Clinical Ethics Support for Healthcare Personnel: An Integrative Literature Review

This study describes which clinical ethics approaches are available to support healthcare personnel in clinical practice in terms of their construction, functions and goals. Healthcare personnel frequently face ethically difficult situations in the course of their work and these issues cover a wide range of areas from prenatal care to end-of-life care. Although various forms of clinical ethics support have been developed, to our knowledge there is a lack of review studies describing which ethics support approaches are available, how they are constructed and their goals in supporting healthcare personnel in clinical practice. This study engages in an integrative literature review. We searched for peer-reviewed academic articles written in English between 2000 and 2016 using specific Mesh terms and manual keywords in CINAHL, MEDLINE and Psych INFO databases. In total, 54 articles worldwide described clinical ethics support approaches that include clinical ethics consultation, clinical ethics committees, moral case deliberation, ethics rounds, ethics discussion groups, and ethics reflection groups. Clinical ethics consultation and clinical ethics committees have various roles and functions in different countries. They can provide healthcare personnel with advice and recommendations regarding the best course of action. Moral case deliberation, ethics rounds, ethics discussion groups and ethics reflection groups support the idea that group reflection increases insight into ethical issues. Clinical ethics support in the form of a “bottom-up” perspective might give healthcare personnel opportunities to think and reflect more than a “top-down” perspective. A “bottom-up” approach leaves the healthcare personnel with the moral responsibility for their choice of action in clinical practice, while a “top-down” approach risks removing such moral responsibility.


Introduction
Healthcare personnel frequently face ethically difficult situations in the course of their work and these issues cover a wide range of areas in clinical practice (Å strom et al. 1995;Beauchamp and Childress 2009;Lindseth et al. 1994;Sørlie et al. 2000;Tabitha et al. 1979) and community home healthcare services (Karlsson et al. 2013). In such situations, healthcare personnel can experience unease or uncertainty (Cohen and Erickson 2006) over what is right or good to do, or there may be disagreement about what should be done. Moreover, some ethical issues can be connected to conflicting interests between healthcare workers and patients and their next-of kin (Beauchamp and Childress 2009;Rasoal et al. 2015); for example, situations where patients do not follow the recommendations of healthcare personnel, such as when patients and healthcare personnel have different opinions regarding what to do (Hermsen and van der Donk 2009;Slettebø and Bunch 2004), or issues that are related to ongoing life-sustaining treatment (Cassel 1984;Schaffer 2007;Silén et al. 2008). At times, healthcare personnel experience distress as a result of ethical issues in patient care (Kälvemark et al. 2004;Pauly et al. 2009).
One way to support healthcare personnel in dealing with these ethical challenges has been through the development of clinical ethics support (CES). CES is defined as the formal or informal provision of advice and support to healthcare personnel on ethical issues arising from clinical practice and patient care within the healthcare setting (Owen 2001;Puntillo et al. 2001;Slowther et al. 2004a). CES is becoming more prevalent with the increased awareness worldwide of the importance of ethical issues in healthcare and with personnel encountering an increasing number of ethical issues in clinical practice (Bartholdson et al. 2015;Doran et al. 2015;Oberle and Hughes 2001;Ulrich et al. 2010).
Philosophical papers and empirical research have led to the development of various approaches to CES that have the goal of supporting healthcare institutions, healthcare personnel, and patients as well as next-of-kin (Å strom et al. 1995;Reiter-Theil and Hiddeman 2000). There are no universal norms regarding which approaches should be used to support healthcare personnel in clinical practice. CES approaches can roughly be divided into ''top-down'' or ''bottom-up'' perspectives, which can be contrasted in terms of the nature, purpose and goals of the support. Within ''top-down'' perspectives, an ethical consultant or a group of ''experts'' has an influential advisory role or act(s) as the primary ethical decision maker, providing advice or recommendations (Aulisio et al. 1998;Crigger 1995;La Puma and Schiedermayer 1991). Those supporting such an approach claim that the ethical issues in healthcare are too complex to be managed by the healthcare personnel themselves. In this vein, personnel facing ethical issues require specialist expertise in the same way that medical doctors need to consult with each other within different specialties (La Puma and Schiedermayer 1991). In contrast, in ''bottomup'' approaches to CES, reflection begins with healthcare personnel's everyday experiences of ethical issues in clinical practice (Hansson 2002). The discussion is facilitated by an ethicist or philosopher, a ''facilitator'' who has the goal of fostering greater insight among the personnel into ethical considerations rather than focusing on decision-making in any particular case (Hansson 2002;Stolper et al. 2014). Adherents of ''bottom up'' approaches claim that ethical issues need to be reflected on critically by the healthcare personnel themselves, since they are the only legitimate decision-makers and are morally responsible for the outcomes (Hansson 2002). The facilitator for such an approach is considered to lack the knowledge needed to give advice and make recommendations for the best course of action. The existence of such contrasting approaches leaves the question open regarding which approach can be ''the golden middle way'' to guide healthcare personnel in clinical practice.
However, to our knowledge, there is a lack of integrative reviews regarding available approaches to ethics support and how different approaches support healthcare personnel deal with ethical issues. It is reasonable to believe that practitioners need some kind of CES reflection that relates to their personal experiences of everyday ethical issues. Therefore, in this paper, we aim to describe which clinical ethics support approaches are available to support healthcare personnel in clinical practice in terms of their construction, functions and goals. from the three databases to 231 articles. The titles, and when available the abstracts, were scrutinized by the authors in relation to the inclusion criteria, which resulted in the exclusion of 177 articles and the selection of 54 articles for further investigation. From the systematic search of all three databases, 54 articles were selected for further investigation. After checking the reference lists of the articles and citations, eight additional articles were found.

