Rationing home-based nursing care: professional ethical implications

Putting patients first: when home-based care staff prioritise loyalty to patients above the system and themselves. An ethnographic study

BACKGROUND

The growing number of older people worldwide poses challenges for health policy, particularly in the Global North, where policymakers increasingly expect seniors to live and receive care at home. However, healthcare professionals, particularly in home-based care, face dilemmas between adhering to care ideals and meeting external demands. Although they strive to uphold ethical care standards, they must deal with patients' needs, cooperation with colleagues and management guidelines. Home-based care is an essential part of healthcare services in Norway, but staff struggle with high patient numbers and time management. This article focuses on how staff deal with ethical challenges related to contextual and organisational constraints.

METHODS

An ethnographic fieldwork in three municipalities in South-East Norway. The first author conducted three to four months of participant observation in each municipality. In addition, she conducted in-depth interviews with key informants in two municipalities and a focus group interview with seven home-based care workers in one municipality. The data was analysed by using a reflexive thematic analysis.

RESULTS

Staff in home-based care are frequently more loyal to the patient than to the system and to their own needs. To provide good care, all informants disregarded the patient's formal decision, i.e. they provided more care than the formalised decision stipulated. To prioritise beneficence to patients, informants also disregarded some of the rules applicable in home-based care. In addition, staff accepted risks to their own safety and health to provide care in the patient's home.

CONCLUSION

The loyalty of home-based care staff to their patients can go beyond their loyalty to the rules of the system and even their own safety. This commitment might be attributed to a sense of doing meaningful work, to providing relationship-based and individualised care, and to strong moral courage. However, the staff's emphasis on flexibility and individualised care also brings challenges related to unclear boundaries related to patient care.

Needs assessment in long-term care: expression of national principles for priority setting in service allocation

BACKGROUND

Long-term care services for older adults are characterised by increasing needs and scarce resources. Political strategies have led to the reorganisation of long-term care services, with an increased focus on "ageing in place" and efficient use of resources. There is currently limited research on the processes by which resource allocation decisions are made by service allocators of long-term care services for older adults. The aim of this study is to explore how three political principles for priority setting in long-term care, resource, severity and benefit, are expressed in service allocation to older adults.

METHODS

This qualitative study uses data from semi-structured individual interviews, focus groups and observations of service allocators who assess needs and assign long-term care services to older adults in Norway. The data were supplemented with individual decision letters from the allocation office, granting or denying long-term care services. The data were analysed using reflexive thematic analysis.

RESULTS

The allocators drew on all three principles for priority setting when assessing older adults' long-term care needs and allocating services. We found that the three principles pushed in different directions in the allocation process. We identified six themes related to service allocators' expression of the principles: (1) lowest effective level of care as a criterion for service allocation (resource), (2) blanket allocation of low-cost care services (resource), (3) severity of medical and rehabilitation needs (severity), (4) severity of care needs (severity), (5) benefit of generous service allocation (benefit) and (6) benefit of avoiding services (benefit).

CONCLUSIONS

The expressions of the three political principles for priority setting in long-term care allocation are in accordance with broader political trends and discourses regarding "ageing in place", active ageing, an investment ideology, and prioritising those who are "worse off". Increasing attention to the rehabilitation potential of older adults and expectations that they will take care of themselves increase the risk of not meeting frail older adults' care needs. Additionally, difficulties in defining the severity of older adults' complex needs lead to debates regarding "worse off" versus potentiality in future long-term care services allocation.

TRIAL REGISTRATION

Not applicable.

Service Allocators' Experiences of Ethical Dilemmas and Strategies in Long-Term Care: A Qualitative Study

The provision of long-term care services for older adults is characterised by increasing needs and scarce resources, leading to ethical dilemmas. This qualitative study explored the ethical dilemmas experienced by healthcare professionals when allocating long-term care services to older adults and the strategies used to handle ethical dilemmas. Data from semi-structured individual interviews, focus group interviews, and observations of service allocators assessing needs and assigning long-term care services to older adults were analysed using content analysis. The overarching theme was the struggle for safe and equitable service allocation. The identified dilemmas were: (i) Struggles with A Just Allocation of Services due to Limited Time and Trust, (ii) Pressure on Professional Values Concerning Safety and Dignity, and (iii) Difficulties in Prioritising One Group Over Another. The strategies to deal with ethical dilemmas were: (i) Assessing Needs Across the Entire Municipality, (ii) Ensuring Distance to Service Recipients, (iii) Working as a Team, and (iv) Interprofessional Decision-Making. Scarce resources, organisational limitations, and political expectations drive the ethical dilemmas in long-term care service allocation. An open public discussion regarding the acceptable minimum standard of long-term care is needed to reduce the ethical pressure on service allocators.

"A becoming in the meeting": the interpretations of competence in home care from the perspectives of older people and registered nurses - a meta-ethnography

AIM

The aim of this meta-ethnography was to identify and synthesize qualitative studies focusing on older people's and registered nurses' interpretations of competence in home care.

METHODS

The meta-ethnography followed the six phases developed by Noblit and Hare (1988).

RESULTS

In Phase 6, the translation process of the included studies, three themes were identified: i) temporality-the feeling of being of value; ii) dignity-a person, not just a patient; and iii) mutuality of being-togetherness. A synthesis was developed, and the phrase "a becoming in the meeting" emerged.

