Feasibility of Participatory Theater Workshops to Increase Staff Awareness of and Readiness to Respond to Abuse in Health Care: A Qualitative Study of a Pilot Intervention Using Forum Play among Sri Lankan Health Care Providers.

Women globally experience mistreatment by health providers during childbirth. Researchers have identified strategies to counteract this type of abuse in health care, but few have been evaluated. We used a theater technique, Forum Play, in a brief training intervention to increase awareness of abuse in health care and promote taking action to reduce or prevent it. The intervention was implemented in four workshops with 50 participating physicians and nurses from three hospitals in Colombo, Sri Lanka. This article reports the views of 23 workshop participants who also took part in four focus group discussions on the acceptability and feasibility of the method. The participants reported that the intervention method stimulated dialogue and critical reflection and increased their awareness of the everyday nature of abuses experienced by patients. Participants appreciated the participatory format of Forum Play, which allowed them to re-enact scenarios they had experienced and rehearse realistic actions to improve patient care in these situations. Structural factors were reported as limitations to the effectiveness of the intervention, including under-developed systems for protecting patient rights and reporting health provider abuses. Nonetheless, the study indicates the acceptability and feasibility of a theater-based training intervention for reducing the mistreatment of patients by health care providers in Sri Lanka.

Counteracting Abuse in Health Care: Evaluating a One-Year Drama Intervention with Staff in Sweden.

In Northern European countries 13-28% of female patients seeking gynecological health care have reported abuse by health care staff (AHC). We conducted workshops with health care staff using the improvised role-play method Forum Play (FP), based on techniques developed by Boal. The study explores to what extent the intervention increased the staff's awareness of AHC and their ability to take action against it. A total of 16 half-day FP workshops were conducted with staff from a Swedish women's clinic over one year. Self-reported questionnaires were distributed to all staff before, during, and after the intervention. Primary outcome measures were the number of reported occasions of AHC and FP participants' ability to act in AHC-situations. We found an increase in the participants' self-reported ability to act in AHC-related situations. However, no change could be observed in the number of reported occasions of AHC between baseline and one year after the intervention. Health care staff's participation in workshops using improvised role-play can increase staff's perceived ability to take action in AHC situations. The voluntary nature of the intervention may have attracted those who were already aware of the topic, and likely explains the unchanged awareness of AHC.

Can Forum Play Contribute to Counteracting Abuse in Health Care? A Pilot Intervention Study in Sri Lanka.

Obstetric violence refers to the mistreatment of women in pregnancy and childbirth care by their health providers. It is linked to poor quality of care, lack of trust in health systems, and adverse maternal and neonatal outcomes. Evidence of interventions to reduce and prevent obstetric violence is limited. We developed a training intervention using a participatory theatre technique called Forum Play inspired by the Theatre of the Oppressed for health providers in Sri Lanka. This paper assesses the potential of the training method to increase staff awareness of obstetric violence and promote taking action to reduce or prevent it. We conducted four workshops with 20 physicians and 30 nurses working in three hospitals in Colombo, Sri Lanka. Participants completed a questionnaire before and three-to-four months after the intervention. At follow-up, participants more often reported that they had been involved in situations of obstetric violence, indicating new knowledge of the phenomenon and/or an increase in their ability to conceptualise it. The intervention appears promising for improving the abilities of health care providers to recognise obstetric violence, the first step in counteracting it. The study demonstrates the value of developing further studies to assess the longitudinal impacts of theatre-based training interventions to reduce obstetric violence and, ultimately, improve patient care.

Silence, shame and abuse in health care: theoretical development on basis of an intervention project among staff.

As health care exists to alleviate patients' suffering it is unacceptable that it inflicts unnecessary suffering on patients. We therefore have developed and evaluated a drama pedagogical model for staff interventions using Forum Play, focusing on staff's experiences of failed encounters where they have perceived that the patient felt abused. In the current paper we present how our preliminary theoretical framework of intervening against abuse in health care developed and was revised during this intervention. During and after the intervention, five important lessons were learned and incorporated in our present theoretical framework. First, a Forum Play intervention may break the silence culture that surrounds abuse in health care. Second, organizing staff training in groups was essential and transformed abuse from being an individual problem inflicting shame into a collective responsibility. Third, initial theoretical concepts "moral resources" and "the vicious violence triangle" proved valuable and became useful pedagogical tools during the intervention. Four, the intervention can be understood as having strengthened staff's moral resources. Five, regret appeared to be an underexplored resource in medical training and clinical work.The occurrence of abuse in health care is a complex phenomenon and the research area is in need of theoretical understanding. We hope this paper can inspire others to further develop theories and interventions in order to counteract abuse in health care.

Ethical guidelines and the prevention of abuse in healthcare.

OBJECTIVE: In obstetrical and gynaecological healthcare, patients often find themselves in a vulnerable position. Sensitive issues such as sexual and reproductive health are addressed and certain procedures can be experienced as abusive. According to research a lifetime prevalence of abuse in healthcare (AHC) can be assumed for 13-28% of female patients in the Nordic countries. In the present study we analyse the content of ethical documents for healthcare professionals within obstetrics and gynaecology in Sweden, in order to find out to what extent ethical guidelines consider issues that have shown to be related to the occurrence of AHC. STUDY DESIGN: We searched the literature to find empirical data on AHC. Guidelines for nurses, midwives and physicians were selected. After developing an analytical framework based on the empirical data the content of the ethical guidelines was analysed. RESULTS: The various ethical guidelines for staff working within obstetrics and gynaecology differ distinctively from each other regarding their content of issues that are related to AHC. Issues that were mostly disregarded were: considering the patient's perspective and the patients' possible experience of violence, considering power imbalances within healthcare, sexual misconduct, how to deal with other professional's ethical misconduct and how professionals relate to each other. We found the ethical guidelines of the International Federation of Gynecology and Obstetrics (FIGO) and of the International Confederation of Midwives to be those which contained most of the issues that have empirically shown to be important in regard to AHC. CONCLUSION: While staff members from different professions may share responsibility for the same patient, their ethical guidelines vary considerably. To become a possible resource for prevention of AHC, we suggest that ethical guidelines in healthcare should be revised following empirical research on ethical conduct. As ethical guidelines cannot be effective by their existence only, we would like to initiate a discussion on the function and use of ethical guidelines in general and regarding AHC in particular. Being aware that ethical guidelines are only a part of ethics in healthcare, however, we envision a broader approach to the aim of preventing AHC, where research is encouraged on how a virtue ethics approach could be applied.

Ethical lapses: staff's perception of abuse in health care.

Objective. Studies have shown high lifetime prevalence of abuse in health care (AHC) in Nordic gynaecological patients. For patients AHC implies feeling disempowered, dehumanised and devalued. The aim of our study was to apprehend health care staff's perceptions of AHC. Study design. Qualitative interviews with staff at a Swedish gynaecological clinic analysed by Constant comparative analysis (N = 21). Results. The two categories - ethical failures against a patient and staff members avoid responsibility - gives two disparate pictures of what AHC is. The interviews showed that these pictures can exist alongside even if they contradict each other. The core category 'ethical lapses' brings staff's contradictory reflections on AHC together in one picture. Notable is that the dualistic notion of AHC did not result in a moral conflict within staff members. Conclusion. Health care staff perceives AHC primarily as ethical lapses. Avoiding responsibility for AHC might lead to a failing recognition of AHC, implying that the problem is not properly dealt with. Our study highlights the need for a more open attitude in health care staff toward AHC. To counteract AHC, staff members need to accept that AHC occurs also in their own units, bringing in moral conflicts in the everyday work.