When pandemic and everyday ethics collide: supporting ethical decision-making in maternity care and paediatrics during the Covid-19 pandemic

Lead Research Organisation: University of Liverpool
Department Name: Public Health and Policy

Abstract

The response to Covid 19 (C19) will have far reaching consequences for the NHS. This project focuses on how this response has created significant ethical issues for providers of non-C19 services when deciding how to prioritise and reconfigure services.

Our central aim is to evaluate and support ethical decision-making in two non-C19 areas: maternity and paediatrics.

We have chosen these areas because they have been significantly affected by the C19 response, with professional and patient organisations highlighting the problematic effects on both areas (First 1001 Days, Royal College of Midwives, Make Births Better).

Objectives
1. Conduct a rapid review of current local policies and policy-making processes for non-C19 maternity and paediatric services.
2. Examine how the policies are applied in clinical practice and pilot test approaches to ethics support.
3. Make recommendations for ethics support at local policy-making and practitioner levels; and develop tools to support good decision-making practice.

This inter-disciplinary project is an empirically informed ethical analysis of current policies, processes and practice in non-C19 maternity and paediatrics.

Design: empirical ethics, employing Frith's symbiotic empirical ethics approach, where philosophical theory is used to explore the data, draw normative conclusions, and make policy and practice recommendations.

Methods: rapid review of local policies and decision-making processes; analysis (against the national ethics framework for pandemics) of the values being engaged; interviews with key stakeholders involved in policy formation, and healthcare practitioners to understand how the policies are being applied in clinical practice and what support they might need in their ethical decision-making.
 
Description • Healthcare professionals have lacked structured ethical support in managing the public health/clinical ethics tensions characterising the reset phase
• Infection prevention measures prevent healthcare professionals from offering treatment that feels caring
• The impact on healthcare professionals of being unable to offer care, as well as treatment opens the door to moral harm
Our research took place within the context of the pandemic, where face-to-face interviews were not possible. As a result, we explored the use of other resources to inform the research. In the context of carrying out a rapid review of NHS Trusts' policies and procedures, for example, we decided to use the Publication Schemes of NHS Trusts to explore Trusts' organisational decision-making. We were able to use papers collated to support Trust Board meetings to identify decision-making priorities. These also helped us design the topic guides for our interviews with senior management.
As a result of social distancing requirements, all our qualitative interviews were carried out remotely, using Zoom™ or Teams™ video-conferencing facilities. Conscious that participants might want to bring difficult experiences to the discussion, our research fellow thought carefully about facilitating an open, safe space for discussion despite the lack of face-to-face engagement. In particular, she found that it is important to allow the everyday challenges of home-working (such as children and pets) to flow through the interview without disrupting it.
The findings from our research have underpinned the development of successful collaborative groups, which, in turn, have amplified the potential for dissemination of similar findings across the collaboration. All elements of the collaboration have been successfully carried out online. The collaborations have not only enabled effective dissemination of research findings, but have also facilitated the discussion of new research questions that have been suggested by common findings. A key new research area for us is the incidence of moral distress and injury in healthcare. The further research we are planning in this area will build on the new knowledge our research has uncovered about the nature and cause of moral harm in the healthcare context, and the important relationship between moral harm and the changed working practices mandated by the pandemic. Where healthcare professionals have been unable to care for their patients in the way they want to, being unable to touch them, for example, or to offer a comforting hug to a sick child, they have described to us a sense that their personal identity that is bound up with their identity as a healthcare professional has been compromised.
Exploitation Route • New knowledge generated; the nature and cause of moral harm in the healthcare context. The important relationship between moral harm and when healthcare professionals are unable to look after their patients in a way that reflects 'who they are as a midwife / nurse' - a sense that their personal identity was compromised.
• New or improved research methods developed : online interviewing, thinking about creating an open space for discussion despite the lack of face-to-face engagement; allowing the everyday challenges of working from home to flow through the interview without disrupting (eg children and pets).
New research resources identified: publication schemes a s source of information about public authorities. Insight into organisational priorities and decision-making priorities..
New research questions opened up : moral harm in the healthcare context.
Negative results or research paths closed off: asynchronous focus groups using online platforms - too complex to set up and use.
New research networks, collaborations or partnerships PIVOT-AL and P&B.
Sectors Healthcare

