Criminal Profiling Process

Criminal/Psychological Profiling
Diane Miller
Abstract
Criminal profiling is not a new concept as variations of it
have been used for many years in an effort to understand
offenders and facilitate crime solving. As the field of Forensic
Nursing grows, the Forensic Nurse plays an important role as a
member of the criminal profiling team especially as a Forensic
Nurse Examiner. This study will examine the criminal profiling
process, the steps leading to the apprehension of the offender
and explore the benefits law enforcement agencies can reap by
including a Forensic Nurse as a member of their team.
Statement of Criminal/Psychological Profiling
Although criminal profiling had been used for many years
it became a more refined process in the 1970’s when the FBI
began conducting research in an effort to provide a better
understanding of serial murderers and rapists. The groundwork
for this profiling was laid by the FBI’s criminal research
project. The FBI’s National Center for the Analysis of Violent
crimes assists local, state and federal agencies by providing
criminal profiles. Profiling uses deduction to paint a picture of
the offender but does not identify him. It does this by focusing
on certain behavioral and personality characteristics.
Literature Review of Criminal/Psychological Profiling
The literature review indicates criminal profiling began
informally in the 1940’s, but caught the interest of the FBI after

the a profile of the “Mad Bomber” done by a New York
psychiatrist, Dr. James Brussel, in the 1950’s proved to be
amazingly accurate.
In the 1970’s the FBI developed a more refined process in
utilizing criminal profiling as an investigative tool. That
process continues today at the FBI’s National Center for the
Analysis of Violent Crime and is instrumental in solving
heinous and violent crimes that otherwise could not be solved.
The literature review supports the value and importance of
criminal profiling today and the role it plays in attaining justice
for the victims of violent crime and their families.
The principles related to criminal profiling outlined in the
literature demonstrate the importance of interpreting crime
scene behavior in order to narrow the field of suspects for a
particular crime and the accuracy it provides.
Criminal/Psychological Profiling
Core Forensic Nursing Principles Related to Criminal Profiling
Core Principles Related to Criminal Profiling
The scientific and social phenomenon of death represents the
two primary aspects of death investigation on which the practice
and philosophy of forensic nursing science is founded.
Experience in forensic nursing and guidelines in death
investigation help provide the ways of knowing and critical
thinking that determine the basis on which acute case
management of questioned deaths can be provided.

(Lynch, 2006)
Utilizing These Principles in Criminal Profiling
The Forensic Nurse assists with the retrieval, assessment and
evaluation of information obtained during the death
investigation.
Understands the variations in criminal action patterns and the
conclusions about the offender that can be drawn from these
patterns.
Utilizes clinical skills as part of the investigation process,
actions and strategies to facilitate the investigation.
Criminal Profiling Process
Legal Implications
Six Stages of the Profiling Process
Input: collecting crime scene information.
Decision process: arranging the input into meaningful patterns,
analyzing victim and offender risk.
Crime assessment: reconstructing the crime and the offender
motivation.
Criminal profile: developing specific descriptions of the
offender.
Investigation: uses the profile as an aid in investigation.
Apprehension: check the accuracy and the description against
new information and change the profile accordingly.
Best Practices in Criminal Profiling
Forensic investigators should gather detailed information from

the crime scene.
The forensic examiner should use written and
photodocumentaiton to precisely preserve details about the
homicide victim’s wounds and sexual acts.
The Forensic Nurse Examiner becomes a valuable team member
in the criminal profiling process by following these guidelines
during the examination process.
This information collected properly is extremely valuable in
developing an accurate profile of the offender.
Legal Implications
Following the six stages of the profiling process and utilizing
best practices in criminal profiling is imperative in developing
an acute profile of an offender.
The Forensic Nurse Examiner must be sure to avoid any
judgmental reactions or attitudes when interpreting a crime
scene.
Forensic nurses are not criminal investigators but function as a
clinical investigator.
The registered nurse is an ideal clinician to fulfill the role of
death investigator.
The Forensic Nurse must be prepared to testify in court.
Looking at Behavioral Characteristics Identified at the Crime
Scene
Behavioral Characteristics and Criminal Profiling
Amount of planning that went into the crime.
Degree of control used by the offender.
Escalation of emotion at the scene.

Risk level of the offender and the victim.
Appearance of the crime scene (organized, disorganized).
The Interpretation Process
Profiling is based on research and years of experience in
reviewing similar cases with similar offender characteristics. It
is not a science or psychic guesses as we are sometimes led to
believe, especially by the media. It is a process the profiler uses
to make behavioral interpretations. This in turn enables the
investigator to limit the suspect pool. According to the FBI”s
research, similar crimes are committed for similar reasons.
The Ultimate Goal of Criminal Profiling: Help Catch the
Offender!
Implications for Forensic Nursing Practice
The Forensic Nurse Examiner
Conducts an investigation of trauma or death.
Provides a forensic examination of physical, psychological, or
sexual assault trauma.
Examines the questioned analysis of medical records or court-
ordered evaluation of mental status.
Assists law enforcement by providing the advent of forensic
nursing science.
Provides multidisciplinary cooperation to bring together clinical
and criminal investigation.

Questions for Discussion
Please answer after viewing the PowerPoint and reading the
attached articles.
Required Readings
Gregory, N., (2005). Offender profiling: a review of the
literature. The British Journal of Forensic Practice, volume 7,
issue 3, 29-33.
Schlesinger, L., (2009). Psychological prodiling: investigative
implications from crime scene analysis. Journal of Psychiatry
& Law, 37, 1, 73-83.
Discussion Questions
Is profiling admissible in the British legal system? Please
explain your answer.
What famous case in the 1950’s brought criminal profiling to
the attention of the public?
Do you think the forensic nurse has a role in criminal profiling?
References
Beauregard, E. (2009). Rape and sexual assault in investigative
psychology:
the contribution of sex offenders” research to offender
profiling. Journal of
Investigative Psychology and Offender Profiling, 7, 1-13.
Bennell, C., Corey, S., Taylor, A., & Ecker, J. (2008). What
skills are required for the
effective offender profiling? An examination of the

relationship between critical
thinking ability and profile accuracy. Psychology, Crime &
Law, 14, 143-157.
Gregory, N. (2005). Offender profiling: a review of the
literature. The British Journal of
Forensic Practice, 7, 3, 29-33.
References
Lynch, V. A. & Duval, J. B. (2006). Forensic Nursing. St.
Louis, MO: Elsevier Mosby.
Schlesinger, L. (2009). Psychological profiling: investigative
implications from
crime scene analysis. Journal of Psychiatry & Law, 37, 73-
83.
Stangeland, P. (2005). Catching a serial rapist: hits and
misses in criminal
profiling. Police Practice and Research. 5, 353-469.
Young, D. (2009). Investigative psychology in the courtroom:
beyond the offender
Profile. Journal of Investigative Psychology
6/6/2017
Ethics: Ethical Issues with Medical Errors: Shaping a Culture of
Safety in Healthcare
http://www.nursingworld.org/MainMenuCategories/ANAMarket
place/ANAPeriodicals/OJIN/TableofContents/Vol-22-2017/No2-
May2017/EthicalIssueswithM… 1/5
Ethics: Ethical Issues with Medical

