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Halvorsen K, Jensen JF, Collet MO, Olausson S, Lindahl B, Saetre Hansen B, Lind R, Eriksson T. Patients' experiences of well-being when being cared for in the intensive care unit-An integrative review. J Clin Nurs 2021; 31:3-19. [PMID: 34159663 DOI: 10.1111/jocn.15910] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 05/14/2021] [Accepted: 05/21/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of this integrative review was to identify facilitators and barriers to patients' well-being when being cared for in an ICU setting, from the perspective of the patients. BACKGROUND To become critically ill and hospitalised in an ICU is a stressful, chaotic event due to the life-threatening condition itself, as well as therapeutic treatments and the environment. A growing body of evidence has revealed that patients often suffer from physical, psychological and cognitive problems after an ICU stay. Several strategies, such as sedation and pain management, are used to reduce stress and increase well-being during ICU hospitalisation, but the ICU experience nevertheless affects the body and mind. DESIGN; METHODS: Since research exploring patients' sense of well-being in an ICU setting is limited, an integrative review approach was selected. Searches were performed in CINAHL, Medline, Psych Info, Eric and EMBASE. After reviewing 66 studies, 12 studies were included in the integrative review. Thematic analysis was used to analyse the studies. The PRISMA checklist for systematic reviews was used. RESULTS The results are presented under one main theme, 'Well-being as a multidimensional experience-interwoven in barriers and facilitators' and six sub-themes representing barriers to and facilitators of well-being in an ICU. Barriers identified were physical stressors, emotional stressors, environmental disturbances and insecurity relating to time and space. Facilitators were meeting physical needs and activities that included dimensions of a caring and relational environment. CONCLUSION Our main findings were that experiences of well-being were multidimensional and included physical, emotional, relational and environmental aspects, and they were more often described through barriers than facilitators of well-being. RELEVANCE FOR CLINICAL PRACTICE This integrative review has shown that it is necessary to adopt an individual focus on patient well-being in an ICU setting since physical, emotional, relational and environmental stressors might impact each patient differently.
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Affiliation(s)
| | - Janet F Jensen
- Department of Anesthesiology, Holbaek Hospital, Holbaek, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Marie O Collet
- Intensive Department, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sepideh Olausson
- Institute of Health and Care Sciences, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Berit Lindahl
- Department of Health Sciences and the Institute for Palliative Care, Medical Falucty Lund University, Lund, Sweden.,Faculty of Caring Sciences, Work Life and Social Welfare, Borås University, Borås, Sweden
| | - Britt Saetre Hansen
- Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Ranveig Lind
- Department of Health and Care Sciences, The Arctic University of Norway, Harstad, Norway.,Research Nurse at Intensive Care Unit, University Hospital of North Norway, Tromsø, Norway
| | - Thomas Eriksson
- Faculty of Caring Sciences, Work Life and Social Welfare, Borås University, Borås, Sweden
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Jensen HI, Halvorsen K, Jerpseth H, Fridh I, Lind R. Practice Recommendations for End-of-Life Care in the Intensive Care Unit. Crit Care Nurse 2021; 40:14-22. [PMID: 32476029 DOI: 10.4037/ccn2020834] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
TOPIC A substantial number of patients die in the intensive care unit, so high-quality end-of-life care is an important part of intensive care unit work. However, end-of-life care varies because of lack of knowledge of best practices. CLINICAL RELEVANCE Research shows that high-quality end-of-life care is possible in an intensive care unit. This article encourages nurses to be imaginative and take an individual approach to provide the best possible end-of-life care for patients and their family members. PURPOSE OF PAPER To provide recommendations for high-quality end-of-life care for patients and family members. CONTENT COVERED This article touches on the following domains: end-of-life decision-making, place to die, patient comfort, family presence in the intensive care unit, visiting children, family needs, preparing the family, staff presence, when the patient dies, after-death care of the family, and caring for staff.
