participants' emotional expressions seriously and not to judge C. Fischer-Grönlund et al. them.Open questions such as "How did you feel?", "What in this situation aroused these feelings?"may stimulate further reflection and also show that there are no given answers.

Reflection
According to Molewijk et al. (2011) there is always an emotional component in an ethically difficult situation.Brännström et al. (2019) showed that sharing experiences and emotions may diminish feelings of not being good enough professionally.If the facilitator can maintain a permissive and trusting approach towards the participants' emotional expressions they may be confident enough to share and further relate to each other's emotions (Brännström et al., 2019).The facilitator's openness towards the participants' expressions and use of humor and the sharing of their own experiences may have a liberating effect on the atmosphere (Grönlund et al., 2016).The facilitator's self-disclosure, however, needs to be brief and to work as an open invitation for the participants to share emotions and feel free to express themselves (Cassedy, 2010 p 103).

Step 3. Formulation of problem/dilemma
The core of ethical communication is to verbalize the ethical dimension of the situation.The participants need to formulate the value conflict.By asking the participants to answer "What is ethically difficult?","How can you formulate the problem/dilemma?","What is the ethical conflict in your story" or "What is at stake?" the facilitator encourages reflection on the ethical dimension.The participants may sometimes have difficulties putting the value conflict into words and may need support from the facilitator.To sustain trusting communication, it is important to be sensitive and understand what stage the participants are at in the communication process, rather than force them to formulate the value conflict.The facilitator needs to be perceptive about the content of the story, interpreting the value conflict and filling in by asking questions related to their stories.

Reflection
Some participants prefer to verbalize the value conflict by telling stories from their practical experience (Grönlund et al., 2018).The dialogue may circle around the core issue.The facilitator can guide the dialogue by listening to what is communicated indirectly, between the lines, reflecting on what the exchanges actually concern (Guvå and Hylander, 2012 p 70) and then using follow-up questions to find the thread.
Step 4. Analysis Sharing knowledge and perspectives may highlight different aspects of the situation, opening the way for further reflection and may promote a broadened understanding.It is, therefore, constructive to let the participants communicate and share experiences and knowledge freely.Asking questions related to the participants themselves and their own stories may stimulate analysis of the situation and reflection over their own roles.Questions such as "How do you understand or explain this situation?","Which perspectives are involved?"or "Which values, principles or norms are at stake?" can pave the way to changing thought patterns concerning the value conflict among the participants, both as individuals and as a group.

Reflection
Asking questions rather than giving definitive answers concerning the ethical dimension enables the participants to confront their own perspectives and share a variety of aspects and knowledge (Guvå and Hylander, 2012 p 64-66).If the facilitator has some theoretical knowledge about the issue of concern, the suggestion is that the knowledge should be shared through asking reflective questions, such as "Could it be in this way … ?" or "Could it be due to … ?"This approach may give the facilitator the opportunity to promote theoretical reflections among the participants without disturbing the equality in the group (Guvå and Hylander, 2012 p 71).
Step 5. Choice of action or approach If the participants are given sufficient time for reflection they have an opportunity to re-interpret the value conflict and their own role in the situation.If important statements and suggestions get diverted, the facilitator needs to reconnect them to the dialogue and ask questions that highlight their importance.By repeatedly asking such questions as: "How can you act?"How can you relate?" the facilitator supports the participants in their search for action options.The facilitator may also encourage the participants by using their stories to inspire further reflection.One way to do this is to ask for advice from those who have said that they can handle the situation.The facilitator needs to summarize and reconnect what has been communicated regularly during the communication process.

Reflection
Summarizing important points that have emerged helps the facilitator to gain a comprehensive overview of the content of the discussion and to move it on.To avoid too many summaries during the dialogue, the facilitator may summarize once an issue has been completed and the discussion is moving toward a new topic (Cassedy, 2010 p 104).At the end of each session key aspects of the content of the dialogue are summarized, these can include ethical issues, experiences, emotions, aspects, perspectives and proposals for action (Grönlund et al., 2018).

Conclusion
In a previous study ethical communication in groups was described by healthcare professionals as meeting in an ethical free zone that promoted ethical maturity.Since healthcare professionals encounter ethical difficulties in their everyday clinical practice, it is essential to have ethical communication in groups when the situation is current.This paper presents an accessible method for facilitating ethical communication in groups in everyday clinical practice.It can be used as an easy approach to support and educate healthcare professionals closely connected to clinical work to facilitate ethics communication in groups.Educating facilitators close to the center of events may have the effect of making engaging in ethical dialogue a natural habit among healthcare professionals.In the long term the inter-professional ethical dialogue may become a natural, ongoing part of everyday clinical practice.Further studies are in progress, including education of facilitators and the introduction of ethical communication in groups in clinical practice using the 'one to five' method.

Fig. 2 .
Fig. 2. Compiled example of questions to facilitate ethics communication in groups during the various steps in the communication process.