Errors: Shaping a Culture of Safety in
Healthcare
^ m d
Sarah’s Story
Jeanne Merkle Sorrell, PhD, RN, FAAN
Citation: Sorrell, J.M., (March 7, 2017) "Ethics: Ethical Issues
with Medical Errors: Shaping a Culture of Safety
in Healthcare" OJIN: The Online Journal of Issues in Nursing V
ol. 22, No. 2.
DOI: 10.3912/OJIN.Vol22No02EthCol01
Patient safety experts at Johns Hopkins have calculated that mor
e than 250,000 deaths per year in the United
States are caused by medical errors (McMains, 2016). In 2013, t
he Centers for Disease Control and Prevention
(CDC) ranked the top three causes of death as heart disease, can
cer, and respiratory disease. In 2016,
researchers at Johns Hopkins found that medical errors replaced
respiratory disease as the third leading cause
of death (Makary & Daniels, 2016; McMains, 2016). In internati
onal comparisons of deaths that are considered
preventable by timely and effective healthcare, data showed that
the United States had the highest number of
preventable deaths in comparison to nine other countries, with F
rance and Australia being the lowest (Nolte &
McKee, 2011). How can nurses help to address this problem by
shaping a culture of safety in healthcare? Keep
reading for some helpful, safety-promoting suggestions.
Students in the Advanced Clinical Nursing class that I taught w

ere assigned to write a paradigm case--a story
that reflected an ethical dilemma that they had experienced in th
eir clinical practice. It was made clear that
they needed to write something they could share with others, as
we would set aside class time to read their
stories aloud. With 22 students gathered in a circle in the classr
oom, Sarah* prefaced the reading of her story
by confiding that she had read it to her husband before class. He
asked her whether she really thought she
should share the story openly. She replied, “Yes.”
Sarah’s story:
“Do no harm.” This ethical principle has guided my nursing pra
ctice for almost 30 years. As a
young nurse I was taught the 5 rights of medication administrati
on. As an oncology nurse, I am
painfully aware that many of the chemotherapy agents that I ad
minister have the potential to
cause death if not administered properly. Some time has passed
now since I made a mistake that
could have easily cost my patient her life. Today I share my stor
y to help us think about what we
can do to reduce the possibility of errors in our practice.
The day that Mrs. May* received more than twice the dose of ch
emotherapy that had been
ordered for her was not just any day. It was very close to Christ
mas. I was feeling especially
excited because after being a registered nurse for over 25 years,
I had finally completed my
Bachelors of Science in Nursing. I was proud of my accomplish
ment and had received many
compliments and best wishes for continued professional success
.

Mrs. May had been a patient in our practice for more than a yea
r following a diagnosis of cancer,
but I had not met her. I introduced myself and administered the
chemotherapy. Afterward, Mrs.
May went directly to see her physician and her chart went with
her, so I did not have a chance to
record the medications that I had given. At the close of the day,
I realized that I had never
charted on Mrs. May’s record, so I retrieved her chart. As I look
ed at the dose of medication the
oncologist had written, I felt a lump forming in my throat. I kne
w for a fact that I had mixed and
administered two and a half times that amount. The medication
was new to me. I remembered
reconstituting 4 vials. I knew that I had given 250 mg instead of
the 100 mg. that had been
ordered.
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Ethical Considerations
My heart began to race. I went back through the chart and realiz
ed that the dilution of the drug
had been written where I had become accustomed to seeing the
dose of the drug. Since the drug
was under the same classification as another that I administered
regularly, I didn’t question that
this might be too high a dose. Immediately, I went to the nurse
manager to tell her what had
happened. I knew that if Mrs. May died, there was a good chanc
e that I would not ever be allowed
to practice nursing again. Instead of giving me a reprimand, my
manager said, “Let’s make sure
that you truly gave that much of the drug. You are always so car
eful.” Together we went through
the trash and found the 4 boxes. My heart sank. I kept thinking,
“This lady is going to die and it is
right at Christmas time.”
Today, I still remember the kindness that was bestowed on me t
hat day. When I told the
oncologist about my terrible error, he stated that he had ordered
a lower dose of the medication
for Mrs. May than normal for a patient with her condition, as sh
e had a life expectancy of only 6
months to a year and didn’t want to live with serious side effect
s from the chemotherapy. The
oncologist said that she would be very, very sick for about a mo
nth but would not die from the
overdose. He would treat her aggressively with agents to increas
e her cell counts so that she
would have enough reserve to keep her counts from going down
to zero.

The next morning Mrs. May came to the clinic. I arrived early t
o tell her how very sorry I was. She
said that her oncologist had told her if I had not come forth and
told him of the mistake, she
might not have lived. She trusted the doctor that she would not
die from the error.
I am happy to say that Mrs. May is still alive today. She certainl
y was a very sick lady for the next
2 weeks. One day she said to me, “I will not lie to you. I have n
ever felt this bad in my life, but I
will make it.” Yes, Mrs. May made it. Her tumor decreased to o
ne half its original size in about a
month. Almost 2 years after this incident, Mr. and Mrs. May we
re able to enjoy an international
vacation together. I talk with Mrs. May whenever she comes to t
he clinic and she always gives me
a hug and reassurance that she is okay.
Was I unbelievably fortunate? Yes. Can a medication error happ
en to even the most careful and
conscientious nurse? Yes. Am I even more conscious of my ethi
cal obligations to provide safe
care? Yes. This incident has changed my life. I share my story
with other nurses with the hope
that it will cause them to think, “If it could happen to her, it cou
ld happen to me.”
Sarah read this story** to my class a number of years ago but I
still remember vividly how I felt after she
finished. The classroom was totally silent. Many of us were figh
ting back tears. A classmate reached over to put
her arm around Sarah’s shoulder, a silent acknowledgement of s
upport and admiration for the courage that
Sarah had shown in sharing such a personal story. I think proba