CONCLUSION

The sense of becoming includes progress, which means becoming something other than before in relation with others and refers to what constitutes the meeting between the older person and the registered nurse working in home care. Competence originates from becoming in the meeting, and registered nurses should therefore value what they do and hold on to this aspect of caring competence that centres on a caring relationship. It is important for registered nurses working in home care to be able to cultivate a caring relationship.

Social inequality in navigating the healthcare maze: Care trajectories from hospital to home via intermediate care for older people in Norway

Although health inequality is a growing concern, striking differences in health and life expectancy still exist across and within OECD countries. In Oslo, the largest city in Norway, life expectancy differs by up to 7 years between districts. Equal access to healthcare can help reduce social differences in health. However, research indicates that older people at the lower level of the social gradient have more difficulty accessing health services. Older people experience early hospital discharge and several transitions between and across care levels. In this study, using Bourdieu's theory of practice as a theoretical lens, we explore social inequality in access to universal healthcare within care trajectories for older people in Oslo. Through observation of family meetings in intermediate care (N = 14) and semi-structured interviews with older patients (N = 15), informal caregivers (N = 12) and healthcare professionals (N = 18), the study identifies 15 unique care trajectories from hospital to home via intermediate care. Informed by a critical realist perspective and moving from west to east via the urban areas, there is a prominent finding of climbing down the social gradient and, subsequently, reduced access to healthcare. An overarching theme, 'Navigating the healthcare maze', was identified along with two subthemes: 'Individuality meets system' and 'Having a feel for the game'. Navigating the healthcare maze depends on where you live, your level of education and health literacy and the ability to mobilize social networks. Furthermore, it is an advantage to fit into the professional habitus of the 'active patient' discourse. The findings will be relevant for politicians, managers, healthcare professionals and other stakeholders working in the field and in the development of services adapted to the needs of various socioeconomic groups.

Rationing of nursing care: A concept analysis

Rationing of nursing care (RONC) refers to necessary nursing tasks that nurses refuse or fail to do because of limited time, staffing level, or skill mix. As an important process factor, it affects the quality of patient care. The concept of rationing of nursing care has not yet been clearly defined and analyzed and there are different views regarding this issue. Using Walker and Avant's eight-step method, this concept analysis was conducted to analyze the meaning, attributes, dimensions, antecedents, and consequences of nursing care rationing. The literature was collected by searching in electronic databases including PubMed, ScienceDirect, Web of Science, Scopus, and Google Scholar with no date limitation. Both qualitative and quantitative studies on rationing of nursing care, which were open-access and published in English, were included in this study. Thirty-three articles were investigated in the present study. The four defining attributes of RONC included the duty of performing nursing care, dealing with problems of doing nursing care, decision-making and prioritizing, and outcome. The antecedents included nurse-related, organization-related, care-related, and patient-related antecedents. A theoretical definition and a conceptual model of RONC were developed. The attributes, antecedents, and consequences of RONC identified in this study can be used in nursing education, research, and managerial and organizational planning.

Municipal healthcare professionals' interprofessional collaboration during older patients' transitions in the municipal health and care services: a qualitative study

Background

Interprofessional collaboration is vital to assist patients towards a healthy transition in the municipal health and care services. However, no study has so far investigated municipal health care providers’ inter-professional collaboration during older patients’ transition in the municipal health and care services. The aim of this study is therefore to describe and explore what influence health care providers’ inter-professional collaboration within and across municipal facilities during older patients’ transitions in the municipal health and care services.

Method

The study has a descriptive, interpretive design. Focus group interviews and individual interviews with municipal health care providers different professions were performed.

Results

Municipal health care providers’ inter-professional collaboration during older patients transitions in the municipal health and care services was challenging. Two main themes were identified: The patient situation itself and Professional. Personal, and Practical circumstances. The results show that the municipal priority of patients staying at home as long as possible facilitated inter-professional collaboration across the short-term care facility and the home care services. Inter-professional collaboration across facilities with the long-term care facility was downgraded and health care providers in this facility had to cope as best they could.

Conclusion

Prioritising and facilitating inter-professional collaboration between the short-term care facility and the home care services, contributed to health care providers experiencing doing a proper and safe patient assistance. Yet, this priority was at a cost: Health care providers in the long-term care facility, and in particular registered nurses felt squeezed and of less worth in the municipal health and care services. It was a strain on them to experiencing unplanned and often rushed patient transition into long-term care facility. To focus on municipal inter-professional and inter-facility collaboration during patients in transition to long-term care placement is vital to maintain the patients, and the health care providers working in these facilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08226-5.

Nurses’ experiences of the ethical values of home care nursing: A qualitative study

Objective

Considering the importance of out-of-hospital services, the emergence of home care nursing, and the need for an ethical framework in nursing practice, the present study aimed to explore the nurses’ experience of ethical values of home care nursing.

Methods

The data of the study was collected using face-to-face individual interviews. Through purposive sampling, 20 nurses who worked in the home care centers in four cities of Iran in 2020 were interviewed. They shared their experiences of the ethical values of home care nursing. Then, the interviews were analyzed based on the content analysis approach and using Graneheim and Lundman method.