Manual Search
The first manual search using the search term ''clinical ethics support'' yielded 184 articles. The second manual search using the search term ''ethics support'' found 512 articles. After applying the inclusion criteria of English-language peer-reviewed articles, published in 2000-2016, the number of articles reduced to 247. Checking the reference lists and citations revealed 11 additional articles.

Quality Appraisal
In total, 320 articles from the systematic and manual searches, as well as additional articles that were identified by checking the reference lists and citations, were included for further investigation. Three of the authors read and appraised the articles by reading the titles, and when available the abstracts. We excluded duplicates, articles that did not match the inclusion criteria, editorials and review articles. After the appraisal of the 320 articles, 54 remained for further analysis. Full text was not available for three of the articles, and they had to be purchased. All the articles were discussed among all of the authors in order to reach agreement regarding the content in relation to the research aim. We used a quality assessment check of the included articles (SBU 2014). The included articles were both theoretical papers and empirical research that reflected on ethically difficult situations in health care and how to support health personnel from diverse cultures and countries worldwide.

Data Analysis
Empirical, qualitative and quantitative studies as well as theoretical papers with various approaches were included. First, the articles were sorted based on the CES approach. Second, a critical review of each article was performed, with particular attention given to the results and conclusions and their relation to the aim provided in the article. Notes were made regarding their content (Table 1). The analysis process was inspired by manifest content analysis (Graneheim and Lundman 2004).Third, the important parts of each article, such as approach, aim, method, results and conclusion, were written up into a matrix (Garrard 2010). Fourth, the results and conclusions of each qualitative, quantitative and theoretical paper were imported into to a new sheet in a word processor so they could be coded. Fifth, the first author performed descriptive coding of the articles' results and conclusions. Sixth, based on content similarities and differences among the similar approaches, descriptive and manifest categories emerged from the codes. Finally, the results of Clinical ethics consultation Theoretical paper To describe the evolution of an ethics consultation service at a metro medical center in an urban public hospital, its struggle to thrive, and subsequent revitalization Ethics consultation utilized a service that increased fourfold over a three-year period, a usage rate maintained since. A key step was its use of an adaptive small-team approach including an ethics consult-care team meeting. These meetings often result in either (1) the dissolution of apparent ethical conflict or uncertainty as lines of communication are opened or (2) clarity on the part of the care team members regarding the next steps they must take in order to address the ethical issues under discussion. The assumption that the consultant does not need specific competencies aside from general knowledge and skills has been rejected by the American Society for Bioethics and Humanities. Ethics consultation is a distinctive services that responds to a specific request for assistance, focuses on addressing uncertainty or conflict regarding value-laden concerns and addresses those value-laden concerns through ''ethics facilitation''. Those designated to perform the role should have the requisite competencies to address the question or concern appropriately in health care consultation. Rasmussen (2011 Rasmussen (2016). Clinical Ethics consultants are not ''ethics'' experts-but they do have expertise.