URL https://www.liverpool.ac.uk/law/research/research-projects/reset-ethics/
 
Description Policy engagement and ongoing collaborative work. We are participating in two collaborative research groups presenting to policy makers and Government ministers across NHS services. The sharing of our findings has enabled the identification of common theses - which have informed specific and directed policy recommendations. In particular: • The COVID-19 maternity services organisation and delivery research (PIVOT-AL) collaborative brings together research into the impact of Covid-19 on maternity and children's services across the UK, and internationally. In December 2021, our research fellow presented our findings, as part of the PIVOT-AL collaboration to a national cohort of NHS leaders in maternity services. The meeting was convened specifically to allow the findings to inform policy discussions. Feedback from the presentation was very positive. • The PIVOT-AL collaborative will host an in-person policy conference in London on 4th April. It is anticipated that senior policy decision-makers from the NHS, Government and regional authorities will be in attendance. • The Pandemic & Beyond collaborative (P&B) (an AHRC-funded collaborative) brings together 70+ teams of researchers across the UK who are exploring the wide-ranging impacts of the Covid-19 pandemic and looking for solutions. We are presenting our findings and policy recommendations as part of a policy webinar on 8th March, 2022. • The P&B collaborative is bringing together an edited book series about Arts and Humanities research on Covid-19.. We are contributing to the collection, and co-editing the ethics, governance and law volume. • The House of Commons Committee of Public Accounts has now held 20 evidence sessions on various aspects of the government's response to the COVID-19 pandemic. Evidence from our Reset Ethics research was included in the list of written evidence considered in the preparation of the Committee's report, published on 25th July 2020. The report set out the Committee's views on what government can learn from its response to the pandemic and what it should do to ensure that those lessons are applied. This report is the first in a body of evidence the Committee is developing which will inform the future independent public inquiry into the government's handling of the COVID-19 pandemic. • In July, 2020 the postdoctoral research fellow hosted a teaching session for paediatric specialists and presented our findings to a meeting of the clinical ethics committee of a large regional NHS foundation Trust. Some very interesting discussions resulted, and feedback from participants indicated that the session was relevant to participants' practice, would be recommended to colleagues and would inform thinking about how to revise practice. • The Royal College of Physicians is currently drafting ethical guidance underpinned by our research findings. LF and CR are part of the guidance development group, responsible for writing the guidance. The Guidance, when finalised, will be supported by around 16 other medical Colleges and healthcare professional groups.
First Year Of Impact 2021
Sector Healthcare
Impact Types Societal,Policy & public services

 
Description Pandemic recovery and future planning for research, policy, and practice in maternal and child health: A meeting for collaboration and consensus
Amount £1,500 (GBP)
Organisation Society for Reproductive and Infant Psychology (SRIP) 
Sector Learned Society
Country United Kingdom
Start 04/2022 
End 09/2022
 
Description Reset ethics: When pandemic and everyday ethics collide
Amount £7,289 (GBP)
Organisation University of Manchester 
Sector Academic/University
Country United Kingdom
Start 02/2022 
End 07/2022
 