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Affiliation(s)
- Hanne Irene Jensen
- Hanne Irene Jensen is an associate professor at the Department of Anaesthesiology and Intensive Care, Vejle and Middelfart Hospitals, Vejle, Denmark, and the University of Southern Denmark, Odense, Denmark
| | - Kristin Halvorsen
- Kristin Halvorsen is a professor and researcher and Heidi Jerpseth is an associate professor and researcher at Oslo Metropolitan University, Faculty of Health Sciences, Oslo, Norway
| | - Heidi Jerpseth
- Kristin Halvorsen is a professor and researcher and Heidi Jerpseth is an associate professor and researcher at Oslo Metropolitan University, Faculty of Health Sciences, Oslo, Norway
| | - Isabell Fridh
- Isabell Fridh is an associate professor at the Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Sweden
| | - Ranveig Lind
- Ranveig Lind is an associate professor at UiT, the Arctic University of Norway, and a research nurse in the intensive care unit at University Hospital of North Norway, Tromsø, Norway
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Abstract
There is no agreed minimum standard with regard to what is considered safe, competent nursing care. Limited resources and organizational constraints make it challenging to develop a minimum standard. As part of their everyday practice, nurses have to ration nursing care and prioritize what care to postpone, leave out, and/or omit. In developed countries where public healthcare is tax-funded, a minimum level of healthcare is a patient right; however, what this entails in a given patient's actual situation is unclear. Thus, both patients and nurses would benefit from the development of a minimum standard of nursing care. Clarity on this matter is also of ethical and legal concern. In this article, we explore the case for developing a minimum standard to ensure safe and competent nursing care services. Any such standard must encompass knowledge of basic principles of clinical nursing and preservation of moral values, as well as managerial issues, such as manpower planning, skill-mix, and time to care. In order for such standards to aid in providing safe and competent nursing care, they should be in compliance with accepted evidence-based nursing knowledge, based on patients' needs and legal rights to healthcare and on nurses' codes of ethics. That is, a minimum standard must uphold a satisfactory level of quality in terms of both professionalism and ethics. Rather than being fixed, the minimum standard should be adjusted according to patients' needs in different settings and may thus be different in different contexts and countries.
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Affiliation(s)
| | - Anne Scott
- National University of Ireland Galway, Ireland
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Mandal L, Seethalakshmi A, Rajendrababu A. Rationing of nursing care, a deviation from holistic nursing: A systematic review. Nurs Philos 2019; 21:e12257. [DOI: 10.1111/nup.12257] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 04/30/2019] [Accepted: 05/02/2019] [Indexed: 01/23/2023]
Affiliation(s)
- Lata Mandal
- Faculty of Nursing Sri Ramachandra Institute of Higher Education and Research Chennai India
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Suhonen R, Stolt M, Habermann M, Hjaltadottir I, Vryonides S, Tonnessen S, Halvorsen K, Harvey C, Toffoli L, Scott PA. Ethical elements in priority setting in nursing care: A scoping review. Int J Nurs Stud 2018; 88:25-42. [PMID: 30179768 DOI: 10.1016/j.ijnurstu.2018.08.006] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 07/04/2018] [Accepted: 08/13/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Nurses are often responsible for the care of many patients at the same time and have to prioritise their daily nursing care activities. Prioritising the different assessed care needs and managing consequential conflicting expectations, challenges nurses' professional and moral values. OBJECTIVE To explore and illustrate the key aspects of the ethical elements of the prioritisation of nursing care and its consequences for nurses. DESIGN, DATA SOURCES AND METHODS A scoping review was used to analyse existing empirical research on the topics of priority setting, prioritisation and rationing in nursing care, including the related ethical issues. The selection of material was conducted in three stages: research identification using two data bases, CINAHL and MEDLINE. Out of 2024 citations 25 empirical research articles were analysed using inductive content analysis. RESULTS Nurses prioritised patient care or participated in the decision-making at the bedside and at unit, organisational and at societal levels. Bedside priority setting, the main concern of nurses, focused on patients' daily care needs, prioritising work by essential tasks and participating in priority setting for patients' access to care. Unit level priority setting focused on processes and decisions about bed allocation and fairness. Nurses participated in organisational and societal level priority setting through discussion about the priorities. Studies revealed priorities set by nurses include prioritisation between patient groups, patients having specific diseases, the severity of the patient's situation, age, and the perceived good that treatment and care brings to patients. The negative consequences of priority setting activity were nurses' moral distress, missed care, which impacts on both patient outcomes and nursing professional practice and quality of care compromise. CONCLUSIONS Analysis of the ethical elements, the causes, concerns and consequences of priority setting, need to be studied further to reveal the underlying causes of priority setting for nursing staff. Prioritising has been reported to be difficult for nurses. Therefore there is a need to study the elements and processes involved in order to determine what type of education and support nurses require to assist them in priority setting.