Clinical ethics consultation
Theoretical paper To describe clinical ethics consultation and their expertise concerning the right moral answer Clinical ethics consultation is substantive, which requires a kind of training that other professions undergo, but that is not normatively binding. Opponents of CEC and moral expertise may essentially be objecting to the idea of people who profess to have the right answer in moral situations, because: (1) they hold that there is no such objectively verifiable thing, and (2) this society respects and protects autonomous moral decision-making more highly than correct moral decision-making. CECs are the only, or indeed the most desirable model for the provision of ethics support and guidance in clinical practice Provision of clinical ethics support may include consideration of individual cases, or debate on the ethical issues they raise; the education of health professionals on such issues; and ethical input into trust policy and guidance. It is accepted that these functions require the identification and analysis of ethical problems within a legal framework, if criticisms of lack of 'due process' are to be addressed.
Since ethical support may be provided by individuals, small groups or committees, the core competencies identified are to be considered as ''collective'' in their application to a particular committee or group. and principlism To analyze two methodologies: the ''dilemmatic'' and the ''problematic'' It is easier to reason than to deliberate. Deliberation is a difficult task and it requires many conditions, such as: lack of external constraints, good will, capacity to give reasons, respect for others when they disagree, an ability to listen, disposition to influence and to be influenced by arguments, and a desire to understand, cooperate and collaborate. This is the framework of a true deliberation process. Deliberation rests not on ''decision'' but on ''commitment.'' Within this framework, almost all existing bioethical methods can be useful to some extent. Molewijk et al. (2008a). Teaching ethics in the clinic. The theory and practice of moral case deliberation. (d) to present the implementation process The results showed that the moral case deliberations, the role of the ethics facilitator, and the train-the-facilitator program were regarded as useful and were evaluated as (very) positive. Healthcare professionals reported that they improved their moral competencies.
They have developed skills to reflect on their work, and to create an atmosphere of dialogue instead of discussion and debate. Molewijk et al. (2008b). Implementing moral case deliberation in Dutch healthcare-Improving moral competency for professionals and quality of care. with an emotion is finding the right middle ground between being overwhelmed and remaining untouched. Moral case deliberation can provide tools for dealing with emotions in clinical practice. This is not just a matter of rationally determining a balance. One has to be able to act in line with the right middle, and embody the appropriate attitude. Dealing with emotions is a matter of virtue and character. To test the assumption that enhanced ethical competence would help to decrease reported moral distress, a prospective controlled study was set up Ethical competence is a key factor in preventing or reducing moral distress. The results show that generally, there were differences in levels of moral distress between pharmacies and hospital departments. Ethics rounds may be seen as opportunities for ethical discourse, where participants jointly explore their own personal sets of values and seek to balance these with professional value sets. The ethics rounds method was also developed to strengthen the organizations' ethical dimension. Svantesson et al. (2008 relief. Negative experiences were associated with a sense of unconcern and alienation, as well as frustration with the lack of solutions and a sense of resignation that change is not possible. In assisting healthcare professionals to learn a way through ethical problems in patient care, a balance should be found between ethical analyses, conflict resolution and problem solving. the primary healthcare workers feel, how important healthcare workers in primary care think it is to better deal with these challenges and what kind of ethics support they want The majority of primary healthcare workers in this study reported that they experience ethical challenges in their work. These challenges were closely related to professional and organizational circumstances, with the lack of resources, e.g., lack of staff and competence being the most prominent. The findings showed that the healthcare workers' values clash with what they see themselves doing in their practice, such as hiding medication in food, tying patients to the chair or using force to clean the patient. These are the issues that are given less attention than, e.g., ethical challenges related to end of life. Magelssen et al. (2016). Ethics support in community care makes a difference for practice. Norway.

Nursing Ethics
Ethics support Quantitative, online questionnaires n = 2. Responses in total n = 354 To study outcomes of ethics activities and examine which factors promote or inhibit significance and sustainability of activities The participants of this study found the ethics project to be highly significant for their daily professional practice. Outcomes include better handling of ethical challenges, better employee cooperation, better service quality, and better relations with patients and next of kin. Factors associated with sustainability and/or significance of the activities were sufficient support from stakeholders, sufficient available time, and ethics facilitators having sufficient knowledge and skills in ethics and access to supervision. The facilitators who are responsible for the activities must receive sufficient follow-up and training in ethics deliberation methods and relevant topics in health care ethics. how it is interwoven with practice A threefold account of the relationship between theory and practice based on narrative and hermeneutical approaches were discussed. The relationship between theory and practice took the form of a ''hermeneutic circle.'' Using theories to interpret experiences makes theoretical concepts clearer. It indicates our basic attitudes to our daily work by summarizing: (1) that we acknowledge our dependencies and responsibilities within the social sphere, and (2) that we believe that all human identities are constructed by means of narratives as (3) we perceive human beings as story-telling agents. In addition, (4) we emphasized our focus on fostering mutual understanding; (5) we acknowledge that understanding is mediated by language, words and concepts; and (6) we opt for taking personal and professional experiences seriously, making them accessible in dialogues, and learn from each other in changing perspectives. Schildmann et al. (2013) (Sandelowski et al. 2006), such as different approaches to CES.