bly everyone in that room still remembers the
moment when we each realized, “It could happen to me.”
Medical errors are not typically caused by a negligent or incom
petent healthcare professional. Instead they are
often the result of a breakdown in processes that guide delivery
of patient care (Bonney, 2014). Sarah was a
competent, careful, and caring nurse, but variances in the usual
process of care set up a situation for error.
The medication was new to Sarah and was ordered in a format t
hat led to confusion of dose versus dilution.
Medication orders should be written in clear and consistent for
mats so that the person administering the drug
can readily understand the appropriate dose. Also, the chart was
removed from the clinic setting before Sarah
had a chance to record the medication administration. Access to
the order on the medical record while
administering the medication provides an important safety chec
k to ensure the correct dose is both
administered and recorded.
Many potential and actual medical errors fall within the sphere
of nursing practice (Lachman, 2007). Thus
nurses have an ethical obligation to help prevent and manage me
dical errors. The remainder of this column will
discuss ethical principles related to medical errors for nurses to
consider, along with recommendations that can
help to shape a culture of safety for the prevention of medical er
rors.
Ethical issues related to medical errors can be categorized aroun
d four ethical principles: autonomy and right to
selfdetermination; beneficence and nonmaleficence; disclosure
and right to knowledge; and veracity (Bonney,
2014). Each of these principles will be discussed below.

Autonomy and Right to Self Determination
Concepts of autonomy and right to self determination acknowle
dge patients’ rights to make their own choices
and to take actions based on their personal views and perceived
benefits. Healthcare providers have an ethical
obligation to inform patients about their ongoing plan of care, i
ncluding if a medical error has occurred. If
Sarah had not informed others of her error, Mrs. May would not
have been able to make appropriate decisions
about the treatment that she needed as a result of the error. Heal
thcare providers are also obligated to assist
patients in making decisions, as the physician did in his care of
Mrs. May. The physician’s honest discussion
6/6/2017
place/ANAPeriodicals/OJIN/TableofContents/Vol-22-2 017/No2-
Medical Errors: Telling Your Story
Reporting Errors
with Mrs. May about the medication error and potential adverse
effects helped her to maintain trust in those
caring for her and follow their instructions for treatment so that
she could minimize harm from the error.
Beneficence and Nonmaleficence

The principles of beneficence and nonmaleficence direct healthc
are providers to do what is best for patients
and avoid harm. This may create moral conflicts for healthcare
providers in terms of balancing projected
benefits with possible risk for the patient. Although there is a ra
nge of severity in errors, they all cause harm –
to the patient, to the person who made the error, and/or to the sy
stem (Kalra, Kalra, & Baniak,
2013).Healthcare providers should take necessary steps to mini
mize the harm caused by an error. Sarah may
have thought that informing Mrs. May of the error would cause
unnecessary worry and suffering but had she
not informed others of her error, Mrs. May would not have recei
ved important treatments to offset potential
harm.
Disclosure and Right to Knowledge
Healthcare providers have an ethical obligation to disclose infor
mation that patients need for informed decision
making. The patient’s bill of rights calls for full disclosure of a
medical error (Ghazal, Saleem, & Ariani, 2014).
Fortunately, in Sarah’s situation healthcare providers disclosed
the information needed to help Mrs. May make
decisions about her care, thus respecting her autonomy and decr
easing the potential for harm. Every institution
needs clear and detailed policies for disclosure of information a
bout medical errors.
Veracity
The principle of veracity requires healthcare personnel to provi
de comprehensive, accurate, and objective
information in a manner that helps patients understand the infor
mation. Telling the truth about medical errors
helps to establish trust. Healthcare providers’ careful communic

ation with Mrs. May helped to establish a sense
of trust that can be seen in the mutual respect that Sarah and Mr
s. May shared years after the unfortunate
incident.
Communication researchers suggest that the ways healthcare pro
viders 'story' their mistake experiences can
help to understand medical errors (Noland & Carmack, 2015).
Storytelling shifts thinking from ‘rational and scientific’ pattern
s to reflective thought that calls forth a detailed
context surrounding the experience. Sarah’s story illustrates the
importance of context as she remembers why
she did not record the medication she had administered to Mrs.
May. She remembers the lump forming in her
throat when she realized her error, her fear of losing her nursing
license, her gratitude for the kindness of her
nurse manager and the physician, and the trust that Mrs. May ha
d in her healthcare providers, even after the
error. Reflective thinking helps to uncover beliefs, values, and k
nowledge embedded in the experience (Noland
& Carmack, 2015). Storying an experience of a medical error he
lps the narrator and ‘listeners’ to come to
know, understand, and make sense of the experience.
The prevention of medical errors within an organization require
s systematic management strategies.
Healthcare providers need education to understand the importan
ce of reporting medical errors. Researchers in
a study of 289 Canadian nurses working in long-term care noted
that participants had different definitions of
what constitutes harm with a medical error; their perceptions of
harm influenced whether they reported the
error (Wagner, Damianakis, Pho, & Tourangeau, 2013). Because
of busy working conditions, these nurses
prioritized which errors to report. One participant stated, “If it’s

caused no harm, it’s no big deal!” (p.3).
Participants indicated overwhelmingly that they would like to re
ceive continuing education to help them learn
how to handle the 'after effects' of error occurrence. Nurses in a
ll settings need education and training to
develop a shared definition of harm and understand the process
for reporting errors.
Although fear of litigation is often cited as a barrier to disclosur
e by healthcare providers, there is no
established link between willingness to disclose medical errors
and the risk of litigation (Bonney, 2014). Sarah’s
story revealed multiple factors that contributed to her error, suc
h as a new medication and a system event that
delayed recording the medication. The culture of the organizatio
n, however, supported 'reporting' of her error.
A 'blame culture' is a major source of medical errors (Kalra et al
., 2013). Organizations must create an
environment where healthcare providers feel supported in report
ing, disclosing, and discussing errors.
Considerable research in recent years has focused on disclosure
of medical errors but has lacked
interdisciplinary dialogue (Hannawa, Beckman, Mazor, Paul, &
Ramsey, 2013). Research is needed that
incorporates disciplinary perspectives of professionals in health
care, law, communication, and ethics to help
6/6/2017