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Affiliation(s)
- Riitta Suhonen
- University of Turku, Department of Nursing Science, Turku University Hospital, and City of Turku, Welfare Division, Turku, Finland.
| | - Minna Stolt
- University of Turku, Department of Nursing Science, Turku University Hospital, Turku, Finland.
| | | | - Ingibjörg Hjaltadottir
- University of Iceland, Clinical Nurse Specialist, University Hospital of Iceland, Iceland.
| | - Stavros Vryonides
- Cyprus University of Technology, School of Health Sciences, Department of Nursing, Limassol, Cyprus.
| | | | | | - Clare Harvey
- Central Queensland University Australia, School of Nursing, Midwifery and Social Sciences, Tertiary Education Division, Mackay, Australia.
| | - Luisa Toffoli
- School of Nursing and Midwifery, University of South Australia, Australia.
| | - P Anne Scott
- National University of Ireland Galway, Galway, Ireland.
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Scott PA, Harvey C, Felzmann H, Suhonen R, Habermann M, Halvorsen K, Christiansen K, Toffoli L, Papastavrou E. Resource allocation and rationing in nursing care: A discussion paper. Nurs Ethics 2018; 26:1528-1539. [PMID: 29607703 PMCID: PMC6681425 DOI: 10.1177/0969733018759831] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Driven by interests in workforce planning and patient safety, a growing body of literature has begun to identify the reality and the prevalence of missed nursing care, also specified as care left undone, rationed care or unfinished care. Empirical studies and conceptual considerations have focused on structural issues such as staffing, as well as on outcome issues - missed care/unfinished care. Philosophical and ethical aspects of unfinished care are largely unexplored. Thus, while internationally studies highlight instances of covert rationing/missed care/care left undone - suggesting that nurses, in certain contexts, are actively engaged in rationing care - in terms of the nursing and nursing ethics literature, there appears to be a dearth of explicit decision-making frameworks within which to consider rationing of nursing care. In reality, the assumption of policy makers and health service managers is that nurses will continue to provide full care - despite reducing staffing levels and increased patient turnover, dependency and complexity of care. Often, it would appear that rationing/missed care/nursing care left undone is a direct response to overwhelming demands on the nursing resource in specific contexts. A discussion of resource allocation and rationing in nursing therefore seems timely. The aim of this discussion paper is to consider the ethical dimension of issues of resource allocation and rationing as they relate to nursing care and the distribution of the nursing resource.
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Affiliation(s)
| | | | | | - Riitta Suhonen
- University of Turku, Turku University Hospital and City of Turku Welfare Division, Finland
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Koksvik GH. Medically Timed Death as an Enactment of Good Death: An Ethnographic Study of Three European Intensive Care Units. OMEGA-JOURNAL OF DEATH AND DYING 2018; 81:66-79. [PMID: 29402160 DOI: 10.1177/0030222818756555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The article is based on ethnographic observation and semistructured interviews with personnel in three European adult intensive care units. Intensive care is a domain of contemporary biomedicine centered on invasive and intense efforts to save lives in acute, critical conditions. It echoes our culture's values of longevity. Nevertheless, mortality rates are elevated. Many deaths follow from nontreatment decisions. Medicalized dying in technological medical settings are often presented as unnatural, impersonal, and undesirable ways of dying. How does this affect the way in which death is experienced by intensive care professionals? What might the enactment of dying in intensive care reveal about our cultural values of good and bad dying?