Results
The results revealed four CES approaches that are available to support healthcare personnel who are dealing with ethical issues (Table 1). They comprised: clinical ethics consultation, clinical ethics committees, moral case deliberation, and ethics rounds/ethics discussion groups/ethics reflection groups, which we have combined together due to the similarity of their form and content. Although CES can be categorized into four main approaches, it is important to point out that due to a lack of firm definitions, it is difficult to draw distinct lines between them, which results in some overlap of the boundaries.

Clinical Ethics Consultation
Clinical ethics consultation is defined as a set of services that generally occurs following requests from healthcare personnel, patients or their surrogates (Aulisio et al. 2000). It can also be performed routinely by a permanent body such as a hospital ethics committee (Reiter-Theil 2000; Tomazic et al. 2004). The consultation is provided by an individual or a small team of individuals in response to ethical issues (Adams 2009;Aulisio et al. 2000; Tarzian and ASBH Core Competencies Update Task Force 2013). Those who provide consultations have various professions, such as physicians, nurses, social workers or members of the clergy (McClimans et al. 2016). It is argued that the person(s) who provide the consultations are required to have certain skills and competencies in ethics, in order to support healthcare personnel in dealing with ethical problems (Aulisio et al. 2000). Ethics consultations have been shown to help patients and personnel clarify ethical problems arising in daily health care practices and to improve collaborative decision-making (Fox et al. 2007; Tarzian and ASBH Core Competencies Update Task Force 2013). Ethics consultations may have the goal of improving quality of care for the patient and/or for solving certain aspects of ethical conflicts that occur between healthcare personnel, patients and next-of-kin (Aulisio et al. 2000;Paola and Walker 2006).
Beside requests concerning specific patient cases, ethical consultation services can provide educational activities in order to increase awareness concerning ethics in the clinic (Fukuyama et al. 2008) or to help deal with moral distress (McClimans et al. 2016).
In the US, there has been a movement to certify ethics consultants to assure that they possess key knowledge and skill competencies (Tarzian and ASBH Core Competencies Update Task Force 2013). Ethics consultants should possess a range of knowledge competencies that includes moral reasoning and ethical theory, relevant ethical codes, health law and local policies, and knowledge regarding the clinical context and staff and patient perspectives (Tomazic et al. 2004). In terms of skills, ethics consultants should have the ability and interpersonal skills to assess the nature of the ethical conflict by drawing on relevant ethics knowledge and ''process'' skills required to conduct clinical ethics consultation services effectively. In addition, a code of ethics has been developed by the American Society for Bioethics and Humanities, which identifies a set of professional responsibilities for those engaged in healthcare ethics consultation (Tarzian et al. 2015).
Ethics consultation services are multifaceted. There is no agreement regarding their core role worldwide and they vary in role and function depending on the country. For example, in Japan, ethics consultation services may prioritize the review of scientific and clinical research (Fukuyama et al. 2008) before case analysis and patient consultation (Adams 2009;Aulisio et al. 2009; Tarzian and ASBH Core Competencies Update Task Force 2013). Ethical consultation services can be used in specific ways, such as in response to requests for assistance in addressing uncertainty or conflict regarding a value-laden conflict of interest (Aulisio et al. 2000;Paola and Walker 2006). This can be between various stakeholders, such as patients, next-of-kin, healthcare personnel or the health organization (Adams 2009; Tarzian and ASBH Core Competencies Update Task Force 2013). The role of ethical consultation may be less specific, such as when consultations are triggered by the institution in order to educate health personnel in how to deal with moral distress, to improve ethical and moral qualities of decisionmaking and actions (McClimans et al. 2016), or to review research protocols (Fukuyama et al. 2008). Some ethics consultant(s), (depending on the country) even have the authority to make decisions or give advice/recommendations, whether alone or in agreement with next-of-kin or healthcare staff, as to the best course of action.
The idea that an ethicist/consultant with specific knowledge can assume the role of ethics expert and make judgments in ethically difficult situations has been supported by some (Aulisio et al. 2000; Tarzian and ASBH Core Competencies Update Task Force 2013). It has been criticized by others, who argue that while there is expertise in ethics, there is no such thing as an ethics expert (Adams 2009;Rasmussen 2011Rasmussen , 2016. Regardless of the contrasting positions described above, the approach of ethics consultation remains authoritarian, because while the consultation process is triggered by health personnel requesting a consultation, it is the consultants who have the authority and power (as a result of their position) to interpret the clinical ethics case (Agich 2001).

