healthmedicinet

What is abuse in health care and why study it?

Health care exists to help and alleviate patients’ suffering and should thus not be
inflicting unnecessary suffering on patients, and yet this happens. The topic is not
often spoken about and when it is discussed a wide range of terms are used, e.g. abuse
in health care (AHC), patient dissatisfaction, medical errors, and suffering related
to or caused by health care 1]. In this article we will focus on AHC, which we define as failed health care encounters
in which patients feel abused and suffer 2], or when staff have reasons to assume that patients feel abused. We presume, in line
with other studies, that most acts of AHC are forms of unintentional harm 2], 3]. AHC may include a large variety of incidents, from a comment that felt legitimate
for staff to utter but which was perceived as humiliating by a patient to e.g. physical
violence from staff to administer an urgent injection a patient verbally refuses.
It may be a subtle issue for staff to recognize when a patient feels abused and probably
those events often even pass unnoticed by staff 4], which is reinforced by patients’ silence as to what they experienced 5]. A large number of studies have identified the existence of AHC in several health
care settings. Some patient groups seem to be at greater risk for abuse, including
children, individuals with learning disabilities, older people, or patients with a
background of other kinds of abuse 6]–8]. However, our studies also confirmed the existence of AHC in general patient and
population samples in the Nordic countries 9]–11].

As AHC implies suffering and is unacceptable for a health care organization, after
more than a decade of empirical studies among staff and patients our research group
designed and evaluated a model for staff interventions. The model focused on staff’s
experiences of encounters in which they perceived patients experiencing abuse, and
was based on a theory about what contributes to the prevalence of AHC. Later we have
also tested the model with staff in a different setting.

Why this article?

The present article describes our present theoretical framework for the occurrence
of and counteracting of AHC and how this framework emerged during our work with interventions
against AHC. The basis of the present framework is four-fold: 1. the initial theoretical
framework; 2. our earlier studies of prevalence of AHC, and of experiences of AHC
among staff and patients; 3. our clinical experiences of handling AHC; and 4. the
development and evaluations of interventions among staff. The character of this article
is therefore theory development. We will illustrate our experiences and theoretical
assumptions with cases and citations that appeared during the workshops or have been
published in earlier articles from our research group.

The initial theoretical framework

Abusive incidents occur in a context

Galtung’s “vicious violence triangle” uses the analogy of the three corners of a triangle,
which all three have to be in place to form a triangle, to illustrate how one corner,
depicting direct events of violence, cannot be understood without at the same time
also analysing the two other corners; depicting structural and cultural violence 12]. He argues that direct events of violence, which is what usually is recognized, are
legitimized and nurtured by structural violence (e.g. hierarchies) and cultural violence
(e.g. ideologies), and that generally speaking there is a causal flow from cultural
via structural to direct violence. Galtung’s reasoning is supported by knowledge from
social psychology, where Zimbardo in a similar way underlines the importance of situations
and systems for the expression of violent acts 13].

Transforming this reasoning to the current field means that if AHC is regarded as
the direct event corner of the triangle, those direct events of AHC would not occur
unless there was a climate and clinical setting indirectly enabling AHC to take place.
Cultural norms have an impact on what constitutes AHC as “[v]iolence within health-care
settings often reflects dynamics that are broadly prevalent in society” (14], p. 1683). A clear example of this is a study by Jewkes, Abrahams and Mvo of patient
abuse in South-African obstetric services, where the authors identified a class and
racial struggle as an important reason for the abuse 15]. This struggle should be understood in the context of the legacy of South-African
apartheid. When Galtung’s approach is applied to AHC, it emphasizes the joint responsibility
of all employed staff including the management, in dealing with abuse.

With this theoretical basis we assumed that direct events of AHC are nurtured by cultural
and structural aspects, and therefore all three should be parts of an intervention
model.