Results

In the present study, 416 codes were extracted. Merging these codes based on the similarity, seven main themes, and 16 sub-themes were extracted. The themes included perception of the professional identity, respect for the client’s autonomy, respecting privacy, establishing human interaction, maintaining mutual safety, observance of justice, and cultural-religious competence. The sub-themes included responsibility, development of professional and inter-professional interactions, maintaining the professional status at home, providing the holistic artistic care, patient’s privacy, nurse’s privacy, and maintaining the confidentiality of information, respect for the client’s choice, honestly informing, empathetic interaction, adjusting the power positions, client's safety, nurse’s safety, establishing justice, respect for the religious beliefs at home and cultural sensitivity.

Conclusion

The participants stated that due to entering the patient’s privacy in the home care cases, the ethical values such as perception of the professional identity, privacy, family interactions’ management, mutual security, and cultural-religious competence became doubly important compared to the hospital caring.

How Is Quality of Care in Home Healthcare Created? A Qualitative Study of Health Professionals' Perspectives

The demographic challenges with an increase in older adults in need of nursing care has put home healthcare services under pressure. However, research on what constitutes quality of home healthcare services and what factors influence good nursing care and patient safety is scarce. The aim of this study was to gain insight into health professionals' perceptions of how quality of care in home healthcare is created and what factors put patient safety at risk. The present study was a qualitative study with semi-structured interviews of eight health professionals working in home healthcare services. Qualitative content analysis was used. Four categories of factors the staff thought had to be present to provide good quality services were identified: (1) A workplace with adequate competence; (2) Communication, information flow and collaboration; (3) Continuity and organisation of care; and (4) Resources. Conclusions: The healthcare professionals perceived that the quality of the services overall was good, and if important factors were present, quality of care was achieved. However, they pointed out some factors that were important to prevent inadequate care and improve services, as quality of care was at risk when deficiencies in these areas occurred.

A scoping review-Missed nursing care in community healthcare contexts and how it is measured

Aim

To examine the extent and nature of missed nursing care in elderly care in community healthcare contexts from the perspective of healthcare staff, and to identify instruments used to measure missed nursing care and the content of these instruments.

Design

Scoping review.

Methods

Searches were conducted in the CINAHL, PubMed, Scopus and Google Scholar databases in March 2020. The selection process followed the PRISMA flow diagram.

Results

Sixteen research papers were found from nine countries. The instruments used in the studies were Basel Extent of Rationing of Nursing Care for nursing homes (BERNCA‐NH), modified MISSCARE survey and study‐specific instruments or items. The item content differed, as did the number of items, which was between one and 44. The studies reported values for missed nursing care, as well as described reasons for and/or the relation between missed nursing care and organization, working climate and patient outcomes.

Loneliness Among Older Home-Dwelling Persons: A Challenge for Home Care Nurses

Aim

To explore how nurses working in the home care service sector perceived the loneliness experienced by older people living at home, and how they met these lonely individuals’ needs.

Background

Loneliness is a well-known phenomenon among groups of older home-dwelling people and has been shown to be a health-related problem. Health care professionals working in the primary care sector, such as home care nurses, may be in the position to identify loneliness among at-home seniors. Identifying and addressing loneliness must become important issues in home care nursing.

Design

A qualitative study.

Methods

Focus group interviews were performed with 11 home care nurses in Norway. The interviews were analyzed in accordance with manifest and latent content analysis. The Coreq checklist was followed.

Findings

Home care nurses identified loneliness among older people as being a complex and sensitive phenomenon that activated conflicted thoughts, feelings and solutions in a system where older people’s loneliness was generally not considered as a need requiring nursing care.

Conclusion

Loneliness among older people challenged the nurses with regard to communicating older people’s feelings of loneliness and meeting their social needs. Organizational structures were perceived as being the main barriers to meeting these needs. Older people’s feelings of loneliness stimulated nurses’ reflections about the purpose of their nursing role. It is important to address loneliness among older home-dwelling people and include the issue in home care nursing in order to meet their need for social contact. Home nursing leaders must pay attention to the nurses’ experiences, promote the nurses’ acquisition of knowledge about this kind of loneliness and learn how to meet an older individual’s needs. There should be a special focus on communicating with lonely older people in order to address their feelings loneliness.

Ethical challenges in home-based care: A systematic literature review

Because of the transfer of responsibility from hospitals to community-based settings, providers in home-based care have more responsibilities and a wider range of tasks and responsibilities than before, often with limited resources. The increased responsibilities and the complexity of tasks and patient groups may lead to several ethical challenges. A systematic search in the databases MEDLINE, CINAHL, and SveMed+ was carried out in February 2019 and August 2020. The research question was translated into a modified PICO (Population, Intervention, Comparison, and Outcome) worksheet. A total of 40 articles were included. The review is conducted according to the Vancouver Protocol. The main findings from the systematic literature review show that ethical challenges experienced by healthcare and social care providers in home-based care are related to autonomy and balancing ethical principles, decisions regarding intensity of care, challenges related to priority settings, truth-telling, and balancing the professional role. Findings regarding ethical challenges within home-based care are in line with findings from institutional healthcare and social care settings. However, some significant differences from the institutional context are also highlighted.

Safe and competent nursing care: An argument for a minimum standard?

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.