Clinical Ethics Committees
A clinical ethics committee is typically a standing committee which functions as an independent institution or authority to provide a formal mechanism for dealing with ethical issues in clinical settings (Akabayashi et al. 2008;Aulisio and Arnold 2008). Generally, the members of clinical ethics committees have various professional backgrounds such as: bioethicists/ethics consultants, clergy, social workers, lawyers, nurses, physicians, psychologists, therapists and community representatives (Akabayashi et al. 2008;Schick and Guo 2001). The goals and responsibilities of the clinical ethics committee are to protect the rights, safety and well-being of the patient in the health care setting or human subjects in research projects (Borovecki et al. 2010;Gaudine et al. 2010;Slowther et al. 2011). In addition, they are to identify and analyze ethical issues in clinical practice (Larcher et al. 2010;Slowther et al. 2001), promote training and education of health personnel, and provide guidance upon request (Caminiti et al. 2011). They commonly respond to requests to address ethical issues related to ongoing as well as retrospective patient cases; identify ethical needs within clinical settings; support healthcare personnel, patients and next-of-kin (Førde and Pedersen 2011), find agreements and make decisions; and review research protocols (Fukuyama et al. 2008;Gaudine et al. 2010). Clinical ethics committees are involved in responding to ethical issues, such as informed consent to treatment (Borovecki et al. 2010;Caminiti et al. 2011). Sometimes they provide decision-making support (Pedersen et al. 2009) in end-of-life situations or the continuation of life support (Slowther et al. 2004b). Clinical ethics committees can also provide education, seminars, workshops and training in ethics for hospital employees (Borovecki et al. 2010;Caminiti et al. 2011;Pedersen et al. 2009). They can review research protocols (except in the United States, where separate committees deal with this process), provide ethical input into hospital policies (Pedersen et al. 2009) and create guidelines (Slowther et al. 2001). Additionally, they can give an ''expert'' opinion regarding issues, such as the provision of treatment against a patient's will and the disclosure of medical information against a patient's wishes when it might be deemed necessary (Wenger et al. 2002). Clinical ethics committees promote an ethical dimension to health care and generate possibilities for improvement in care quality (Caminiti et al. 2011;Czarkowski et al. 2015).
There is no formal legal or regulatory governing framework for clinical ethics committees, which is in contrast to research ethics committees worldwide (Larcher et al. 2010;Slowther et al. 2004b;Wenger et al. 2002). Clinical ethics committees vary in function, structure and goals worldwide, but there are some commonalities in terms of the provision of advice (Slowther et al. 2001) and recommendations concerning the best course of action or discussions that lead to a good decisionmaking process (Schick and Guo 2001;Slowther et al. 2004b). Some committees themselves assume the responsibility to develop and improve guidelines and policies regarding prospective ethical challenges in clinical practice, and others are mandated by the health care institutions to do so (Aulisio and Arnold 2008;Slowther et al. 2001). Clinical ethics committees seem to have formal authority and legitimacy (without generalizing) to provide advice and recommendations concerning ethical issues arising in healthcare institutions (Slowther et al. 2004b).

Moral Case Deliberation
The approach of Moral Case Deliberation (MCD) has been described in several ways. It is said to consist of a collaborative, systematic reflection on real clinical cases (Molewijk et al. 2008a, b;Weidema et al. 2012); methodological reflection on concrete cases among healthcare professionals; and facilitator-led collective dialogue (Gracia 2001) of healthcare personnel who reflect on a concrete moral question connected to real cases in their practice (Janssens et al. 2014;Molewijk et al. 2008a, b;Weidema et al. 2012). The goal of MCD is to support healthcare personnel to manage ethically difficult situations in their clinical practice (Svantesson et al. 2014), and to enhance ethical reflection among healthcare personnel concerning ethical issues and thus improve the quality of patient care. In other words, MCD can help deal with concrete problems and help train healthcare personnel so that they improve their ethical competencies. MCD is a ''deliberationist'' approach to ethical issues that supports the idea that reflection over ethically difficult situations is vital, and aims to make health personnel aware of ethical issues as well as related theories and how they might be applied in practice . It supports health personnel in managing ethical issues and making independent decisions from the standpoint that health personnel are entitled to make decisions about how to deal with issues in clinical practice (Molewijk et al. 2008a, b).
During an MCD session, which can last from 45 minutes to one day and is led by an external facilitator, participants reflect individually and collectively about the moral aspects of a particular patient case (Molewijk et al. 2011a). The collective group discussion is facilitated by an ethicist or someone trained in some kind of conversation method relevant to ethics (Molewijk et al. 2008a, b;Svantesson et al. 2014;Weidema et al. 2012). MCD sessions are led by a facilitator who has no authority to decide on or to provide/recommend suggestions concerning the best course of action (Molewijk et al. 2008a, b;Weidema et al. 2012). The facilitator's main role is only to stimulate an ethical discussion (mutual reflection) and to illuminate the ethical aspects of the case Gracia 2001).
In an MCD session, health personnel take the initiative to discuss a patient's case that they have found ethically difficult to manage (Molewijk et al. 2008a, b;Molewijk et al. 2011a). Each person participates in the MCD on equal terms regardless of his or her job title and all voices are to be listened to and respected. During the MCD session different kinds of emotion, e.g., frustration, anger, sadness can be expressed (Molewijk et al. 2011a). MCD is similar in many ways to ethics rounds (described below), but it is distinctive because it uses theoretically based conversation methods (Janssens et al. 2014), such as the Dilemma method or Socratic Dialogue (Svantesson et al. 2014;Weidema et al. 2012). The Dilemma method has been used in the Netherlands with the goal of helping healthcare personnel seek consensus regarding ethical issues (Molewijk et al. 2008a(Molewijk et al. , b, 2011aWeidema et al. 2012). In contrast, Socratic Dialogue aims to help healthcare personnel develop ethical skills and a reflective attitude towards the ethical issues they experience in their everyday clinical practice (Molewijk et al. 2008a, b).