Conclusion
Authors
References
healthcare providers understand and implement ethical practices
for prevention and management of medical
errors.
The American Nurses Association (ANA) defines a Culture of S
afety as a work culture in which healthcare
providers at all levels of the organization are committed to core
values and behaviors that emphasize safety
over competing goals (ANA, 2016). Literature related to medica
l errors suggests that most medical errors are
preventable (Bonney, 2014). The categories listed in the Box be
low reflect important ways that nurses can
contribute to prevention and management of medical errors (Nol
and & Carmack, 2015; Zikhani, 2016). As the
largest group of healthcare professionals, over 3 million strong,
registered nurses are in a unique position to
lead initiatives that promote a culture of safety (ANA, 2016).
Box. Strategies for Prevention and Management of Medical Erro
rs
Rules and Policies. Involve nurses in the development of clear a
nd detailed policies for creating a safer
environment in their organization.
Communication. Convey messages promptly and clearly. Hando
ff tools, such as SBAR or task debriefing,
are effective ways to reduce communication failures.

Checklists, Reminders, and Double Checks. Design checklists a
nd similar tools to reduce medical errors,
especially in situations where errors tend to occur.
Simplification, Standardization, and Organization. Break down
and standardize procedures and
organize care-implementation processes into simple steps.
Computerization and Automation. Identify best practices for usi
ng technologies, such as healthcare
informatics, to promote efficiency and accuracy and avoid error
s.
Forcing Function. Devise procedures that make it almost imposs
ible for errors to occur. For example,
prevent an individual from entering a wrong medication into the
computer or starting a process
without submitting a completed checklist.
Sharing Stories of Errors. Encourage students and practitioners t
o tell their stories of medical errors,
rather than hiding errors out of fear, and to listen to stories fro
m others. Knowing how others have
handled mistakes, or wish they had handled them, can help other
staff prevent and/or manage
healthcare errors.
Notes:
*Sarah and Mrs. May are pseudonyms used to protect the privac
y of individuals involved in this story.
**This story is adapted from the chapter, Do no harm, as report
ed in the book Defining moments: The courage
to be [Chapbooks]. The book was part of a class project and self

-published by Jeanne Sorrell. The copyright
date for this book is May 2001 and the copyright is held by Jean
ne Sorrell.
Jeanne Merkle Sorrell, PhD, RN, FAAN
Email: [email protected]
Jeanne Sorrell is former Senior Nurse Scientist, Nursing Resear
ch and Innovation, at the Cleveland Clinic in
Cleveland, OH, and Professor Emerita, George Mason Universit
y in Fairfax, VA. She earned a BSN from the
University of Michigan in Ann Arbor, MI, a MSN from the Univ
ersity of Wisconsin in Madison, WI, and a PhD
from George Mason University. Her scholarly interests focus on
philosophical inquiry, writing across the
curriculum, qualitative research, and ethical considerations in h
ealthcare.
American Nurses Association (ANA). (2016). American Nurses
Association calls for a culture of safety in all
health care settings. Retrieved from http://www.nursingworld.or
g/Call-for-Culture-of-Safety.html
Bonney, W. (2014). Medical errors: Moral and ethical considera
tions. Journal of Hospital Administration, 3(2),
80-88. doi:10.5430/jha.v3n2p80
Ghazal, L., Saleem, Z., & Ariani, G. (2014). A medical error: T
o disclose or not to disclose. Journal of Clinical
Research & Bioethics, 5(2). doi:10.4172/2155-9627.1000174
mailto:[email protected]
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Hannawa, A. F., Beckman, H., Mazor, K. M., Paul, N., & Ramse
y, J. V. (2013). Building bridges: Future
directions for medical error disclosure research. Patient Educati
on and Counseling, 92, 319-327. doi:
10.1016/j.pec.2013.05.017.
Kalra, J., Kalra, N., &Baniak, N. (2013). Medical error, disclos
ure and patient safety: A global view of quality
care. Clinical Biochemistry, 46, 1161-1169. doi: 10.1016/j.clinb
iochem.2013.03.025.
Lachman, V. D. (2007). Patient safety: The ethical imperative.
MEDSURG Nursing, 16(6), 401-403.
Makary, M., & Daniels, M. (2016). Medical error –
The third leading cause of death in the U.S., British Medical
Journal, 353, 1-5. doi:10.1136/bmj.i213
McMains, V. (2016). Johns Hopkins study suggests medical erro
rs are third-leading cause of death in U.S. Johns
Hopkins Magazine. Retrieved from http://hub.jhu.edu/2016/05/0
3/medical-errors-third-leading-ca use-of-death/
Noland, C. M., &Carmack, J. (2015). Narrativizing nursing stud
ents’ experiences with medical errors during
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10.1177/1049732314562892.
Nolte, E., & McKee, M. (2011). Variations in amenable mortalit
y – Trends in 16 high-income nations. Health

Policy, 103(1), 47-52. doi: 10.1016/j.healthpol.2011.08.002 Ret
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X/pdf
Wagner, L. M., Damianakis, T., Pho, L., & Tourangeau, A. (201
3). Barriers and facilitators to communicating
nursing errors in long-term care settings. Journal of Patient Safe
ty, 9(1), 1-7.
doi:10.1097/PTS.0b013e3182699919.
Zikhani, R. (2016). Seven-step pathway for preventing errors in
healthcare. Journal of Healthcare
Management, 61(4), 271-281.
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Managing ethical issues in patient care and the need
for clinical ethics support
Evan Doran1,4 BA, Grad Dip Health Soc Sci, PhD, Associate
Research Fellow
Jennifer Fleming1 BA, MHA, PhD, Postdoctoral Research
Fellow
Christopher Jordens1 BA(Hons1), MPH, PhD, Associate
Professor
Cameron L Stewart2 Bec, LLB(Hons), PhD, Professor
Julie Letts3 MBioeth, Manager, Clinical Ethics and Policy
Ian H Kerridge1 MPhil(Cantab), FRACP, FRCPA, Director
1Centre for Values, Ethics and Law in Medicine, University of
Sydney, Medical Foundation Building,
92–94 Parramatta Road, Camperdown, NSW 2006, Australia.
Email: [email protected];

