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

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