Home-care nurses' distinctive work: A discourse analysis of what takes precedence in changing healthcare services

Ongoing changes in many Western countries have resulted in more healthcare services being transferred to municipalities and taking place in patients' homes. This greatly impacts nurses' work in home care, making their work increasingly diverse and demanding. In this study, we explore home-care nursing through a critical discourse analysis of focus group interviews with home-care nurses. Drawing on insights from positioning theory, we discuss the content and delineation of their work and the interweaving of contextual changes. Nurses hold a crucial position in home healthcare, particularly in ensuring care for sicker patients with complex needs. Assessing health needs, performing advanced care, and at the same time, providing customized solutions in various homes were identified as distinctive for home-care nurses' work. Changes have made nurses' work become driven by comprehensive tasks and acute medical needs that require much of their competence and time. Urgent care seems to take precedence in nurses' work, leaving less time and attention for other tasks such as conversations and support for coping with everyday life. This underlines the need to investigate and discuss the content and scope of nurses' work to help shape the further development of home-care nursing.

Balancing contradictory requirements in homecare nursing-A discourse analysis

Aim

To explore prevailing discourses on nursing competence in homecare nursing to boost understanding of practice within this field.

Design

A qualitative study with a social constructivist perspective.

Methods

Six focus-group interviews with homecare nurses in six different municipalities in Norway. Adapting a critical discourse analysis, data were linguistically, thematically and contextually analysed in the light of theories on competence, institutional logic and discourses.

Results

The analysis found homecare nursing to be a diverse and contradictory practice with ever-increasing work tasks. Presented as binary oppositions, we identified the following prevailing discourses: individualized care versus organizing work; everyday-life care versus medical follow-up; and following rules versus using professional discretion. The binary oppositions represent contradictory requirements that homecare nurses strive to balance. The findings indicate that medical follow-up and organizational work have become more dominant in homecare nursing, leaving less time and attention paid to relational and everyday-life care.

A nation-wide cross-sectional study of variations in homecare nurses' assessments of informational continuity - the importance of horizontal collaboration and municipal context

Background

Numerous studies have revealed challenges associated with ensuring informational continuity in municipal care services for older adults with comprehensive, prolonged and complex care needs. Most research is qualitative and on the micro-level. The aim of the current study is to map variation in homecare nurses’ assessments of available information in the municipalities’ documentation system and investigate the extent to which these assessments are associated with perceived quality of collaborations and with municipal context.

Methods

We used data from a nationwide web-based survey among 1612 nurses working with older adults (65+) in homecare services in Norway. Responses from individual homecare nurses were linked with municipal-level data from the public registers. Data were analysed with descriptive statistics and multilevel regression analyses.

Results

Information on the recipients’ medications and medical condition was considered most often available (42.8 and 20.0% responding very often/always), whereas information related to psychosocial needs and future follow-up was perceived less available (4.5 and 6.7% responding very often/always). Homecare nurses’ perceptions of the quality of collaboration with the GP and the allotment office were independently and positively associated with assessments of informational continuity (ß =0.86 and ß =0.96). A modest share of the total variation (8%) in assessments of informational continuity was at the structural level of municipality. Small municipalities (< 5000 inhabitants) had, on average, better informational continuity compared to larger municipalities (ß = -0.47).

Conclusions

Documentation systems have a limited focus on long-term care needs of older care recipients beyond clinical and medical information. There is a potential for enhanced communication- and care-pathways between GPs, the allotment office and nurses in homecare services. This can support the coordinating role of homecare nurses in ensuring informational continuity for older adults with prolonged and complex care needs and help develop the facilitating role of (electronic) documentation systems.

A qualitative study of old patients' experiences of the quality of the health services in hospital and 30 days after hospitalization

Background

The number of people aged 80 years and above is projected to triple over the next 30 years. People in this age group normally have at least two chronic conditions. The impact of multimorbidity is often significantly greater than expected from the sum of the effects of each condition. The World Health Organization has indicated that healthcare systems must prepare for a change in the focus of clinical care for older people. The World Health Organization (WHO) defines healthcare quality as care that is effective, efficient, integrated, patient centered, equitable and safe. The degree to which healthcare quality can be defined as acceptable is determined by services’ ability to meet the needs of users and adapt to patients’ expectations and perceptions.

Method

We took a phenomenological perspective to explore older patients’ subjective experiences and conducted semistructured individual interviews. Eighteen patients (aged from 82 to 100 years) were interviewed twice after discharge from hospital. The interview transcriptions were analyzed thematically.

Results

The patients found their meetings with the health service to be complex and demanding. They reported attempting to restore a sense of security and meaning in everyday life, balancing their own needs against external requirements. Five overarching themes emerged from the interviews: hospital stay and the person behind the diagnosis, poor communication and coordination, life after discharge, relationship with their next of kin, and organizational and systemic determinants.

Conclusion

According to the WHO, to deliver quality healthcare, services must include all six of the dimensions listed above. Our findings show that they do not. Healthcare focused on measurable values and biomedical inquiries. Few opportunities for participation, scant information and suboptimal care coordination left the patients with a feeling of being in limbo, where they struggled to find balance in their everyday life. Further work must be done to ensure that integrated services are provided without a financial burden, centered on the needs and rights of older people.

Nordic homecare nursing from the perspective of homecare nurses-a meta-ethnography

The pressure on homecare nursing in the Nordic countries has increased in recent years because of a reorganisation of healthcare systems that has put a focus on very early discharge from hospital as well as demographic changes. This article details an analysis of the findings of 13 published qualitative research reports about Nordic homecare nurses' experiences of their work. Using a process of meta-ethnography, the authors identify five themes within the primary research: home care as a professional practice on foreign ground; home care as a massive time constraint; home care as fair rationing; home care as relationships with relatives as fellow players or opponents; and home care as latent paternalism. These have two main implications for practice: homecare nurses should continuously be taught how to cooperate with partners who are emotionally involved; and also homecare nurses may benefit from training that focuses on the challenges of carrying out professional work in private settings.