[email protected]; [email protected]
2Centre for Health Governance, Law and Ethics, University of
Sydney, New Law Building, Camperdown,
NSW 2006, Australia. Email: [email protected]
3Office of the Chief Health Officer, NSW Ministry of Health,
73 Miller Street, North Sydney, NSW 2060, Australia.
Email: [email protected]
4Corresponding author. Email: [email protected]
Abstract
Objective. To investigate the range, frequency and management
of ethical issues encountered by clinicians working in
hospitals in New South Wales (NSW), Australia.
Methods. A cross-sectional survey was conducted of a
convenience sample of 104 medical, nursing and allied health
professionals in two NSW hospitals.
Results.
Somerespondentsdidnotprovidedataforsomequestions,thereforeth
edenominatorislessthan105for
some items. Sixty-two (62/104; 60%) respondents reported
occasionally to often having ethical concerns. Forty-six
(46/105;
44%) reported often to occasionally having legal concerns. The
three most common responses to concerns were: talking to
colleagues (96/105; 91%); raising the issue in a group forum
(68/105; 65%); and consulting a relevant guideline (64/105;
61%). Most respondents were highly (65/99; 66%) or
moderately (33/99; 33%) satisfied with the ethical environment
of the
hospital. Twenty-two (22/98; 22%) were highly satisfied with
the ethical environment of their department and 74 (74/98;
76%) were moderately satisfied. Most (72/105; 69%)
respondents indicated that additional support in dealing with
ethical

issues would be helpful.
Conclusion. Clinicians reported frequently experiencing ethical
and legal uncertainty and concern. They usually
managedthisbytalkingwithcolleagues.Althoughthisapproachwasc
onsideredadequate,andtheethicsoftheirhospitalwas
reported to be satisfactory, most respondents indicated that
additional assistance with ethical and legal concerns would be
helpful. Clinical ethics support should be a priority of public
hospitals in NSW and elsewhere in Australia.
Whatis knownaboutthe topic? Clinicians working in hospitalsin
theUS, Canadaand UK have accessto ethics expertise
to help them manage ethical issues that arise in patient care.
How Australian clinicians currently manage the ethical issues
they face has not been investigated.
What does this paper add? This paper describes the types of
ethical issues faced by Australian clinicians, how they
manage these issues and whether they think ethics support
would be helpful.
What are the implications for practitioners? Clinicians
frequently encounter ethically and legally difficult decisions
and want additional ethics support. Helping clinicians to
provide ethically sound patient care should be a priority of
public
hospitals in NSW and elsewhere in Australia.
Received 14 February 2014, accepted 22 September 2014,
published online 17 December 2014
Journal compilation � AHHA 2015
www.publish.csiro.au/journals/ahr
CSIRO PUBLISHING
Australian Health Review, 2015, 39, 44–50

http://dx.doi.org/10.1071/AH14034
HEALTH POLICY
Introduction
Clinical ethics support (CES) is the emerging field of theory
and practice concerned with enhancing the ethical quality or
‘ethicality’ of clinical practice within hospitals and other
health-
care institutions.1,2 ‘Ethical quality’ has several interrelated
meanings. It can mean that clinical practices are consistent with
social norms, such as patient autonomy; it can mean that ethical
conflicts over patient care are minimised or appropriately
resolved; it can mean that ‘moral distress’ among clinicians is
adequately managed; and it can mean that a health organisation
has an ethically reflective and engaged culture. With varying
emphases between individual services, these elements of ethical
quality are the main goals of CES.
CES is typically delivered by a multidisciplinary ethics com-
mittee, an individual ethicist or some combination of the two.
It aims to provide ‘expert’ ethical input into an organisation’s
policies and staff education, and assist with ethically difficult
decisions about patient care. CES was initially introduced to
help
resolve ethical dilemmas and conflict, but it has since evolved
to a more ambitious preventative model of fostering an ‘ethical

environment’, where the ethical aspects of patient care are
routinely and openly considered throughout an institution.3–5
CES services are an established feature of healthcare in the
US and Canada and are becoming so in the UK and elsewhere in
Europe and Asia.6–18 The growth of such services
internationally
is often taken to indicate a growing perceived need among
clinicians for assistance with the many ethical and legal issues
they face.14–17 Although clinicians have always faced complex
ethical decisions, the need for CES is driven by factors that
have
increased the ethical complexities of patient care, such as
greater
social andvalue plurality, technologicaladvancesand heightened
patient autonomy.19–21 Clinicians have traditionally dealt with
ethical issues by keeping their own counsel, turning to trusted
colleagues or professional codes of ethics or seeking guidance
from religious authorities.22 According to advocates of CES, it
is
no longer sufficient in a morally pluralistic world to rely on
professional opinion and codes to ensure ethically sound patient
care: ethical quality requires ethical expertise.23–26
CES services are currently available in some Australian
hospitals, but they have not been widely adopted. According
to the few available studies of such services in Australia, their
operation has contributed to better patient outcomes, clinician
satisfaction and improved ethics literacy across their host insti-
tution. 27–29 Given that observational and experimental studies
of
CES conducted in the US have also shown positive results,30–
35 it
is possible that many Australian clinicians and their patients are
missing out on valuable support. This can lead to conflict that is
avoidable orunresolved,moraluncertainty and distressandalack

of ethical scrutiny of clinical and administrative policies, pro-
cesses and decisions.
Herein we report the results of a survey that was conducted as
part of a project aimed at developing CES services within
public
hospitals in New South Wales (NSW), Australia. The project
began with a qualitative study in one NSW public hospital,
which
found that most clinicians regarded their hospital ethical envi -
ronment as ‘mostly right’, but that difficult ethical issues fre-
quently arose and clinicians were receptive to the idea of
CES.36
The aim of the survey was to build on these findings by asking
clinicians in the same hospital and an additional NSW hospital
about the ethical issues they face, the ethical environment in
which they work and whether they supported the idea of addi -
tional ethics support.
Methods
The survey
We conducted a cross-sectional survey of a convenience sample
ofclinicalstaff(medical,nursingand midwiferyandalliedhealth)
in two departments in two large NSW public hospitals. All data
were collected using a self-completed questionnaire. The ques-
tionnaire included both closed questions with fixed response
options and open-ended questions, and required, on average,
15–20 min to complete.
Respondents were asked how often they thought about the
ethical and legal implications of their clinical work, whether
they
had experienced uncertainty or concern about such issues in