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Affiliation(s)
- Gitte H Koksvik
- Department of Interdisciplinary Studies of Culture, Norwegian University of Science and Technology, Trondheim, Norway
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Vryonides S, Papastavrou E, Charalambous A, Andreou P, Merkouris A. The ethical dimension of nursing care rationing: A thematic synthesis of qualitative studies. Nurs Ethics 2014; 22:881-900. [PMID: 25367000 DOI: 10.1177/0969733014551377] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND In the face of scarcity, nurses may inevitably delay or omit some nursing interventions and give priority to others. This increases the risk of adverse patient outcomes and threatens safety, quality, and dignity in care. However, it is not clear if there is an ethical element in nursing care rationing and how nurses experience the phenomenon in its ethical perspective. OBJECTIVES The purpose was to synthesize studies that relate care rationing with the ethical perspectives of nursing, and find the deeper, moral meaning of this phenomenon. RESEARCH DESIGN A systematic review and thematic synthesis of qualitative studies was used. Searching was based on guidelines suggested by Joana Brigs Institute, while the synthesis has drawn from the methodology described. Primary studies were sought from nine electronic databases and manual searches. The explicitness of reporting was assed using consolidated criteria for reporting qualitative research. Nine studies involving 167 nurse participants were included. Synthesis resulted in 35 preliminary themes, 14 descriptive themes, and four analytical themes (professional challenges and moral dilemmas, dominating considerations, perception of a moral role, and experiences of the ethical effects of rationing). Discussion of relationships between themes revealed a new thematic framework. ETHICAL CONSIDERATION Every effort has been taken, for the thoroughness in searching and retrieving the primary studies of this synthesis, and in order for them to be treated accurately, fairly and honestly and without intentional misinterpretations of their findings. DISCUSSION Within limitations of scarcity, nurses face moral challenges and their decisions may jeopardize professional values, leading to role conflict, feelings of guilt, distress and difficulty in fulfilling a morally acceptable role. However, more research is needed to support certain relationships. CONCLUSIONS Related literature is limited. The few studies found highlighted the essence of justice, equality in care and in values when prioritizing care-with little support to the ethical effects of rationing on nurses. Further research on ethical dimension of care rationing may illuminate other important aspects of this phenomenon.
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Abstract
Introduction: We discuss Carol Gilligan's original concept of mature care in the light of the altruistic approach to caring and good clinical judgment. Discussion: In particular, we highlight how the concept of mature care can capture important challenges in today's nursing. Further, we illuminate how mature care might differ normatively from an altruistic approach to caring and the traditional prudential virtues in nursing. We also discuss similarities between mature care and virtue ethics. Conclusion: For nursing and nurses' identity, in today's health care system that is increasingly pressured to ‘produce' health, we believe it is important to both developing further theories on mature care and having normative discussions about care.
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HOEL H, SKJAKER SA, HAAGENSEN R, STAVEM K. Decisions to withhold or withdraw life-sustaining treatment in a Norwegian intensive care unit. Acta Anaesthesiol Scand 2014; 58:329-36. [PMID: 24405518 DOI: 10.1111/aas.12246] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND To withhold and withdraw treatment are important and difficult decisions made in the intensive care unit (ICU). The aim of this study was to investigate the incidence of withholding or withdrawing treatment, characteristics of the patients, and how these decision processes were handled and documented in a general ICU from 2007 to 2009 in a university hospital in Norway. METHODS Patient characteristics and outcomes of treatment were prospectively registered. We retrospectively reviewed the medical records for information on limitations in treatment. RESULTS In total, 1287 patients were admitted to the ICU. The ICU mortality was 208 (16%), and the hospital mortality was 341 (26%). In total, 301 patients (23%) had treatment withheld or withdrawn. Medical and unscheduled surgical patients with limitations in treatment had higher Simplified Acute Physiology Score II (P < 0.001) and were older (P < 0.001) than those without limitations in treatment. The most common main reason for withdrawing treatment was poor prognosis. According to the medical records, the patient was involved in the decision-making regarding withdrawal of treatment in only 2% of the cases, and the patient's relatives were involved in the decision-making in 77% of the cases. In 12% of the cases, type of treatment withdrawn was not documented. CONCLUSION Withholding or withdrawing treatment in the ICU was common. Medical and unscheduled surgical patients with limitations in treatment were older and more severely ill than patients without limitations. There is a potential for better documentation of the processes regarding withholding or withdrawing life-sustaining intensive care treatment.