Description PIVOTAL: Parent-Infant CoVid OrganisaTional Academic Learning collaborative 
Organisation University of Central Lancashire
Country United Kingdom 
Sector Academic/University 
PI Contribution This UCLan-led research collaborative, brings together research into the impact of Covid-19 on maternity and children's services across the UK, and internationally. The collaboration involves 12 Universities, a number of NHS Trusts and a variety of healthcare providers in different settings across the country, as well as colleagues in the Netherlands. Our team has been represented on the collaboration since the start of our funded period. Our research fellow has been involved in the planning and organising of a face-to-face meeting in London (November 2021) and, together with two others from the collaborating research projects, presented policy recommendations and research findings on behalf of both the Reset Project and other projects involved. This presentation was to national NHS decision-makers (maternity services) and took place on 6th December 2021.
Collaborator Contribution All the Universities represented in the PIVOTAL collaboration are actively engaged. There are regular meetings, an active pooling of research outputs and co-construction of ideas for dissemination and impact. An in-person policy conference with government Ministers, local government representatives, senior policy makers, representatives of the Royal Societies and other interested parties will take place in London in April, 2022. The venue will be provided by UCL. One of the collaborating Universities, King's College London, has successfully applied to the Society for Reproductive & Infant Psychology for a development grant. £1,500 has been awarded to support a planned workshop of UK academics, to discuss current issues and recommendations for future research, policy, and practice, about the psychosocial effects of COVID-19 and the healthcare system recovery from the pandemic, with the aim of producing a consensus statement including policy and practice recommendations and a priority list for future research which will be drafted for publication.
Impact Policy briefings presented in an online meeting on 6th December 2021. Policy briefs from each participating project were made available to policy makers and a joint presentation summarised findings from across all collaborating research teams.
Start Year 2020
 
Description Pandemic & Beyond 
Organisation University of Exeter
Country United Kingdom 
Sector Academic/University 
PI Contribution The Pandemic & Beyond collaborative (P&B) - this AHRC-funded collaborative brings together 70+ teams of researchers across the UK who are exploring the wide-ranging impacts of the Covid-19 pandemic and looking for solutions. We are working with P&B on two projects. P&B's aim is to ensure that the right decision-makers hear the research recommendations at the right time, and we are presenting as part of a policy webinar on 8th March, 2022. The other project is an edited book series being led by the P&B team. The books describe the Arts and Humanities research on Covid-19 which is being carried out by the research teams taking part in the P&B collaboration. The books are intended to be published by Cambridge University Press as part of their new "Academic Impact" series that is targeting an educated general readership. We are contributing a chapter to, and co-editing the ethics, governance and law volume. We are also making use of the opportunities to participate in networking and training events, to discuss policy recommendations and press releases with colleagues at the University of Exeter (as host of the P&B collaboration) and to benefit from other relevant opportunities as and when they become available.
Collaborator Contribution All collaborating research teams are being supported to prepare policy briefs, which are published on the P&B website, and to participate in a series of policy webinars, targeted at policy-makers across the range of interests represented by the collaboration. We are working with researchers from two other partners to prepare a set of joint recommendations from findings that are common to our three projects, and have prepared a joint policy brief which will also be presented at the webinar on 8th March.
Impact See policy briefs here: https://pandemicandbeyond.exeter.ac.uk/projects/ethics-law-and-governance/when-pandemic-and-everyday-ethics-collide-supporting-ethical-decision-making-in-maternity-care-and-paediatrics-during-the-covid-19-pandemic/ Webinar for policy-makers will take place on 8th March, 2022
Start Year 2021
 
Description Prof. Heather Draper gave the Hoffenberg Lecture to the British Transplant Society's Winter Ethics Symposium 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Prof. Heather Draper gave the Hoffenberg Lecture to the British Transplant Society's Winter Ethics Symposium (which will also be available to the main British Transplant Society meeting). Heather's lecture was entitled, 'Transplant Ethics and the pandemic legacy'.
Year(s) Of Engagement Activity 2020
URL https://bts.org.uk/events-meetings/upcoming-bts-events/
 