Gaming the system to care for patients: a focused ethnography in Norwegian public home care

Background

With its emphasis on cost-reduction and external management, New Public Management emerged as the dominant healthcare policy in many Western countries. The ability to provide comprehensive and customized patient-care is challenged by the formalized, task-oriented organization of home-care services. The aim of this study is to gain deeper understanding of how nurses and the patients they care for, relate to and deal with the organizational systems they are subjected to in Norwegian home care.

Methods

The focused ethnographic design is based on Roper and Shapira’s framework. Data collection consisted of participant observation with field notes and semi-structured interviews with ten nurses and eight patients from six home care areas located in two Norwegian municipalities.

Results

Findings indicate cultural patterns regarding nurses’ somewhat disobedient behaviors and manipulations of the organizational systems that they perceive to be based on economic as opposed to caring values. Rigid organization makes it difficult to deviate from predefined tasks and adapt nursing to patients changing needs, and manipulating the system creates some ability to tailor nursing care. The nurses’ actions are founded on assumptions regarding what aspects of nursing are most important and essential to enhance patients’ health and ensure wellbeing – individualized care, nurse-patient relationships and caring – which they perceive to be devalued by New Public Management organization. Findings show that patients share nurses’ perceptions of what constitute high quality nursing, and they adjust their behavior to ease nurses’ work, and avoid placing demands on nurses. Findings were categorized into three main areas: “Rigid organizational systems complicating nursing care at the expense of caring for patients”, “Having the patient’s health and wellbeing at heart” and “Compensating for a flawed system”.

Conclusions

Our findings indicate that, in many ways, the organizational system hampers provision of high-quality nursing, and that comprehensive care is provided in spite of - not because of - the system. The observed practices of nurses and patients are interpreted as ways of “gaming the system” for caring purposes, in order to ensure the best possible care for patients.

Case Manager Resource Allocation Decision-Making for Adult Home Care Clients: With Comparisons to a High Needs Pediatric Home Care Clients

Home care programs have become integral parts of the overall health service system in Canada and in many other developed nations. Resource allocation decision-making by home care case managers (CM) is a complex task where CMs are challenged to meet the dual responsibilities for clients, in order that they achieve high quality care, and to the system to contain costs. The purpose of this study was to extend what is known about resource allocation decision-making factors identified in a previous systematic literature review and ethnographic study within a high needs pediatric context conducted by the principal investigator in Western Canada. Spradley’s ethnoscience method was used in this research. The study sample consisted of 17 home care CMs, professional practice leads, and their managers from two separate home care offices. All participating CMs had assigned caseloads and were involved in the assessment and implementation of care planning for clients. Purposive sampling methods were employed. In keeping with Spradley’s ethnoscience approach, data collection occurred in three distinct phases or rounds. The first round of data collection began with a series of one-on-one interviews with card sorts, the second round of data collection was another series of one-on-one interviews with CMs who were not interviewed in the prior round, and the third and final round of data collection was a focus group to accomplish further refinement and verification of our established categories. Participants identified five categories of factors that effected their resource allocation decision-making. The categories were related to one of five main areas: the client, the CM, the home care program, community resources, or the health care system. The findings of this study reinforced the complexity of CM resource allocation decision-making in home care. This study provides new insights into CM resource allocation decision-making based on multidisciplinary, integrated home care teams caring for adults, the majority of whom are 65 years and older. This study also provides the comparison of taxonomy that differs between pediatric and adult home care populations that influence resource allocation decision-making.

The nurse-patient relationship in the New Public Management era, in public home care: A focused ethnography

AIM

The aim of this study was to gain deeper understandings of nurse-patient relationships in the New Public Management era, by exploring beliefs and practices of nurses and patients in Norwegian public home care.

BACKGROUND

Organization of Norwegian home care services is based on New Public Management-ideologies, which have led to a rigidly formalized and task-oriented nursing practice that may jeopardize individual nursing care. Nurse-patient relationships have several positive effects on patients' health and well-being, but organizational boundaries and time pressure affect the quality of relationships.

DESIGN

Focused ethnography.

METHODS

Data were collected between November 2015-July 2016 using participant observation and semi-structured interviews with 10 nurses and eight patients in six different home care areas, in two Norwegian municipalities. Data analysis was based on Roper and Shapiras framework.

FINDINGS

Findings demonstrate the continued importance of nurse-patient relationships in contemporary home care, while identifying extensive variations in the degree of closeness and emotional involvement. Organizational boundaries, time constraints, high workload, and disharmony between nurses "competence and patients" complex illnesses, influence practice in ways that reduce the significance of nurse-patient relationships and affect conditions under which they develop and evolve. Facing a system nurses perceive to function suboptimal, they govern practices based on their own professional assessments, and findings indicate cultural patterns in the way both nurses and patients prioritize to safeguard nurse-patient relationships.

CONCLUSION

Home care cultures based on traditional nursing values continue, despite New Public Management influences, but a transition into New Public Management culture may, over time, influence the quality of nurse-patient relationships and meanings attributed to them.

