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During the last decade, the Swedish health care system has undergone fundamental changes. The changes have made health care more complex and ethics has increasingly become a required component of clinical practice. Considering this, it is not surprising that many health care professionals suffer from stress-related disorders. Stress due to ethical dilemmas is usually referred to as 'moral distress'. The present article derives from Andrew Jameton's development of the concept of moral distress and presents the results of a study that, using focus group method, identifies situations of ethical dilemmas and moral distress among health care providers of different categories. The study includes both hospital clinics and pharmacies. The results show that all categories of staff interviewed express experiences of moral distress; prior research has mostly focused on moral distress experienced by nurses. Second, it was made clear that moral distress does not occur only as a consequence of institutional constraints preventing the health care giver from acting on his/her moral considerations, which is the traditional definition of moral distress. There are situations when the staff members do follow their moral decisions, but in doing so they clash with, e.g. legal regulations. In these cases too, moral distress occurs. Hitherto research on moral distress has focused on the individual health care provider and her subjective moral convictions. Our results show that the study of moral distress must focus more on the context of the ethical dilemmas. Finally, the conclusion of the study is that the work organization must provide better support resources and structures to decrease moral distress. The results point to the need for further education in ethics and a forum for discussing ethically troubling situations experienced in the daily care practice for both hospital and pharmacy staff. Keywords: Ethics; Moral distress; Pharmacy practice; Clinical practice; Ethical dilemmas; Nursing; Sweden

Downsizing of staff is becoming increasingly common in hospitals as a way to meet the demands of shrinking budgets. This study, based in Sweden, used a longitudinal design to study staff views of their work environment, their individual health and the quality of the care they were delivering during a period of hospital downsizing. Although there were no significant changes in perceptions of quality of care, perceptions of workload substantially increased whilst perceptions of mental energy substantially decreased. These two changes could point to future problems with quality of care after a period of hospital downsizing. Keywords: Quality of care; Work environment; Downsizing; Hospitals; Sweden

In the current review, a biopsychosocial perspective is applied to current changes in the health of populations. It is proposed that the psychosocial environments either promote health or precipitate disease. Changes in the types of stress that people experience as well as its prevalence over time are discussed. In addition, possible biological mechanisms linking the psychosocial environments to health are presented. 'Food for thought' is the possible interaction between the physical/chemical and the psychosocial environments and changes in health of individuals. Clearly, our traditional view of disease mechanisms is not sufficient to understand recent phenomena, such as environmental illness and chronic fatigue syndrome. Issues worthy of further discussions are the role of the 'just-in-time' society, where individuals increasingly have to change jobs, cope with reorganizations and increased production pressure, and its impact on health and well-being. Further, in what way can we develop better models to truly assess the impact of an increasingly complex interaction between individual and environmental factors on health? A major obstacle to enhancing our understanding of causes of change in the health of populations is the use of inappropriate or outdated statistical analytical models. Finally, it is suggested that prospectively controlled studies of the impact on health of changes in the health and welfare systems are carried out. This would further add to our understanding of factors contributing to changes in the health of population. Key words - public health, modern society, complex causes

Evaluates the effects of a structured organizational and staff intervention program on perceived psychosocial work quality, supporting resources and self-reported health and well-being of health care workers in Sweden. Determinants for more favorable changes; Psychosocial impact of personnel cut-backs in health care; Elimination of negative work stressors.