Ethics Rounds/Ethics Discussion Groups/Ethics Reflection Groups
These three approaches overlap with each other to some extent since they have commonalities in terms of how they are constructed as well as in their functions and goals.
Ethics rounds are a form of facilitator/ethicist-led reflection, which involves discussion of a particular patient's medical and ethical issues (Grönlund et al. 2016;Silén et al. 2014;Svantesson et al. 2008). During ethics rounds, healthcare personnel from different disciplines reflect over a patient's case that they are finding ethically difficult to resolve (MacRae et al. 2005;Svantesson et al. 2008), or over ethical challenges related to professional and organizational circumstances (Grönlund et al. 2016;Lillemoen and Pedersen 2012). The goal of the ethics round is to stimulate ethical reflection and promote mutual understanding between professional groups (MacRae et al. 2005;Silén et al. 2014), particularly through listening to each other's perspectives (Svantesson et al. 2008). Ethics rounds have been described as supporting healthcare personnel develop ethical competencies and gain insight into ethical issues (Silén et al. 2014;Sporrong et al. 2007). They help healthcare personnel to examine their own views and obtain a better awareness and understanding of their colleagues' ways of thinking and acting (Grönlund et al. 2016;Sporrong et al. 2007).
Other kinds of ethics support alongside ethics rounds are ethics discussion groups and ethics reflection groups, which have been used by healthcare personnel in nursing homes to discuss issues regarding end-of-life care, lack of resources and coercion (Bollig et al. 2015;Lillemoen and Pedersen 2012). Ethics discussion groups have also been used to improve the work climate and job satisfaction among nursing staff (Forsgärde et al. 2000), while ethics reflection groups have been described as an approach in which healthcare personnel sit together and reflect over ethical challenges in their daily practice (Lillemoen and Pedersen 2015). Other related kinds of ethics support have been used to train and educate healthcare personnel to acquire skills needed to respond to ethical issues (Dörries et al. 2010;MacRae et al. 2005). Promotion of ethics support in health care can be fostered by focusing on the needs of the healthcare institution and using ethical theory to interpret the experiences of the healthcare personnel's everyday work (Dauwerse et al. 2011;Porz et al. 2011). Ethics support facilitated by a person with knowledge in ethics has been shown to help staff handle ethical challenges, improve cooperation between employees (Magelssen et al. 2016), increase healthcare personnel's awareness of ethical aspects, and improve relations between staff and patients/next-of-kin (Magelssen et al. 2016;Schlairet et al. 2012). To ensure that ethics support is improving the quality of care, evaluation is essential (Schildmann et al. 2013).
These approaches to ethics support are all characterized by the involvement of inter-professional healthcare teams in collective group discussions to encourage reflection over ethical issues that occur in clinical practice from the perspectives of the healthcare personnel themselves (Schlairet et al. 2012). A bioethicist or facilitator has the role of creating an equal atmosphere for everyone during the ethics rounds/discussion (MacRae et al. 2005). It is common that the bioethicist/facilitator receives some information concerning the case in advance, or asks the participants to prepare a case or an ethical issue to reflect over (Grönlund et al. 2016). The bioethicist/facilitator has no authority and does not act as an expert in ethics, nor do they provide advice about what to do, but only stimulates group discussion (Magelssen et al. 2016;Silén et al. 2014). One fundamental idea with these kinds of discussions is that the personnel may stimulate each other, enhance critical thinking (Svantesson et al. 2008), or change their attitudes regarding the situations. These discussions have the goal of helping personnel deal with moral distress (Sporrong et al. 2007), getting them to help each other and to cooperate in order to find alternative ways of handling situations, and to ultimately improve the quality of patient care (Dauwerse et al. 2011;Janssens et al. 2014). In these types of ethics support, healthcare personnel are considered to be qualified (Dörries et al. 2010) and legitimate decision-makers in regard to ethically difficult situations. Ultimately, making decisions or reaching a consensus regarding the best course of action in a particular case remains with the healthcare personnel (Silén et al. 2014;Sporrong et al. 2007).