AHC as erosion of individuals’ moral resources

To understand how the violence triangle operates on an individual level we turned
to works in moral philosophy and found Glover’s thorough analysis of how “ordinary
people” can perform inhumane deeds, portrayed in his book Humanity16]. Though Glover’s analysis centres on major atrocities that took place during the
20
^th
century, the mechanisms he describes can be transferred to other contexts, e.g., health
care settings 17]. In short, Glover finds that it is the erosion of people’s moral resources (respect,
sympathy, and moral identity) that may lead them to perform inhumane deeds. When applied
to health care these mechanisms would include e.g. the fragmentation of responsibility
(common in hospital settings with many subspecialties), distancing to others (often
technology-aided), fear (e.g. of negative reactions by others), the imposition of
a belief-system (e.g. an overriding claim to reduce cost), or moral slide (a gradual
change towards inhumane behaviour with a pace so slow that the change often passes
unnoticed). Any of these mechanisms can override and distort health care staff’s moral
resources. These resources should be cared for, protected and “cultivated” by the
organization, as they constitute a power to resist moral erosion, and therefore may
contribute to a lower risk for AHC.

With this theoretical basis we assumed that direct events of AHC could be attributed
to health care staff’s eroded moral resources, and an intervention model against AHC
should therefore be based on efforts to strengthen staff’s moral resources.

Patient and staff experiences of AHC

Operationalization in surveys among patients and prevalence accordingly

In our survey studies we operationalized AHC by means of three questions in the NorVold
Abuse Questionnaire (NorAQ), which was developed in the 1990s in order to study lifetime
prevalence of physical, emotional, and sexual abuse, as well as AHC in the Nordic
countries 18], 19]. The abuse items of NorAQ have been validated for Swedish men and women 20], 21].

Studies using NorAQ have shown high life-time prevalence of AHC; 19.7 % in a Swedish
female gynaecology patient sample, and 8 % in a Swedish male out-patient sample 10], 11].

Patient experiences

In qualitative studies, both male and female patients emphasized a loss of their human
value. Women seemed to turn these emotions inwards and felt powerless, ignored, and
that they were treated with carelessness and non-empathy, which could be summarized
in the core category “nullified” 22]. Men perceived a crisis in confidence in the health care system, and felt ignored
and frustrated, and these emotions could be summarized in the core category “mentally
pinioned” illustrating the men’s inability to act according to their own interests
23].

Staff experiences

In qualitative studies among staff at a Department of Obstetrics and Gynaecology (at
which we later organized an intervention; see below), staff’s understanding and awareness
of patients’ experiences of AHC were explored: staff defined AHC as an ethical failure,
while at the same time they did not take on responsibility; the incidents were seen
as “ethical lapses” 4]. Staff’s awareness of AHC was dependent on the situation and staff’s room for manoeuvre,
rather than being something staff had or had not 24]. In contrast to patients, who gave vivid narratives with many concrete details, staff’s
examples were few, vaguely formulated and seldom self-experienced.

The results from these studies made us conclude that it was an urgent task to develop
an intervention model and evaluate its potential effects.

Clinical experiences of handling AHC

From clinical experiences we knew that some major pedagogic problems emerge when involving
staff in discussions on how to handle situations where patients have felt abused:

I. When staff is confronted with the fact that their patient experienced abuse, this
is contrary to what they aimed for, which may create “self-defence” reactions, such as dismissing the problem in an aggressive way or defending the abusive action
(“I didn’t do anything abnormal”. “We had done everything that possibly could have
been done thus it was correctly dealt with” 4]). In a discussion with the patient who felt abused, such strategies from staff easily
become destructive for the patient, who then may feel re-abused 25].

II. Situations in which staff felt they did something morally wrong are prone to being
suppressed/”forgotten”, which may be another way of handling what happened. This often interferes with staff’s
chance to learn from mistakes; increasing the risk of repeated, abusive behaviour
26].

III. One reason for negative reactions among staff is that what happened is left to
the individual. As AHC mostly is a non-topic, staff may presume that they are the only ones in the
workplace having displayed such misconduct.

IV.
A focus on mistakes and how to eliminate bad behaviour is seldom as productive as a focus on good behaviour and on possibilities to expand
it, combined with positive reinforcement for every little step forward on that path
27].

According to our clinical experience an intervention against AHC therefore should
include ways to handle oblivion and negative reactions to abusive events happening
in the past, and at the same time look for ways to intervene by stimulating good efforts
in group processes. Therefore, we searched for an intervention which could: 1. Transform
AHC to a “hot topic” at the index clinic. 2. Reshape the problem from an individual
one associated to negative reactions to one that could safely be displayed for others
in a joint search for morally acceptable solutions. 3. Train groups of staff in handling
AHC constructively.