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Affiliation(s)
- H. HOEL
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - S. A. SKJAKER
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - R. HAAGENSEN
- Department of Anaesthesiology; Akershus University Hospital; Akershus Norway
| | - K. STAVEM
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
- Department of Pulmonary Medicine; Medical Division; Akershus University Hospital; Akershus Norway
- Health Services Research Unit; Akershus University Hospital; Akershus Norway
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"Values that vanish into thin air": nurses' experience of ethical values in their daily work. Nurs Res Pract 2013; 2013:939153. [PMID: 24024030 PMCID: PMC3760096 DOI: 10.1155/2013/939153] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Revised: 07/08/2013] [Accepted: 07/11/2013] [Indexed: 11/18/2022] Open
Abstract
The objective of this study was to examine how nurses experience ethical values as they are expressed in daily practice in a Norwegian hospital. A growing focus in Western healthcare on effectiveness, production, and retrenchment has an influence on professional nursing standards and nursing values. Lack of resources and subsequent ethically difficult prioritizations imply a strain on nurses. This study is qualitative. Data collection was carried out by conducting 4 focus group interviews. The data was analyzed using content analysis. The results are presented in two main themes: (1) values and reflection are important for the nurses; (2) time pressure and nursing frustrations in daily work. The results demonstrate that nurses believe the ethical values to be of crucial importance for the quality of nursing; however, the ethical values are often repressed in daily practice. This results in feeling of frustration, fatigue, and guilty conscience for the nurses. There is a need for changes in the system which could contribute to the development of a caring culture that would take care of both patients and nurses. In an endeavour to reach this goal, one could apply caritative leadership theory, which is grounded on the caritas motive, human love, and mercy.
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Papastavrou E, Andreou P, Efstathiou G. Rationing of nursing care and nurse-patient outcomes: a systematic review of quantitative studies. Int J Health Plann Manage 2013; 29:3-25. [DOI: 10.1002/hpm.2160] [Citation(s) in RCA: 144] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 11/21/2012] [Accepted: 12/06/2012] [Indexed: 11/11/2022] Open
Affiliation(s)
- Evridiki Papastavrou
- School of Health Sciences, Department of Nursing; Cyprus University of Technology; Cyprus
| | - Panayiota Andreou
- School of Health Sciences, Department of Nursing; Cyprus University of Technology; Cyprus
| | - Georgios Efstathiou
- School of Health Sciences, Department of Nursing; Cyprus University of Technology; Cyprus
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Papastavrou E, Andreou P, Tsangari H, Schubert M, De Geest S. Rationing of Nursing Care Within Professional Environmental Constraints. Clin Nurs Res 2013; 23:314-35. [DOI: 10.1177/1054773812469543] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this study was to examine rationing of nursing care and the possible relationship between nurses’ perceptions of their professional practice environment and care rationing. A total of 393 nurses from medical and surgical units participated in the study. Data were collected using the Basel Extent of Rationing of Nursing Care (BERNCA) instrument and the Revised Professional Practice Environment (RPPE) Scale. The highest level of rationing was reported for “reviewing of patient documentation” ( M = 1.15, SD = 0.94; 31.2% sometimes or often) followed by “oral and dental hygiene” ( M = 1.06, SD = 0.94; 31.5% sometimes or often) and “coping with the delayed response of physicians” ( M = 1.04, SD = 0.96; 30% sometimes or often). Regression analyses showed that teamwork, leadership and autonomy, and communication about patients accounted in total 18.4% of the variance in rationing. In regard to application, the association between the practice environment and rationing suggests improvements in certain aspects that could minimize rationing.
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Fernandes MID, Moreira IMPB. Ethical issues experienced by intensive care unit nurses in everyday practice. Nurs Ethics 2012; 20:72-82. [PMID: 22918059 DOI: 10.1177/0969733012452683] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This research aims to identify the ethical issues perceived by intensive care nurses in their everyday practice. It also aims to understand why these situations were considered an ethical issue and what interventions/strategies have been or are expected to be developed so as to minimize them. Data were collected using a semi-structured interview with 15 nurses working at polyvalent intensive care units in 4 Portuguese hospitals, who were selected by the homogenization of multiple samples. The qualitative content analysis identified end-of-life decisions, privacy, interaction, team work, and health-care access as emerging ethical issues. Personal, team, and institutional aspects emerge as reasons behind the experience of these issues. Personal and team resources are used in and for solving these issues. Moral development and training are the most significant strategies.