Discussion
The included articles (n = 54) covered a range of clinical ethics support. The study aim was to describe which clinical ethics support approaches are available to support healthcare personnel in clinical practice in terms of their construction, functions and goals. The existing literature clearly demonstrates the increased worldwide interest for clinical ethics support.
There are similarities and differences among the established approaches. In the first approach, clinical ethics consultation, the ethicist assists the healthcare personnel with patient cases where there could be issues regarding patient autonomy, informed consent, confidentiality, and surrogate decision making (Aulisio et al. 1998(Aulisio et al. , 2000. Ethics consultation can sometimes be recognized as having an authoritarian ''top-down'' perspective (Adams 2013;Agich 1995;Aulisio et al. 1998), especially if the outcomes of the consultation are not beneficial for the patient or the healthcare personnel. Here the consultant has an influential advisory role and may propose solutions, or act as the primary ethical decision maker with respect to the outcome and the process (Aulisio et al. 2000;La Puma and Schiedermayer 1991).
The second approach utilizes clinical ethics committees; it has many similarities to clinical ethics consultation. In this approach, instead of an individual person with expertise in ethics, a group of ''experts'' assists healthcare personnel by providing advice or recommendations from an ''expert'' point-of-view (Dauwerse 2013;Hoffman 1991). Traditionally, both clinical ethics consultation and clinical ethics committees have focused on providing advice or recommendations to healthcare personnel in clinical practice (Cranford and Doudera 1984). In addition, clinical ethics committees have been involved in supporting patients and their next-of-kin. Sometimes patient representatives are included in ethics committees (Førde and Pedersen 2011) when discussing patient cases. However, there seems to be variation in function and role regarding ethics support in ethics consultation and ethics committees both between countries and even within them. There is still no clear universal consensus of what ethics consultation should or should not provide during a case consultation.
In a third approach to CES, MCD is sometimes described as a ''bottom-up'' approach, in which reflection starts from the healthcare personnel's experiences of everyday ethical issues related to clinical practice (Molewijk et al. 2008a, b;Spijkerboer et al. 2016). This approach seeks to increase the healthcare personnel's insight into their moral responsibility (Svantesson et al. 2008) and to broaden perspectives through reflection. MCD differs from clinical ethics consultation and clinical ethics committees in that it fosters dialogue on ethical questions and reflection on ethical dilemmas (Dauwerse 2013;Stolper et al. 2014) rather than on decision-making in ethically difficult situations. The reflection in MCD is usually guided by a facilitator (Molewijk et al. 2011a), who is trained in various conversation methods, e.g., the Dilemma method and Socratic Dialogue (Molewijk et al. 2008a, b;Plantinga et al. 2012). The facilitator in the MCD does not claim be an ''expert'' in ethics, but merely stimulates healthcare personnel by asking questions about the case like Socrates did in his time (Stolper et al. 2014).
Finally, there are ethics rounds/ethics discussion groups/ethics reflection groups that are closely related to each other in how they are facilitated and the content they discuss. For this reason, we have chosen to discuss all three together as one approach. This fourth approach is also closely related to MCD. In a previous study, MCD was used as an umbrella term for ethics rounds/ethics discussion groups and ethics reflection groups (Svantesson et al. 2014). Previous studies described the group reflections as being positively regarded by healthcare personnel (van der Dam et al. 2011Dam et al. , 2013Verkerk et al. 2004). It was said to increase their awareness concerning ethically difficult situations they experience in their clinical practice (Lillemoen and Pedersen 2015). It also increased job satisfaction and was associated with lower burnout rates, while workplaces without reflection remained unchanged.
Reflection is the act of sharing experiences and narratives in which the person is receptive for personal development. It has also been described as a process of learning and representation (Moon 2013). A reflective conversation for healthcare personnel in practice is fundamental in order to provide quality services (Schon 2003). The primary purpose of reflection is not to solve an issue arising in everyday practice, but to increase awareness of the various aspects of the issue. A positive side-effect of reflection could be that it leads to the ability to solve an issue that occurs. Reflection supports the idea of an enhanced critical thinking process. According to Dewey (1933), the purpose of reflection is to process knowledge in order to get a deeper understanding of a phenomenon. In health care, the personnel reflect on ethically difficult situations in order to learn more of what it means to act or not act in a certain way. Therefore, clinical ethics support in the form of reflection is vital for personnel working in health care settings. Personnel benefit from approaches that can create an atmosphere where they can have the freedom to express their feelings and emotions related to a case they are struggling with (Molewijk et al. 2011b).
Clinical ethics support from a ''bottom-up'' perspective might give healthcare professionals opportunities to think and reflect on issues they are facing in their everyday work. A dominant ''top-down'' perspective could be a less risky approach if, and only if, it removes ethical responsibility from the healthcare personnel (Agich 1995;Hansson 2002). For example, if a consultant makes a decision, or gives advice or a recommendation that is not beneficial for either the patient or the personnel, but only beneficial from an economical perspective. If later on the consequences of that decision or advice/recommendation proved detrimental to the patient, the healthcare personnel involved could free themselves from guilt by placing the blame on the consultant. If a decision or recommendation was based on a ''bottom-up'' approach that involves the reflections of the healthcare personnel, they would need to assume greater ethical responsibility and perhaps wish to reflect more in such situations. Consequently, the status of a professional ''expert'' in ethics might lead to a risk, an undermining, or a challenge to the healthcare personnel's personal autonomy, e.g., a limitation on their autonomy when dealing with ethical issues. According to Schon (2003), professional practitioners are specialists that encounter certain types of situations again and again in their daily work. They learn what to look for and how to respond to those particular types of situations (Schon 2003). Even though many ethically difficult situations are unique, repeating patterns can be found. Therefore, the ethical responsibility and choice of what to do should remain with the healthcare personnel in clinical practice (Hansson 2002). To permit someone from the outside to make a decision or give a recommendation in a particular situation could be risky (Hansson 2002).