The development and evaluations of interventions among staff

The model

In order to tackle the theoretical assumptions and empirical data described above,
we turned to Forum Play (FP), a Swedish modification of the Theatre of the Oppressed
(TO), developed by Boal as a tool to fight social injustices and increase people’s
ability to liberate themselves from oppression 28]. In the TO context the idea of change is central, and focus is especially on how
to accomplish change on any level from a position of being oppressed and deprived
of power in a system characterized by structural oppression. In FP, interactive improvised
role play is combined with reflection and value-clarification 29], 30]. FP has previously been shown to be a valuable method for reflective learning in
care settings 31]. In Table 1 below we summarize the procedures of the model we used.

Table 1. Procedure during a Forum Play workshop

The processes taking place in FP can also be understood in terms of Cognitive Behavioural
Therapy (CBT). Behaviour experiments constitute a very powerful therapeutic strategy
and the way we used FP has many similarities with such strategies: when a behaviour
of the client is dysfunctional, a new behaviour is searched for which could eliminate
the negative consequences of the old behaviour. The new behaviour is then tested in
an experiment. If the new behaviour is followed by the desired consequences, this
demonstrates to the client the need to revise earlier presumptions 32]. In FP, new behaviour is tested in action and evaluated, followed by scrutinizing
of the presumptions on which the old behaviour was based.

Empirical results from evaluations of the intervention project among staff

At a Department of Obstetrics and Gynaecology (OB/GYN clinic) in the south of Sweden,
we performed 16 workshops with FP during a one-year period. A typical workshop lasted
3–4 hours and was run by a drama instructor. About half of all staff at the clinic,
56 % (76/136), participated in at least one workshop. Participation was voluntary
but took place during work hours and was strongly recommended by the head of the clinic.
The intervention study was approved by the regional ethical review board in Linköping,
Sweden (reg. no. 194–06).

A series of both qualitative and quantitative studies that analysed the impact and
meaning of the intervention project have been published. Except for the two pre-intervention
studies 4], 24] which have been cited above, three studies took place post-intervention, which enabled
us to identify changes in staff’s perceptions of AHC during the intervention period
33]–35]. One of the post-intervention studies was performed by an external evaluator 35].

In post-intervention interviews, staff showed stronger empathy with patients when
talking about AHC than before the intervention. They also gave fewer explanations,
justifications and trivializations 33], and their standpoint towards AHC revealed a stronger responsibility and more moral
imagination than in the pre-intervention interviews 34]. The findings of an external evaluator included examples of how staff had behaved
differently and more “courageously” after the intervention, had felt more self-confident
in finding ways to confront colleagues who abused a patient, and had an increased
wish to receive feedback from colleagues about their own behaviour (Citation 1) 35].

Citation 1

.

The qualitative post-intervention studies 33], 34] also confirmed that the silence surrounding AHC had been broken. Increased awareness
and more daily conversations among staff made the existence of AHC a shared problem.
At the clinic, talking about and acting against AHC “had become ‘the right thing to
do’” (33], p. 7), and staff no longer accepted that AHC passed unnoticed.

The two drama instructors who led the FP workshops have each published a report containing
detailed reflections on the processes taking place during the workshops 36], 37]. On top of detailed descriptions of their theoretical stance and their drama methods,
they both describe scenarios that were used, what happened in the room, and how staff
was affected by what happened.

Finally a thesis has been published, evaluating the intervention as a whole, including
a quantitative evaluation 38]. All staff at the clinic filled out questionnaires, evaluating their attitudes toward
AHC and willingness to take action when abuse was heard of or witnessed. The times
of measurement were before, during, and after the intervention (five months, 14 months
and 25 months after the first workshop). The questionnaires contained questions about
matters such as the perceived impact of AHC, the experience of FP, and the perceived
impact of FP. Matched pre- and post-data was tested for differences on relevant items.

In the quantitative evaluation, staff who participated in FP reported an increased
ability to act according to their moral beliefs 38].