Description A webinar hosted by Pandemic & Beyond: Ethics, law and decision-making during COVID-19 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact The Pandemic and Beyond brings together 77 teams of leading researchers from across the UK exploring the wide-ranging impacts of the Covid-19 pandemic and their implications for future policy. The purpose of the webinar was to share the expertise and insights of the arts and humanities researchers in the Pandemic and Beyond portfolio, including Reset Ethics, to ensure that policy makers have the information they need to make targeted and well-informed decisions. The webinar was accompanied by a policy brief for each participating study, together with collaboratively produced policy briefings from studies whose findings were complementary. The Pandemic and Beyond policy hub contains policy briefings, research reports and additional material. The Pandemic and Beyond webinar series was presented in partnership with Culture Commons - an advocacy and policy development organisation working with the creative, cultural and associated research sectors to amplify their voices to have an impact on policy at a local, national and international level. By the morning of the webinar, 92 people had signed up. These included a significant number of people from NHS Digital, the Head of Policy, Standards and Ethics at the General Medical Council, the Bishop of Oxford, the Deputy Director of the Cabinet Office and the Director of the Covid-19 Task Force.
Year(s) Of Engagement Activity 2022
URL https://pandemicandbeyond.exeter.ac.uk/policy/
 
Description Blog for Journal of Medical Ethics 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Blog post looking beyond the initial Covid tsunami and reviewing the ethical challenges in balancing public health and the ongoing health needs of individuals and their families as NHS services are reset
Year(s) Of Engagement Activity 2020
URL https://blogs.bmj.com/medical-ethics/2020/10/30/beyond-the-initial-covid-tsunami-reviewing-the-ethic...
 
Description Blog for Socio-Legal studies association 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Blog post considering ethical decision-making in the 'reset' phase of the pandemic - specifically considering how to support ethical decision-making in non-Covid Health Services
Year(s) Of Engagement Activity 2020
URL http://slsablog.co.uk/blog/blog-posts/reset-ethics-supporting-ethical-decision-making-in-non-covid-h...
 
Description How to navigate public health legally and ethically in times of Covid? 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact Talk and panel session at the European Society of Clinical Microbiology and Infectious Diseases Postgraduate Education Course Overcoming future
pandemics: Tools to control viral threats.
Year(s) Of Engagement Activity 2021
URL https://www.escmid.org/fileadmin/src/media/PDFs/1Dates_Events/event_flyers/FuturePandemicsCourse21.p...
 
Description Presentation of a paper 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact Prof. Heather Draper gave a paper to a clinical ethics training conference at University Hospital Coventry. The paper was entitled, 'duty to work during the covid 19 pandemic'
Year(s) Of Engagement Activity 2020
 
Description Presentation to Alder Hey Children's NHS Foundation Trust ethics committee 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact Presentation to ethics committee at NHS Trust targeted as potential host site for the study
Year(s) Of Engagement Activity 2020
 
Description Presentation to NHS policy makers 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact The presentation was by representatives of the PIVOT-AL (Parent-Infant CoVid OrganisaTional Academic Learning) collaborative, representing 18 academic institutions, together with third sector and international research engagement. The subject of the presentation was early insights from new research on maternity services to inform service COVID-19 recovery. The presentations gave evidence-based recommendations as to which changes in approach and working practices to accommodate Covid-19 should be stopped, which should be continued and also suggested the re-instatement of some services that had been stopped during the pandemic. Present on the call (the meeting was held via online conferencing software) were representatives of NHSE, the Chief Medical Officer, the Chief Midwifery Officer in England and around 35 other senior NHS policy and decision-makers. The Reset Ethics research fellow was one of the presenters, and our findings were the only ethics-based findings to be presented.
Year(s) Of Engagement Activity 2021
 
Description Presentation to ethics advisory group of Birmingham Women's and Children's NHS Foundation Trust 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact Presentation to ethics advisory group intended to support recruitment of Birmingham Women's and Children's NHS Foundation Trust as a host site for the study
Year(s) Of Engagement Activity 2020
 
Description Presentation to international bioethics conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Presentation to a paper session "Looking Forward/Looking Back: Law, Ethics, and Policy in the Age of COVID-19" taking place on 3-4th December, 2020
Year(s) Of Engagement Activity 2020
URL https://aabhl.org