specified situations during the previous 12 months, how often
they experienced uncertainty or concern about certain aspects of
patient care (e.g. aggressive treatment), their response to such
concern and the frequency and focus of discussions related to
ethical issues in their work.
Using a four-point Likert scale, we asked respondents to
indicate how strongly they agreed or disagreed with two sets of
statements. One focused on the ethical environment of their
hospital, the other on their department. Participants’ responses
toeach setofstatements were combinedto formaprimaryscale to
indicate their degree of satisfaction with these ethical environ-
ments. A total score across all items was calculated. Scores
were
divided into three equal strata: a score of 7–13 indicated low
satisfaction; a score of 14–20 indicated moderate satisfaction;
and a score of 21–28 indicated high satisfaction. To be deemed
highly satisfied, an individual would have agreed or strongly
agreed to most positively worded items. Each scale was
evaluated
using Cronbach’s a to determine whether it measured the same
underlying latent variable (i.e. degree of satisfaction).
The questionnaire also included open-ended questions asking
how clinical ethics could be improved at their hospital and
within
theirdepartment,and fixed-responsequestionsaboutexisting and
preferred means of ethics support. Demographic information
was
also solicited, including age, gender and profession.
Survey administration
Respondents could complete the survey online or as a pen-and-
paper questionnaire. The online survey was distributed via an
email from the research team that contained a hyperlink to the

questionnaire. The email assured anonymity, described the sur -
vey and provided an estimate of the time it would take to
complete. An email reminder was sent 2 weeks following the
initial mail out. The pen-and-paper questionnaire was
distributed
topotentialrespondentsinpersonbytheclinicalsupportofficeror
thenursingunitmanager.Clinicianswerealsoinvitedtocomplete
the survey at a pre-arranged meeting.
Data analysis
Data were summarised using descriptive statistics. Proportions
are shown as percentages rounded to the nearest whole number.
Responses were further analysed on the basis of gender, age,
The need for clinical ethics support Australian Health Review
45
profession and hospital. Associations were tested using Pearson
Chi-squared analysis and odds ratios (OR) with 95% confidence
intervals (CI). In some analyses, age and profession were
dichot-
omised (21–40 years vs >40 years and medical vs non-medical,
respectively). ORs are used to show significant associations,
and
we report only statistically significant associations (P � 0.05).
This study was approved by the Hunter New England Human
Research Ethics Committee (10/12/15/4.12) and the NSW Hu-
man Research Ethics Committee (HREC/10/HNE/373).
Results
From the two hospitals, 105 clinicians participated in the

survey.
The denominator is less than 105 for some items because: 1 –
answering was conditional on the basis of preceding question
(e.g. If Yes, then. . .?); and 2 – a small number of respondents
did
not provide data for some questions. Values are presented with
denominator.
Respondent characteristics are listed in Table 1.
Response rate
We were unable to determine how many clinicians received or
sighted the email invitation, or were made aware of the pen-
and-
paper survey, so were unable to calculate a response rate.
Do clinicians experience concern about ethical
and legal issues?
Over half (58/103; 56%) the respondents reported that i n the
past
12 months they had often considered the ethical implications of
their decisions, but a much smaller proportion reported having
often been uncertain or concerned about ethics (Table 2). Com-
bining ‘often’ and ‘occasionally’, over half (62/104; 60%) the
respondents reported being concerned about what is ethically
the
‘right thing to do’ and the majority (74/104; 71%) reported
being
concerned about the ethics of the decisions and actions of
others.
Respondents were also asked about the legal implications of
their decisions (Table 2). Less than half (44/104; 42%) reported
often thinking about the legal implications of their decisions.

Again, smaller numbers of respondents reported often being
uncertain or concerned. Combining ‘often’ and ‘occasional ly’,
46 (46/105; 44%) respondents reported that in the past 12
months
theyhad been concerned about what is legallythe right thing
todo
and 57 (57/105; 54%) reported being concerned about whether
what other clinicians were doing was legally right.
What situations are associated with ethical difficulties?
Respondents were given a list of situations and asked whether
they had experienced ethical and/or legal uncertainty or concern
relatedtoaparticularrelevantsituation.Experiencingbothethical
and legal uncertainty was the most commonly reported category
foreachsituation.Table3combinesthosereportingethicaland/or
legal concern in relevant situations. Concern in two situations
showed a significant difference according to age. Younger
respondents (21–40 years) were more likely to report ethical
and/or legal concern at a patient refusing recommended
treatment
than older respondents (86% vs 61%; OR 3.9, 95% CI 1.4–
11.5).
Younger respondents were less likely to report being concerned
about carrying out an advance directive (8% vs 35%; OR 0.2,
95% CI 0.3–0.9).
Respondents were asked about the specific causes for their
ethical concern or uncertainty. The most frequently indicated
cause(s) for concern were: (1) whether the patient is receiving
the
treatment they really want (63/102; 62%); (2) the quality of the
Table 1. Respondent characteristics (n = 105)
Note, seven respondents did not provide data for the first four
characteristics;

13 did not provide data for the last. Unless indicated otherwise,
data show the
number of respondents in each group
Age (years)
Mean ± s.e.m. 43 ± 1
Range 21–70+
Years in profession
Mean 16.5 ± 1.2
Range 1–40+
Gender
Female 81
Male 17
Occupation
Medical 32
Nursing 45
Allied health 21
Area of employment
Oncology 30
Midwifery 23
Haematology 23
Obstetrics and gynaecology 10
MFM 2
Neonatology 1
Palliative care 1
Other 2
Table 2. Frequency of ethical uncertainty and concern
Data show the number of respondents in each group, with
percentages in parentheses

How often do you face a clinical situation where. . . Often
Occasionally Rarely Never
Ethical
. . .you will think about the ethical implications of your clinical
decisions 58 (56%) 36 (33%) 9 (9%) 0
. . .you are uncertain or concerned about what is ethically the
right thing to do 13 (12%) 49 (47%) 41 (39%) 1 (1%)
. . .you are uncertain or concerned about the ethics of the
decisions and actions of others 13 (12%) 61 (58%) 29 (28%) 1
(1%)
Legal
. . .you will think about the legal implications of your clinical
decisions 44 (42%) 34 (33%) 18 (17%) 8 (8%)
. . .you are uncertain or concerned about what is legally the
right thing to do? 12 (11%) 34 (32%) 47 (45%) 12 (11%)
. . .you are uncertain or concerned whether what others are
doing is legally right? 8 (8%) 49 (47%) 40 (38%) 8 (8%)
46 Australian Health Review E. Doran et al.
information the patient is being given, and how (62/103; 60%);
(3) whether the treatment is too aggressive (59/102; 58%);
(3) beingrestricted by resources in providing the care or
treatment
it was believed a patient needs (57/102; 56%); (4) patient pre-
ferences and whether choice is being respected (52/102; 49%);
(5) concern that the personal values of clinical staff may be
inappropriately influencing patient care (27/100; 27%); and
(6) concern regarding the appropriateness and quality of care
generally (22/101; 22%). There were no significant differences
according to gender, age, profession or hospital.