The research team’s experience of carrying through the intervention

The intervention was a pilot project and was introduced as such at the index clinic
which may have increased potential participants’ hesitance to take part in the workshops.
This was further reinforced by the stance taken by the head of the clinic and the
drama instructors: taking part had to be voluntary. In contrast to other projects
at the clinic aiming to improve quality of care, the message of voluntary participation
may have made the intervention project somewhat dubious. This was further underlined
by the character of the workshops, where the participants may have feared that they
would be forced to “play theatre”. For the individual staff member a choice was introduced
and the alternative to participate became more of an individual challenge than if
all staff were to take part.

At another three clinics, where we tried to introduce the project in order to perform
a replica, similar reasons, but now on an organizational management level, may have
contributed to inhibit the clinics’ participation even before we had met any staff
members.

Staff generally reacted very positively on the transformation of AHC to a task which
the whole staff group carried responsibility for, and sometimes this approach relieved
an almost tangible tension in the group. During all workshops the initial round among
the participants revealed that everybody had memories of when they had been bystanders
or perpetrators of abusive incidents in which they had not acted according to their
inner moral. Thus all participants soon realized that they shared such experiences
with everybody else in the room. A feeling of belonging to a safe group emerged during
the workshops, based on the sharing of having been in AHC situations and of the same
values and ethical stances taken towards AHC. The participants also realized that
together they were able to find many alternative ways of acting other than the abusive
one, or not acting as a bystander, and that they could benefit from sharing these
experiences and helping each other out.

This made the research team reflect on the issue of shame and guilt that seemed to
have been handled as individual problems in the climate that had prevailed at the
clinic so far.

The drama instructors gave instructions about how to use one’s body to reinforce the
message one wanted to convey and these were regarded as extremely helpful by the participants
who generally were astonished over which effects they could achieve in precarious
situations merely by reflection on which gestures, body posture, body placing and
voice they wanted to use and by acting accordingly. How to practice a desired body
language seemed to the participants to be an underutilized source of strategies for
resolving AHC situations.

Acting out the ideas that came up during the role plays was a similar issue which
was regarded very instructive by the participants and much more so than just analyzing
and discussing an AHC situation. By acting out participants learnt to register what
they felt in their own bodies when acting, and the co-participants reflected back
how different bodily actions influenced bodily reactions on their part. This pedagogy
also emphasized the message “you need to act” in future real AHC situations.

It became evident that the theoretical concepts (the vicious triangle and moral resources)
we had used as a framework were pedagogically well suited. Staff quickly adopted them
and started to use them and they seemed to function well in the communications about
the complicated processes we handled.

Discussion of the results of the evaluations in relation to the initial theoretical
framework

When evaluating our results as a whole we turn back to our original theories (Galtung
and Glover) to revise our initial assumptions. First we draw on data and experiences
from FP workshops and relate those findings to the original assumptions. In the Theory
Development section we develop further the theoretical fundaments of our research
on basis of what was learnt during the interventions.

Data and experiences during FP workshops in relation to the original assumptions

The direct events of AHC could be regarded as nurtured by the culture at the OB/GYN
clinic and our intervention worked not only by giving staff alternative ways to handle
direct events of AHC, but seemed also to have influenced the culture at the clinic
regarding AHC.

When staff had the opportunity to work together in groups and find alternative ways
of acting against AHC, they together created a climate during the study period in
which AHC was recognized, much talked about and deemed unacceptable, i.e. influencing
the prevailing culture. It may be presumed that if this change of cultural norms continues
over time, staff would in the long run question rules and policies imposed on them
which they feel are unacceptable, and thus not only culture but also structures may
change. Seeking for alternative ways to act against direct events of violence may
enable a group to reveal oppressive structures, thereby offering possibilities to
tackle and change these structures 28].

What came true of these presumptions? There were indications that silencing of AHC
was no longer accepted by staff and that individual responsibility for the occurrence
of AHC had changed into being a problem staff as a group felt responsible for and
which needed counteraction. These changes signal cultural changes at the clinic, at
least temporarily.

Structures at the clinic seemed however to be resistant towards change, at least during
the study period. Even if a work group was established with staff from all professions
and with the task to work with questions of failing patient encounters including AHC,
this group had no support from the clinic management, could not effectuate changes
and died out without the management giving the show away.

The workshops revealed professional hierarchies often to be involved in staff’s inability
to protect patients against abusive incidents by someone superior in the hierarchy
(see Case 1). Even if post-intervention studies showed that staff had found new ways
to confront colleagues (Case 2) 35] or report incidents of abuse to someone higher up in the hierarchy 33], we could not observe any changes in the hierarchical structures at the clinic, and
could therefore not conclude that the intervention had influenced this structural
aspect of AHC.