Ethical elements in priority setting in nursing care: A scoping review

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.

Using a new interrater reliability method to test the modified Oulu Patient Classification instrument in home health care

Aim

To test the interrater reliability of the modified Oulu Patient Classification instrument, using a multiple parallel classification method based on oral case presentations in home health care in Norway.

Design

Reliability study.

Methods

Data were collected at two municipal home healthcare units during 2013-2014. The reliability of the modified OPCq instrument was tested using a new multiple parallel classification method. The data material consisted of 2 010 parallel classifications, analysed using consensus in per cent and Cohen's kappa. Cronbach's alpha was used to measure internal consistency.

Results

For parallel classifications, consensus varied between 64.78-77.61%. Interrater reliability varied between 0.49-0.69 (Cohen's kappa), the internal consistency between 0.81-0.94 (Cronbach's alpha). Analysis of the raw scores showed 27.2% classifications had the same points, 39.1% differed one point, 17.9% differed two points and 16.5% differed ≥3 points.

Resource allocation and rationing in nursing care: A discussion paper

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.

Care relationships at stake? Home healthcare professionals' experiences with digital medicine dispensers - a qualitative study

BACKGROUND

Although digital technologies can mitigate the burdens of home healthcare services caused by an ageing population that lives at home longer with complex health problems, research on the impacts and consequences of digitalised remote communication between patients and caregivers is lacking. The present study explores how home healthcare professionals had experienced the introduction of digital medicine dispensers and their influence on patient-caregiver relationships.

METHODS

The multi-case study comprised semi-structured interviews with 21 healthcare professionals whose home healthcare service involved using the digital medicine dispensers. The constant comparative method was used for data analyses.

RESULTS

Altogether, interviewed healthcare professionals reported three main technology-related impacts upon their patient-caregiver relationships. First, national and local pressure to increase efficiency had troubled their relationships with patients who suspected that municipalities have sought to lower costs by reducing and digitalising services. Participants reported having to consider such worries when introducing technologies into their services. Second, participants reported a shift towards empowering patients. Digital technology can empower patients who value their independence, whereas safety is more important for other patients. Healthcare professionals needed to ensure that replacing care tasks with technology implies safe and improved care. Third, the safety and quality of digital healthcare services continues to depend upon surveillance and control mechanisms that compensate for less face-to-face monitoring. Participants did not consider the possibility that surveillance exposes information about patients' everyday lives to be problematic, but to constitute opportunities for adjusting services to meet patients' needs.

CONCLUSIONS

Technologies such as digital medicine dispensers can improve the efficiency of healthcare services and enhance patients' independence when introduced in a way that empowers patients as well as safeguards trust and service quality. Conversely, the patient-caregiver relationship can suffer if the technology does not meet patients' needs and fails to offer safe and trustworthy services. Upon introducing technology, home healthcare professionals therefore need to carefully consider the benefits and possible disadvantages of the technology. Ethical implications for both individuals and societies need to be further discussed.

Ethics support in community care makes a difference for practice

BACKGROUND

Through the Norwegian ethics project, ethics activities have been implemented in the health and care sector in more than 200 municipalities.

OBJECTIVES

To study outcomes of the ethics activities and examine which factors promote and inhibit significance and sustainability of the activities.

RESEARCH DESIGN

Two online questionnaires about the municipal ethics activities. Participants and research context: A total of 137 municipal contact persons for the ethics project answered the first survey (55% response rate), whereas 217 ethics facilitators responded to the second survey (33% response rate). Ethical considerations: Based on informed consent, the study was approved by the Data Protection Official of the Norwegian Social Science Data Services.

FINDINGS

Around half of the respondents found the ethics project to have been highly significant for daily professional practice. Outcomes include better handling of ethical challenges, better employee cooperation, better service quality, and better relations to patients and next of kin. Factors associated with sustainability and/or significance of the activities were sufficient support from stakeholders, sufficient available time, and ethics facilitators having sufficient knowledge and skills in ethics and access to supervision.

DISCUSSION

This study shows that ethics initiatives can be both sustainable and significant for practice. There is a need to create regional or national structures for follow-up and develop more comprehensive ethics training for ethics facilitators.

CONCLUSION

It is both possible and potentially important to implement clinical ethics support activities in community health and care services systematically on a large scale. Future ethics initiatives in the community sector should be designed in light of documented promoting and inhibiting factors.

Reflecting on one's own death: The existential questions that nurses face during end-of-life care

Objective:

When registered nurses care for patients at the end of life, they are often confronted with different issues related to suffering, dying, and death whether working in hospital or community care. Serious existential questions that challenge nurses’ identities as human beings can arise as a result of these situations. The aim of our study was to describe and gain a deeper understanding of nurses’ existential questions when caring for dying patients.

Method:

Focus-group interviews with registered nurses who shared similar experiences and backgrounds about experiences in end-of-life care were employed to gain a deeper understanding about this sensitive subject. Focus-group interviews were performed in hospice care, in community care, and in a palliative care unit in western Sweden. A qualitative hermeneutic approach was employed to interpret the data.

Results:

Nurses’ existential questions balanced between responsibility and guilt in relation to their patients, between fear and courage in relation to being professional caregivers and fellow human beings, and between hope and despair in relation to the other's and their own death.