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Affiliation(s)
- Maria I D Fernandes
- Department of Medical-Surgical Nursing, Nursing School of Coimbra, Portugal.
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Nordhaug M, Nortvedt P. Mature care in professional relationships and health care prioritizations. Nurs Ethics 2011; 18:209-16. [DOI: 10.1177/0969733010389257] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This article addresses some ambiguities and normative problems with the concept of mature care in professional relationships and in health care priorities. Mature care has recently been introduced in the literature on care ethics as an alternative to prevailing altruistic conceptions of care. The essence of mature care is an emphasis on reciprocity, where the mature agent has the ability to balance the concerns of self with those of others and act from a principle of not causing harm. Our basic claim is that the prevailing concept of mature care does not capture the real nature of professional relationships and role obligations in health care. As the focus of attention in professional care is and must be the patient’s particular medical and care needs, such care must principally be altruistic. Furthermore, we argue that mature care cannot adequately address moral conflict in health care without accepting some more principle-based approaches and a richer notion of partiality.
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Abstract
PURPOSE OF REVIEW Critical care medicine (CCM) is expensive. CCM costs have continued to rise since they were first calculated in the 1970s. By 2005, CCM costs in the US were estimated to be $81.7 billion accounting for 13.4% of hospital costs, 4.1% of the national health expenditures and 0.66% of the gross domestic product. RECENT FINDINGS This review first addresses the methodology and inherent limitations of calculating global CCM costs using the Russell equation and the challenges of defining critical care in the US when universal definitions of intensive care unit (ICU) bed types do not exist. Studies and concepts recently put forth to control CCM costs are then discussed. These include rationing ICU care, caring for patients in non-ICU locations, regionalizing care, changing the ICU workforce, imposing care protocols and bundles, and adjusting long-term ICU traditions. Many of these programs have benefits but may also have unintended expenses. Even documenting ICU costs themselves may be quite challenging as costs are frequently shifted between the ICU and its supporting clinical and hospital services. SUMMARY Cost containment is difficult to attain in critical care as the programs proposed to achieve cost control may be so pricey, that potential cost savings are offset. Some CCM cost saving methodologies may benefit patient care, whereas others may be detrimental to society. CCM cost containment may prove as illusory in the future as it has been in the past.
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Halvorsen K, Førde R, Nortvedt P. Value choices and considerations when limiting intensive care treatment: a qualitative study. Acta Anaesthesiol Scand 2009; 53:10-7. [PMID: 19032565 DOI: 10.1111/j.1399-6576.2008.01793.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND To shed light on the values and considerations that affect the decision-making processes and the decisions to limit intensive care treatment. METHOD Qualitative methodology with participant observation and in-depth interviews, with an emphasis on eliciting the underlying rationale of the clinicians' actions and choices when limiting treatment. RESULTS Informants perceived over-treatment in intensive care medicine as a dilemma. One explanation was that the decision-making base was somewhat uncertain, complex and difficult. The informants claimed that those responsible for taking decisions from the admitting ward prolonged futile treatment because they may bear guilt or responsibility for something that had gone wrong during the course of treatment. The assessments of the patient's situation made by physicians from the admitting ward were often more organ-oriented and the expectations were less realistic than those of clinicians in the intensive care unit who frequently had a more balanced and overall perspective. Aspects such as the personality and the speciality of those involved, the culture of the unit and the degree of interdisciplinary cooperation were important issues in the decision-making processes. CONCLUSION Under-communicated considerations jeopardise the principle of equal treatment. If intensive care patients are to be ensured equal treatment, strategies for interdisciplinary, transparent and appropriate decision-making processes must be developed in which open and hidden values are rendered visible, power structures disclosed, employees respected and the various perspectives of the treatment given their legitimate place.
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Affiliation(s)
- K Halvorsen
- Faculty of Nursing Education, Akershus University College, Lillestrøm, Norway.
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