Case 1

.

Case 2

.

Staff’s moral resources were strengthened in the following way: when the shame connected
to the incongruity of one’s own intentions and the negative outcome for the patient
in suppressed/“forgotten” events of AHC was clearly displayed and handled constructively
in the group, staff learnt that there were alternative ways of acting that felt morally
acceptable in abusive situations – others than the only one they previously had employed.

In post-intervention interviews, staff showed stronger empathy with patients, more
of moral imagination and they felt a stronger responsibility for taking action against
AHC than before the intervention 33], 34]. In the report from the external evaluator there were many examples of staff’s more
courageous acting in AHC situation 35]. And in the quantitative evaluation, staff who participated in FP reported an increased
ability to act according to their moral beliefs 38].

Thus, we assumed that the intervention with FP seemed to initiate a process of counteracting
erosion of staff’s moral resources e.g. by triggering emotions related to respect
and sympathy and by stimulating the development of moral imagination 16].

A special case of increased ability to act was seen in instances where staff dealt
with suppressed/“forgotten” events during workshops, which staff may have suppressed
for a long time in order to avoid painful memories 24]. During one workshop, a midwife told a very personal story about an incident that
had taken place more than 10 years ago, in which a patient had been hurt (Case 3).
In the FP sessions, staff regularly recognized, when looking back at incidents of
AHC in which they had been bystanders, that even if they at that moment had felt totally
incapable of acting as they saw no way out, there had in fact been other and for the
patient less destructive ways to act than the one chosen. We therefore regard their
moral resources to have become strengthened by participating in the workshops.

Case 3

.

To summarize, we presume that the FP intervention could be regarded to strengthen
staff’s moral resources and increase their ability to act according to their inner
morality. The effects were clearly there on an individual level, and on a group level
we could observe a change in attitude to AHC, implying that it had become acceptable
and sometimes even the first choice to take a stand against it and act accordingly.
The need to deal with AHC was now seen as “a stone in the shoe”, something that calls
for action 33]. Changes in “structures” could not be documented.

Theory development on basis of what was learnt during the interventions

What happens if nothing is done?

Figure 1 illustrates what happens in an AHC situation, using our initial theoretical concepts
and combining them with the empirical findings from the intervention project. When
AHC occurs, patients are victims and staff become “perpetrators”, even if they only
take the role of silent bystanders. This fact is in itself provoking and may encourage
the covering up of AHC incidents, like the midwife did in Case 3 (see above). In Fig. 1, Galtung’s vicious violent triangle is placed in the centre of the figure and it
is suggested that events of abuse are often concealed by several mechanisms. Structures,
e.g. hierarchies in health care, contribute; meaning that a staff member from a group
that is inferior to the “perpetrator” should not try to intervene and stop the abusive
situation, nor speak up about what happened (see Case 1). Culture in health care also
helps in legitimizing abuse, most of all by denying its existence (Citation 2).

Fig. 1. “What happens if nothing is done?” (Referring to the situation among staff and patients
before intervention)

Citation 2

.

All the three corners of the triangle therefore fail to legitimise the experience
of a patient, who is experiencing abuse and who is apt to feel nullified or mentally
pinioned (lower part of Fig. 1) 22], 23]. Two common ways out of this frightful situation for the patient are silence and/or
anxiety. If silence is chosen, the experience and the emotions associated with it
are often suppressed; i.e. “put in a jar with a lid fastened on top” (see Fig. 1 lower part). Suppressing a situation that has been experienced as very abusive results
in feelings of inferiority, powerlessness and an inability to act, and also the patient’s
moral resources may be eroded – all contributing even more to silence 39]. When on the contrary, anxiety is a main strategy for the patient, it may be too
strong to live through and the individual seeks anxiety-reducing strategies, e.g.
drugs, self-mutilation, eating disorders, or avoids health care totally. Although
such behaviours in the short run may reduce anxiety, using them will in the long run
increase anxiety as well as guilt and shame over the behaviour 26]. Guilt and shame will then act as reinforcement on silence in a negative spiral 26]. A third strategy used by patients to handle guilt and shame is to become aggressive
and accusing, which with untrained staff may lead to a destructive conflict, which
patients are likely to lose 25], 40] (exemplified in Case 4).