Significance of results:

Nurses in end-of-life care experience various emotions from patients related to things physical, spatial, and temporal. When nurses encounter these emotions as expressing a patient's suffering, they lead to challenges of balancing between different feelings in relation to patients, as both professional caregivers and fellow human beings. Nurses can experience growth both professionally and as human beings when caring for patients at the end of life.

[Ethical problems experienced by nurses in primary health care: integrative literature review]

The aim of this study is to identify ethical problems experienced by nurses in primary health care and resources for coping based on publications on the subject. An integrative literature review was performed between the months of October and November 2013, using the databases: BDTD, CINAHL, LILACS, MEDLINE, Biblioteca Cochrane, PubMed, RCAAP and SciELO. Articles, dissertations and theses published in Portuguese, English and Spanish were included, totalling 31 studies published from 1992 to 2013. This analysis resulted in four categories: ethical problems in the relationship between team members, ethical problems in the relationship with the user, ethical problems in health services management and resources for coping with ethical problems. Results showed that nurses need to be prepared to face ethical problems, emphasizing the importance of ethics education during the education process before and during professional practice to enhance the development of ethical sensitivity and competence for problem resolution.

Ethical challenges related to next of kin - nursing staffs' perspective

BACKGROUND

Patients in clinical settings are not lonely islands; they have relatives who play a more or less active role in their lives.

OBJECTIVES

The purpose of this article is to elucidate the ethical challenges nursing staff encounter with patients' next of kin and to discuss how these challenges affect clinical practice.

RESEARCH DESIGN

The study is based on data collected from ethical group discussions among nursing staff in a nursing home. The discussions took place in 2011 and 2012. The data were analysed and interpreted by using hermeneutic methodology.

ETHICAL CONSIDERATIONS

All the data have been anonymised and handled with confidentiality. Written informed consent was obtained from all participants.

FINDINGS

Ethical challenges relating to patients' next of kin were found to be an issue frequently discussed in the groups. Our findings indicate that next of kin have different characteristics, categorised as 'the professionals' and 'the shadows'. In this article, we will describe the next of kin's characteristics and the ethical challenges and practical implications that nursing staff experience in this connection.

DISCUSSION

We will discuss the findings in the light of the four basic principles of medical ethics and propose interventions to help nurses manage ethical challenges related to next of kin.

CONCLUSION

The study reveals the need to enhance nursing staffs' communicative and ethical skills on an individual level, but most importantly, to establish routines in clinical settings for informing and following up next of kin in a systematic and structured way.

Impact of home care management on the involvement of informal caregivers by formal caregivers

This study explores the link between management characteristics of home care agencies and the involvement of informal caregivers in caregiving. Based on a study of policy documents of two agencies and semi-structured interviews with five team managers and 31 formal caregivers, we conclude that, although the importance of involving informal caregivers is emphasized in official documentation, actual contact with informal caregivers is often lacking. Comparison of the work processes of the two agencies shows that contact with informal caregivers and their potential involvement are enhanced by smaller teams, less task division, and clarity about the responsibilities of formal caregivers.

Towards a comprehensive research design for studying integrated care

Given that integrated care includes many different aspects, this paper seeks to design a comprehensive research approach and explains how this approach is applied in the CORTEXS research project on integrated care in the Flemish Community in Belgium. A systemic view on integrated care is translated into a multi-level, multi-disciplinary, multi-method and multi-stakeholder research design. A phased approach of taxonomy development and literature review, comparative case studies, social lab activities and valorisation initiatives is devised in order to link fundamental research with strategic valorisation of the research results. While this innovative comprehensiveness is seen as a major strength, it is acknowledged that the research design comes with certain risks that need to be tackled.

The ethical dimension of nursing care rationing: A thematic synthesis of qualitative studies

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.

A descriptive retrospective study of time consumption in home care services: how do employees use their working time?

BACKGROUND

Home care services in Norway are provided for free, and municipalities are responsible for their provision to all those in need of them, in accordance with the Act on Municipal Health and Care Services. The costs of home care services are increasing. Many municipalities are now working to find the best cost-effective solutions to ensure that home care services are of sufficient quality but still affordable. This paper describes how nurses and health workers spend their working time, with a hypothesis that driving time and time required to document details of the care given are underestimated in weekly planning schedules.

METHODS

This article sets out a descriptive retrospective study of day-schedules and driving routes for staff working in home care services. Data were analyzed using GIS.

RESULTS

The driving time was between 18% and 26% of working time in municipality A, and between 21% and 23% in municipality B. Visiting time varied between 44% and 62% in municipality A, and 40% and 56% in municipality B. Other tasks, including the legally-required documentation of the care given, varied between 19% and 32% in municipality A and 21% and 38% in municipality B. Overall, 22% of the driving routes in municipality A, and 14% in municipality B, took more time than expected. In municipality A, 22% of the day-schedules underestimated overtime; this figure was 14% in municipality B.

CONCLUSIONS

In home care services, time taken for driving and to write statutory documentation seems to have been underestimated. Better planning and organization of driving routes would reduce driving time and allow more time for other necessary work.

The hidden ethical element of nursing care rationing

Objective:

To explore nurses’ experiences and perceptions about prioritizations, omissions, and rationing of bedside nursing care.

Methods:

A total of 23 nurses participated in four focus groups. The interviews were based on a semi-structured interview guide; data were analyzed using a thematic analysis approach.