What are the most common ways of dealing
with ethical difficulties?
Respondents were asked what they do when they are uncertain
or
concerned about the ethical implications of a clinical situation.
Most (96/105; 91%) indicated they would ask for the opinions
of
colleagues; approximately two-thirds indicated they would raise
the issue in a group forum (68/105; 65%) or consult a relevant
guideline (64/105; 61%); 39 (39/105; 37%) indicated they
would
meet with the patient and/or family and allow them to decide;
29
(29/105; 28%) indicated they would consult with a clinical
ethics
committee or other source of ethics expertise; and 23 (23/105;
22%) indicated they would discuss the situation with their
partner
or close friend. There were no significant differences according
to
gender, age, profession or hospital.
What is the perceived adequacy of current ways
of dealing with ethical difficulties?
Respondents were asked ‘How often is what you usually do not
helpful in addressing your uncertainty or concern?’. Sixty-nine
(69/105; 66%) respondents indicated that their actions were
‘never’ or ‘rarely’ helpful, 18 (18/105; 17%) indicated that their
actions were ‘occasionally’ helpful and four (4/105; 4%)
reported
that their actions were ‘always’ helpful.
How do clinicians evaluate the ethical environment
of their hospital?

Respondents were asked to agree or disagree with set of state-
ments about their hospital. As indicated in Table 4, a large
majority of respondents agreed to strongly agreed with the
positive statements and disagreed with the single negative state-
ment (‘This hospital is too ready to accede to external politica l
demands’). The statements were scaled and a summary score
estimating the individual’s satisfaction with the ethics of their
hospital was derived (see Methods). The scale was evaluated
using Cronbach’s a (0.87). Sixty-five (65/99; 66%) respondents
indicated they were highly satisfied with the ethical
environment
of the hospital, whereas 33 (33/99; 33%) indicated moderate
satisfaction. Only one respondent indicated low satisfaction.
There were no significant differences between medical and
non-medical respondents or according to hospital.
How do clinicians evaluate the ethical environment
of their department?
Respondents were asked to indicate their agreement with a set
of
statements about their department (Table 4). The ethical envi -
ronment of the department was also explored by scaling the
statements and by estimating individual respondent satisfaction.
The scale was evaluated using Cronbach’s a (0.82). Twenty-two
respondents (22/98; 22%) indicated they were highly satisfied
with the ethical environment of their department and 74 (74/98;
76%) indicated moderate satisfaction.Two respondents indicated
low satisfaction. There were no significant differences between
medical and non-medical respondents or according to hospital.
Do clinicians indicate a need for clinical ethical support?
Respondents were asked whether they believed that clinicians

are
usually comfortable handling the more common clinical situa-
tions involving ethical issues. Most (71/105; 68%) answered
‘Yes’; nine (9%) answered ‘No’ and 17 (16%) answered ‘Don’t
know’. When they were asked ‘Are there some ethically
complex
or challenging situations where more support might be helpful?’
most (72/105; 69%) responded ‘Yes’. These respondents were
then asked to identify what they felt may be helpful.
What types of support are preferred?
Table 5 shows what types of support respondents indicated
would be most helpful. The three most commonly preferred
Table 3. Proportion of respondents reporting uncertainty or
concern in relevant situations
In the past 12 months did you experience uncertainty or concern
related
to the following situations?
Yes (ethically,
legally or both)
Neither
A patient refusing recommended treatment 67 (73%) 25 (27%)
Disagreement among staff about care or treatment 61 (70%) 26
(30%)
A patient requesting treatment of borderline necessity or benefit
58 (69%) 26 (31%)
Ordering and/or participating in aggressive treatment of a
terminally ill patient 40 (62%) 24 (38%)

A patient requesting treatment outside hospital guidelines 49
(60%) 33 (40%)
The handling of a medical error or incident 53 (58%) 39 (42%)
Making the decision to withdraw or withhold treatment 25
(43%) 33 (57%)
A request for late termination of pregnancy 18 (43%) 24 (57%)
A patient request to withhold information from his/her family
36 (42%) 49 (58%)
A family request to withhold information from a patient 30
(37%) 51 (63%)
Staff withholding information from a patient and/or family 19
(24%) 60 (76%)
Carrying out an Advanced Directive 12 (21%) 44 (79%)
Carrying out a Do Not Resuscitate order 11 (20%) 43 (80%)
47
types of support were protocols and guidelines (44/72; 61%),
having ethics or legal issues covered in routine clinical
meetings
(42/72; 58%) and having an ethics or legal expert available for
advice (39/72; 54%).
Discussion
Most of the clinicians surveyed for this study were sometimes
to
often troubled by the ethical and legal implications of their own
clinicaldecisionsandthoseoftheircolleagues.Respondentswere
most concerned about situations that are known to be ethically
and legally sensitive, such as end-of-life care, medical errors
and
patient privacy.37–42 Patient autonomy appeared to be the most

common source of concern. The five situations that were most
commonly reported to be troubling were (in rank order) a
patient
refusing recommended treatment, disagreement among staff,
a patient requesting a treatment of uncertain value, aggressive
treatment of a terminally ill patient and a patient requesting
treatment outside hospital guidelines. The first, third and last of
these situations are related to managing patient preferences and
choice.Patientautonomywasalsoprominentinwhatrespondents
indicated were the specific causes of their uncertainty and con-
cern: whether the care a patient is receiving is really what the
patient wants, concern about the information a patient is being
given and concern about patient preferences being respected and
staff inappropriately influencing care.
The majority of respondents appeared to be satisfied with the
ethical environment of their hospital and their department. At
the
hospital level, most respondents indicated being highly satisfied
that policies and procedures were ethically appropriate;
patients’
interests generally have priority and the values upheld at the
hospital mostly reflected their own personal and professional
values. Although fewer clinicians indicated being as highly
satisfied with their department as they were with the hospital,
most still indicated a general satisfaction with the ethics of their
department and that ethical issues are attended to appropriately,
openly and inclusively.
Most respondents indicated that they were generally comfort-
able dealing with the ethical issues they face and, similar to the
findingsofotherstudies,6,42 whentheyareuncertainorconcerned
Table 4. Respondents’ degree of satisfaction with the ethical
environment of their hospital and department