When looking at the staff half of Fig. 1, their concealment of abusive episodes also creates guilt and shame, which reinforces
their silence. These feelings may give rise to powerlessness or justification responses,
which both however tend to erode staff’s moral resources and increase their inability
to act according to their moral compass. As described for patients, concealed episodes
of abuse that staff felt they did not handle correctly may be suppressed and may reinforce
a culture of silence (see Case 3 and Case 4).

Case 4

.

As Fig. 1 demonstrates, for staff as well as patients, the concealing of the abusive situation
and its aftermath of silence may lead to erosion of moral resources, which increases
the risk that patients and staff will run into a similar situation again and will
once more be incapable of handling it in a constructive way. It also displays the
central role of guilt (individual failure) and shame (a failure that becomes socially
recognized) in nurturing silence and hence a “taboo” surrounding AHC. Thus, guilt
and shame as consequences of abusive incidents are likely to increase a silence culture
around AHC, which increases the risk of AHC occurring again in a vicious circle manner.

Figure 1 illustrates the individual perspective for staff as well as for patients, and the
content of the figure can be illuminated by Case 4. The patient A in Case 4 illustrates
that situation: several sessions, aiming at conciliation and alleviating the patient’s
burden of unacknowledged shame 41], turned into new fights when A in an aggressive way expressed his desperation about
the catastrophe that had struck him, which made the head of the delivery ward defend
the actions taken by referring to medical facts (“justification” in Fig. 1) 25].

What happened after the intervention? “Breaking the silence and the effect thereof”

Figure 2 is constructed in a similar way as Fig. 1. The new factor added is the training of staff with FP, thus adding group processes
to the scenario. Staff had experienced during the workshops that even when the situation
seemed hopeless and without any acceptable way out, many alternative ways of acting
could still be created when the group worked together, and these ways could be tried
out the next time they ran into similar dilemmas. Thus staff had learnt first of all
that when an abusive situation occurs, action is needed; secondly that they knew of
acceptable ways to intervene, and thirdly that they could support one another. Taking
action reduced guilt and shame, which also increased their ability to express regret.
It may be presumed that feeling competent in future awkward situations would strengthen
their moral resources and increase their possibility to act. And for each time they
did act, their new behaviour would be positively reinforced as the outcome of the
situation most probably would turn into something positive for the patient and usually
also for the “perpetrator”. When action was taken to end the abusive situation, the
patient felt that she/he had been seen, her/his reactions legitimized, and her/his
dignity restored. As the patient’s moral resources had thus increased, she/he was
able to meet the abusive person and conciliation could occur (see also Fig. 3). These events could take place within seconds, and small acts on the staff’s side
were able to create “wonders”, having empowering effects on both staff and patients
42].

Fig. 2. What happens when staff learns to act in abusive situations?

Fig. 3. The “regret feedback loop”

Figure 2 shows how the impact of silence and shame which could be seen in Fig. 1 was reduced when staff as a group learnt to take action against AHC. One such case
when a bystander took action is illustrated in case 2 above.

Shame

When shame operates without being acknowledged as such or properly named, it often
creates behaviours that may seem inexplicable 41]. Scheff and Retzinger describe in their book Emotions and violence: shame and rage in destructive conflicts how human beings need secure bonding to important persons, which creates pride and
is a prerequisite for functional communication and cooperation [41, p. 34-39, 65–69].
For patients the need of secure bonding to an important care giver is evident and
the threat when bonding does not work is alienation, which easily is followed by shame.
For staff, in a corresponding way, the bond to a patient is presupposed to function
to everybody’s content. When confronted with their own wrong-doing, the bond not only
to the patient is threatened but also to the colleagues, and the worst case scenario
is being expelled from the community of staff, and shame will be a common reaction.
For both parts, if shame is acknowledged as such, functional communication can occur
and cooperation can take place concerning what happened and what could be done to
find a way out. However, when shame is unacknowledged, it easily creates intense reactions,
e.g. of anger or other types of disrespectful behaviour, which will disturb the communication
and possibilities to cooperate. Disrespectful behaviour by one party is prone to create
(unacknowledged) shame in the other, who may react in a disrespectful way, and there
is a risk of vicious loop (41], p. 65–69) (see Case 4). A full-blown conflict may occur between two persons who
are caught by their shame reactions and have problems finding a constructive solution
to the situation. When shame is acknowledged, on the other hand, respectful reactions may be the consequence and
constructive cooperation more easily found 41].