Findings:

Four themes were developed based on the data: (a) priorities in the delivery of care; (b) professional roles, responsibilities, and role conflicts; (c) environmental factors influencing care omissions; and (d) perceived outcomes of rationing.

Discussion:

The delivery of nursing care is framed by the biomedical ethos and inter-professional role conflict while the standards of basic care are jeopardized. Organizational and environmental factors appear to exert significant influence on prioritization. Failure to carry out necessary nursing tasks may lead to adverse patient outcomes, role conflict, and an ethical burden on nurses.

Conclusion:

There is a need for further exploration and possible redesign of the nursing role, scope, and responsibilities, as well as addressing the arising ethical issues of rationing in nursing care.

Moral distress and professional freedom of speech among doctors

BACKGROUND

Previous studies indicate that Norwegian doctors experience distress in their encounter with differing and partly contradictory ideals, such as the obligation to criticise unethical and inappropriate practices. The objective of this study was to investigate the perception of moral distress and professional freedom of speech among Norwegian doctors as of today, as well as identify changes that have occurred since the previous study undertaken in 2004.

MATERIAL AND METHODS

A total of 1,522 economically active doctors received a questionnaire listing various statements describing the perception of moral distress and professional freedom of speech. The responses were compared to responses to the 2004 study.

RESULTS

Altogether 67% of the doctors responded to the questionnaire. The proportion who reported «fairly strong» or «strong» moral distress varied from 24% to 70% among the different statements. On the whole, the «rank and file» hospital doctors reported the highest degree of moral distress. Nevertheless, a decrease in the scores for moral distress could be observed from 2004 to 2010. During the same period, the perception of professional freedom of speech increased slightly.

INTERPRETATION

A reduced level of distress associated with ethical conflicts in working life may be due to improved methods for handling distressing situations, or because the consequences of the health services reorganisations are perceived as less threatening now than in 2004, immediately after the introduction of the hospital reform. However, the perceived lower distress level may also be due to professional and ethical resignation. These findings should be followed up by a qualitative study.

Case managed community aged care: what is the evidence for effects on service use and costs?

OBJECTIVE

To evaluate the effects of case management in community aged care (CMCAC) interventions on service use and costs.

METHOD

Five databases were searched from inception to 2011 July to include randomized control trials and comparative observational English studies. Results were summarized by using the best-evidence synthesis approach.

RESULTS

Twenty-one studies were included. Available studies supported improvements in clients' use of case management services (all of the four studies), some community services (8 of the 10) and nursing home admission and stay (around one half), delay of nursing home placement (all of the two studies), and achieving cost neutrality (8 of the 11). The effects on medical care utilization were varying.

DISCUSSION

In general, these positive effects justify the further development and refinement of CMCAC programs. Result applicability is limited by only including English studies. Cost studies applying a societal perspective, and full economic appraisals where appropriate are warranted.

Nurses' information exchange during older patient transfer: prevalence and associations with patient and transfer characteristics

Introduction

To ensure continuity of care, it is important to effectively communicate the health status of older patients who are transferred between health care organizations. The objectives of this study were to: (1) evaluate the prevalence of nursing transfer documents, and (2) identify patient and transfer characteristics associated with the presence of nursing transfer documents for older patients transferred from home care to hospital and back to home care again after hospitalization.

Methods

Nursing documents were reviewed from a total of 102 records of older inpatients admitted from home care to medical wards at a local hospital in central Norway and later discharged home. Frequencies were used to describe patient and transfer characteristics, and the prevalence of transfer documents. Pearson’s χ² test and logistic regression were used to identify possible associations between patient and transfer characteristics and the presence of nursing transfer documents.

Results

While nursing admission notes were present in 1% of the patient transfers from home care to the hospital, 69% of patient discharges from the hospital to home care were accompanied by nursing discharge notes. Patient and transfer characteristics associated with the presence of a nursing discharge note were age, gender, medical department facility, and length of hospital stay.

Conclusions

The low prevalence of nursing transfer documents constitutes a challenge to the continuity of care for hospitalized home care patients. Patient and transfer characteristics may impact the nurses’ propensity to exchange patient information. These findings emphasize the need for nurses and managers to improve the exchange of written information. While nurses must strive to transfer accurate patient information at the right place and at the right time, the managers must facilitate this by providing appropriate guidelines and standards, as well as adequate personnel and resources.

Co-creating possibilities for patients in palliative care to reach vital goals--a multiple case study of home-care nursing encounters

The patient's home is a common setting for palliative care. This means that we need to understand current palliative care philosophy and how its goals can be realized in home-care nursing encounters (HCNEs) between the nurse, patient and patient's relatives. The existing research on this topic describes both a negative and a positive perspective. There has, however, been a reliance on interview and descriptive methods in this context. The aim of this study was to explore planned HCNEs in palliative care. The design was a multiple case study based on observations. The analysis includes a descriptive and an explanation building phase. The results show that planned palliative HCNEs can be described as a process of co-creating possibilities for the patient to reach vital goals through shared knowledge in a warm and caring atmosphere, based on good caring relations. However, in some HCNEs, co-creation did not occur: Wishes and needs were discouraged or made impossible and vital goals were not reached for the patients or their relatives. Further research is needed to understand why. The co-creative process presented in this article can be seen as a concretization of the palliative care ideal of working with a person-centered approach.

Rationing of Nursing Care Within Professional Environmental Constraints

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.