Procedures and processes: General Practitioners’ and Practice Nurses’ experiences of ethical dilemmas within primary care

Kate Robins-Browne1, Nancy Sturman2, Kelsey Hegarty3, Christopher Dowrick4, Victoria Palmer5

1 Department of General Practice, Melbourne Medical School, The University of Melbourne, 200 Berkeley St, Carlton, Vic, 3053,
2 University of Queensland Medical School; 288 Herston Road, Herston, Qld, 4006
3 Department of General Practice, University of Melbourne, 200 Berkeley St, Carlton, Vic, 3053
4 University of Liverpool, Institute of Psychology, Liverpool; United Kingdom; L69 3BX
5 Department of General Practice, University of Melbourne, 200 Berkeley St, Carlton, Vic, 3053

A significant proportion of healthcare takes place in the primary care setting, but the clinical ethics literature is heavily weighted towards problems that occur in the inpatient (secondary care) settings.  Inpatient problems may be more time critical and garner more attention, but primary care presents its own ethical dilemmas and challenges which to date have received only minimal attention in the published literature.  Primary healthcare professionals (PHPs) experience ethical tensions within their relationship with the patient, the family, other healthcare professionals, and the health service system and attendant regulations.  There is currently no formal mechanism whereby a PHP can seek support regarding an ethical problem.  Furthermore, while it is recognised that primary care ethics is different to hospital ethics, there is relatively little research regarding PHPs’ experience of these problem or the supports they use to address them.  To address this gap we conducted 6 focus groups with Victorian GPs (3 groups) and primary care practice nurses (PNs) (3 groups) as part of a study to explore clinical ethics support services (CESS) for primary care.  The focus groups were audio-recorded and a note taker documented the group processes and interactions.  The data for each group was integrated into a single document and analysed thematically.  We found that GPs and PNs tended to recount different ethical problems.  GPs commonly described difficulties in maintaining the doctor-patient relationship, particularly in situations where there was conflict within the relationship, and were concerned with the blurring of the boundaries of the relationship; they had a greater focus on process.  By contrast, PNs were more likely to identify tensions within their working relationships, in particular with the GPs; they had a greater focus on procedures.  The two groups also utilised different supports to resolve their concerns.  Both groups thought a primary care CESS would be useful.


Kate Robins-Browne is a general practitioner with an interest in clinical ethics.  Her PhD was focused on decision making when the patient’s ability to participate is impaired.  This drew her attention to the difficulties healthcare providers encounter when they face ethical dilemmas and the lack of formal support structures, particularly for primary healthcare providers.

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