However, there may be other reactions to unacknowledged shame than attacking others.
Nathanson talks also about attacking oneself, avoidance, or withdrawal, as individual
patterns of reactions to such shame 43]. An individual often uses the same strategy when repeatedly landing in such situations.
Our patient A (Case 4) had used avoidance all his life, until the confrontation in
the delivery room led to a breakdown of that strategy when he was drowned in his unacknowledged
shame, and attacking others instead became his main strategy. This behaviour was totally
inexplicable to the health care staff, who was unprepared to even try to see what
factors were beneath his strong aggression. The final result of this conflict, which
was based on unacknowledged shame by both parties, was – silence.

Shame and silence are so intertwined that it is difficult to separate them, as illustrated
in Case 3.

The “regret feedback loop”

Figure 3 summarizes another theoretical direction that we explored based on FP workshops with
staff. Many of the suppressed/“forgotten” episodes of AHC had already existed as an
uncomfortable feeling, irritating now and then, but never allowed to be put in words,
discussed or handled consciously. Staff repeatedly and frankly admitted that in their
training they had never discussed how to handle feelings of regret. Regret could therefore
be described as an underexplored moral resource in medical training and clinical work
37]. By regret here, we refer to the feeling of having done something (morally) wrong,
and the will to learn from the incident in order to change future choices and behaviour.

In Fig. 3 we follow what happens when a staff member vaguely perceives that she/he has just
violated a patient. The patient suffers from the incident and the staff member feels
uneasy. This is when a choice appears: the staff member either acknowledges the uneasiness
as shame and takes action (lower part of the figure) or does not acknowledge this
and reacts with justifications (upper part).

When staff members acknowledge their shame, they realize that the patient had felt
abused and regret their wrongdoing. This makes staff try to put things right, approach
the patient and tell her or him that they are sorry for the inflicted harm. Most likely,
the patient’s suffering will decrease, and staff will have learnt something, meaning
that the risk has decreased that a similar abusive situation will occur again (see
Case 2) 25], 44].

When unacknowledged, shame can make staff react with justifications of their behaviour,
such as: “I made no (medical) mistakes!”, which are examples of the type of explanations
given to legitimise AHC and which were seen in interviews from before the intervention
4]. This means that staff suppresses their uneasiness, learns nothing, and the patient’s
suffering increases (see Case 4). The risk is then greater that staff will repeat
similar behaviours than if they had taken the “regret feedback loop”; illustrated
in the lower half of Fig. 3.

Limits of the intervention study

In this article, an empirical basis was used to display our theoretical development
based on the intervention and to demonstrate what happened “on the floor” by means
of cases and citations from the workshops and earlier publications. The developments
are demonstrated in the figures. As they are theoretical interpretations based our
research perspectives, there are pros and cons with this arrangement. For practical
reasons and in order to learn as much as possible about the course and effects of
the intervention, parts of the research team were present at many of the workshops.
This led to a deepened understanding of the processes taking place, which we considered
to be a greater advantage than the theoretical risk of changing the course of the
workshops in particular directions.

In a study of FP training courses given to employees associated with the county council’s
ethical committee, the research team was only very occasionally present during the
course and the results were similar to those reported here 45]. This may support our assumption that potential bias created by our participation
in workshops during the intervention probably had played a minor role for the outcome
of the studies. In the study the core-category “developing response-ability” captured
the essence of the participants’ experiences of the course 45]. These findings strengthen the developments presented in the current article, especially
the observation that staff’s moral resources were strengthened during the study period
and that they had developed the attitude that taking action against AHC was the right
thing to do.

Even though we were able to document positive effects on an individual level and for
some groups at the target clinic, we did not make great progress in our trials to
influence policy documents or strategies on a higher level in the organization. Turning
back to Galtung’s vicious violent triangle, we did not manage to influence the structural
violence corner of the triangle, and probably only partly and temporarily the cultural
violence corner.