Statement Strongly agree Agree Disagree Strongly
disagree
Hospital
The policies and procedures of this hospital are generally
ethically appropriate 19 (19%) 76 (76%) 5 (5%) –
The interests of this hospital are rarely put before the interests
of the patient 14 (14%) 55 (56%) 27 (28%) 2 (2%)
Patients at this hospital are generally treated equally 23 (23%)
67 (68%) 8 (8%) 1 (1%)
The values upheld at this hospital mostly reflect my
professional values 14 (14%) 79 (80%) 5 (5%) 1 (1%)
The values upheld at this hospital mostly reflect my personal
values 12 (12%) 78 (79%) 8 (8%) 1 (1%)
My conscience is rarely troubled by the care patients receive at
this hospital 9 (9%) 79 (80%) 10 (10%) 1 (1%)
The values upheld at this hospital mostly reflect values of the
community 10 (10%) 71 (73%) 16 (16%) –
This hospital is too ready to accede to external political
demands 4 (4%) 43 (47%) 42 (46%) 3 (5%)
Department
When an ethical issue arises it will be openly discussed 24
(24%) 67 (68%) 7 (7%) –
If I am concerned that a patient’s best interest isn’t being met I
am able to air my view 23 (23%) 68 (69%) 6 (6%) 1 (1%)
Ethical issues are usually handled appropriately 18 (18%) 77
(79%) 3 (3%)
Ethical issues are often overlooked 1 (1%) 14 (14%) 73 (75%) 9
(9%)
We talk about ethics as much as is necessary 8 (8%) 72 (74%)
17 (18%) –
We could handle ethics issues better than we currently do 2

(2%) 47 (49%) 47 (49%) –
If an ethical issues arises all staff are able to voice their view 9
(9%) 67 (70%) 19 (20%) 1 (1%)
There should be more discussion of the ethical aspects of our
clinical practices 11 (12%) 54 (57%) 29 (31%) 1 (1%)
Table 5. Types of support respondents believed would be most
helpful
Types of support believed to be helpful with ethically complex
or challenging situations n = 72
Having protocols/guidelines in place that outline appropriate
responses to ethical/legal issues 44 (61%)
Having ethical/legal issues as a routine element of grand rounds
or morbidity and mortality meetings 42 (58%)
Having an individual ethics and/or legal expert available for
advice 41 (57%)
More ‘in-service’ training or education on the ethics and law of
patient care 39 (54%)
Having regular educational seminars on ethics and law 37 (51%)
Having a member(s) of the clinical team trained in ethics who
can provide ethical advice when needed 37 (51%)
Having an advisory group (made of clinicians, lawyers,
ethicists, patient representative) 34 (47%)
Having an internet based resource (storing relevant literature,
case studies, policies etc.) 33 (46%)
they are most likely to talk to their colleagues. Raising an issue
of concern at a group forum was also commonly reported, as

was consulting a relevant guideline. Although these actions
were
generally considered helpful, over two-thirds of respondents
indicated that additional clinical ethics or legal support would
behelpful.Protocolsandguidelines,havingclinicalethicsfeature
in routine clinical meetings, continuing education and training
and having an individual clinical ethics or legal expert available
for advice appeared to be most preferred options for further
support. A clinical ethics committee was among the least pre-
ferred options.
Although talking to colleagues or consulting a relevant guide-
line or policy can help address ethical uncertainty or concern, it
does indicate that clinicians are largely relying on traditional
approaches to dealing with ethical issues. As discussed in the
Introduction, these approaches are increasingly considered inad-
equateforensuringethicalqualityinthecontextofamoresocially
and morally diverse contemporary society. Given that the social
factors that make clinical work more ethically and legally com-
plex are evident in Australia, the scarcity of CES means most
Australian clinicians are currently left to navigate their way
through complex ethical issues with little specialised support.
Ethical tensions and difficulties that may arise anywhere in a
hospital (from the bedside to the boardroom) are not always
recognised and acted on as such and, even where recognised,
may
be considered too hard and avoided. Left unrecognised or over-
looked, ethical issues can block communication, create uncer -
tainty or distress about treatment goals and ultimately
undermine
qualitycare.Aclinicalethicssupportserviceprovidingassistance
with policy development, staff education and difficult cases can
foster an ethically aware environment where issues are
addressed
and uncertainty and distress minimised.

Clinician satisfaction with the ethical environment does not
indicate that ethical quality is consistently achieved. As one
prominent clinical ethicist has observed: ‘Doctors and other
healthcare professionals are seldom widely educated in ethics,
and no matter the length of their experience, they are by no
means
guaranteed to have ‘ethical perspicacity’.’43 The majority of
the
clinicians we surveyed appeared to recognise this by indicating
that additional support would be helpful in working through
ethical and legal concerns that face themin their day-to-day
work.
Limitations
Responses to this survey were drawn from a non-random sample
in which female respondents were clearly over-represented.
The findings are also susceptible to social desirability bias (i.e.
respondents may have tended to provide what they saw as the
most socially appropriate response, instead of what they truly
believe). These considerations reduce the generalisability of the
findings.
Conclusion
The results of our survey support our qualitative findings
reported
elsewhere,36 namely that most clinicians see the ethical
environ-
ment of their hospital and department as ‘mostly right’, that
troubling ethical and legal issues frequently arise and that,
although these are considered to be generally adequately man-
aged, further support in dealing with these issues would be
welcome. CES can take the form of an individual clinical

ethicist,
a multidisciplinary clinical ethics committee or a hybrid of the
two.Whichtypeofsupportisthemostsuitableandwhatfunctions
(e.g. case consultation) should be undertaken are questions that
require further investigation. Helping clinicians to provide eth-
ically sound patient care should be a priority of public hospitals
in
NSW and elsewhere in Australia.
Competing interests
The authors declare no competing interests.
Acknowledgements
This study was funded by the NSW Ministry of Health. The
authors acknow-
ledge the support of the Clinical Ethics Capacity Building
Project Reference
Group:MrTerryClout,DrJoMitchell,DrPeterSaul,MsSarahThackw
ayand
Professor William Walters.
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