Strengths and Limitations
A strength of this study is that the conclusions are based on literature that allowed an analysis of the established clinical ethics support approaches worldwide. In this integrative review, both qualitative and quantitative studies as well as theoretical papers were included. An integrated review allows the inclusion of several methodologies and can take into account a broader range of studies to develop a more comprehensive understanding of a phenomenon (Whittemore and Knafl 2005). Another strength is that we have searched data systematically with Mesh terms as well as manually. There are limitations as well. It was difficult to decide which articles to exclude since there are no real definitions as to what clinical ethics consultation really is. We included articles that described a clinical ethics support approach empirically, or theoretical papers that discussed an established approach. It was difficult to decide where to draw the line between approaches aimed only at supporting healthcare personnel with ethically difficult situations and approaches that support healthcare personnel as well as patients and next-of-kin. For example, some clinical ethics committees do support the patients and their next-of-kin, while other clinical ethics committees do not involve patients and next-of-kin in their annual meetings or when considering different situations. Even though there are similarities in the ''top-down'' perspective of the clinical ethics consultation and clinical ethics committees, it does not mean they are similar worldwide. Clinical ethics consultation and clinical ethics committees in different countries can differ in their role and function as well. In addition, in this review we considered only English-language papers and it is possible that other methods of ethics support have been developed in other language cultures. Future studies need to focus on defining and characterizing what clinical ethics support actually is, how it should function and if it should function differently in different countries; and if so, what are the possible reasons since many of the ethical issues are similar globally. Lastly, an additional interesting avenue for future research would be to perform a large-scale study of what types of ethical support practitioners are receiving, if they are satisfied with it and their perceptions regarding any effects on patient outcomes.

Conclusions and Implications
Clinical ethics support in the form of reflection is an important approach in order to deal with ethical challenges in health care settings. Traditionally, clinical ethics committees and ethics consultations have been the two approaches that are sometimes recognized (without generalizing) as having a focus on providing suggestions or recommendations to healthcare personnel from an expert point-ofview, and often with a basis in different medical principles or theories. Moral Case Deliberation (MCD) and ethics rounds/ethics discussion groups/ethics reflection groups seem to focus on fostering dialogue on ethical questions and ethical inquiries that are brought up by the healthcare personnel. It has been argued that approaches based on reflection may generate insight (Moon 2013). In MCD for example, reflection from a ''bottom-up'' perspective may support healthcare personnel to process their own thoughts and feelings. This might further help them become aware of other aspects they were previously unaware of in ethically difficult situations and how to deal with them in clinical practice. MCD is an explicit form of clinical ethics support that gives professionals support to improve their moral reflection skills . Reflection in groups might in the long-term help healthcare personnel discover their own way of dealing with ethically difficult situations in order to act in the best interest of the patient.
To summarize, clinical ethics support from a ''bottom-up'' perspective might provide healthcare personnel with opportunities to think and reflect more than from a ''top-down'' perspective. While a ''bottom-up'' approach leaves healthcare personnel with the moral responsibility for their choice of action in clinical practice, a ''top-down'' approach risks removing that responsibility.