Fair nursing care when resources are limited: the role of patients and family members in Norwegian home-based services

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.

Older patients' perspectives on illness and healthcare during the early phase of the COVID-19 pandemic

BACKGROUND

Equal access to healthcare is a core principle in Norway's public healthcare system. The COVID-19 pandemic challenged healthcare systems in the early phase - in particular, related to testing and hospital capacity. There is little knowledge on how older people experienced being infected with an unfamiliar and severe disease, and how they experienced the need for healthcare early in the pandemic.

AIM

To explore the experiences of older people infected by COVID-19 and their need for testing and hospitalisation.

RESEARCH DESIGN

An explorative and descriptive approach, with qualitative interviews conducted in October 2020.

PARTICIPANTS AND RESEARCH CONTEXT

Seventeen participants above 60 years of age hospitalised due to COVID-19 during spring 2020 were recruited 6 months after discharge.

ETHICAL CONSIDERATIONS

Ethical approval was granted by the Regional Committee for Medical and Health Research Ethics in South-Eastern Norway (155425).

FINDINGS

The main finding was that the informants experienced vulnerability and arbitrariness. This finding was supported by three sub-themes: experiences with a severe and unfamiliar disease, the strict criteria and the importance of someone advocating needs.

DISCUSSION

Participants described varying access to healthcare. Those who did not meet the national criteria to be tested or hospitalised struggled against the system. Findings reveal arbitrary access to healthcare, in contrast to Norway's ethical principle of fair and just access to health services. Moreover, to access and receive necessary healthcare, informants were dependent on their next-of-kin's advocacy.

CONCLUSION

Even when dealing with an unfamiliar disease, health professionals' assessments of symptoms must be performed with an ethical obligation to applicate competent appraisal and the exercise of discernment; this is in line with care ethics and ethical standards for nurses. These perspectives are a significant part of caring and the intension of doing good.

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.

The Dramaturgical Act of Positioning Within Family Meetings: Negotiation of Patients' Participation in Intermediate Care Services

Family meetings are a cornerstone in intermediate care (IC) and a powerful tool in achieving patient participation. Staff in IC are nevertheless uncertain about how to run these meetings. This study explores the negotiation of patient participation in 14 family meetings by observing the interactions between patients, relatives, and staff. Using Goffman's dramaturgical theory, supplemented by positioning theory, we illustrate, through four cases, how the participants negotiate their opinions by enacting positions like performer, director, audience, and nonperson. Patient participation takes place when the family meetings are characterized by respect and empathy, when the staff restore and elicit patients' and relatives' preferences, and there exist real alternative outcomes of the meetings. The emphasis should be on meeting structure, group composition, and preparation of the patient team. The findings are valuable for staff, patient organizations, and policy makers responsible for program development and tools to optimize patient participation within family meetings.

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.

Health-care professionals' experiences of patient participation among older patients in intermediate care-At the intersection between profession, market and bureaucracy

Background

Patient participation is a key concern in health care. Nevertheless, older patients often do not feel involved in their rehabilitation process. Research states that when organizational conditions exert pressure on the work situation, care as a mere technical activity seems to be prioritized by the health‐care staff, at the expense of patient involvement.

Objective

The aim of this article is to explore how health‐care professionals experience patient participation in IC services, and explain how they perform their clinical work balancing between the patient's needs, available resources and regulatory constraints.

Design

Using a framework of professional work and institutional logics, underpinned by critical realism, we conducted semi‐structured interviews with 18 health‐care professionals from three IC institutions.

Results

IC appears as an important service in the patient pathway for older people with a great potential for patient participation. However, health care staff may experience constraints that prohibit them from using professional discretion, which is perceived as a threat to patient participation. Further, they may adopt routines that simplify their interactions with patients. Our results call for more emphasis on an individualized rehabilitation process and a recognition that psychological and social aspects are critical for patient participation in IC.

Conclusion

Patients interact in the face of conflicting institutional priorities or protocols. The study adds important knowledge about the practice of patient participation in IC from a front‐line provider perspective. Underlying mechanisms are identified to understand and recommend how to facilitate patient participation at different levels in narrowing the gap between policy and clinical work in IC.

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.

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.

Allocation of home care services by municipalities in Norway: a document analysis

Background

In Norway, elder care is primarily a municipal responsibility. Municipal health services strive to offer the ‘lowest level of effective care,’ and home healthcare services are defined as the lowest level of care in Norway. Municipalities determine the type(s) of service and the amount of care applicants require. The services granted are outlined in an individual decision letter, which serves as a contract between the municipality and the home healthcare recipient. The purpose of this study was to gain insight into the scope and duration of home healthcare services allocated by municipalities and to determine where home care recipients live in relation to home healthcare service offices.

Methods

A document analysis was performed on data derived from 833 letters to individuals allocated home care services in two municipalities in Northern Norway (Municipality A = 500 recipients, Municipality B = 333 recipients).

Results

In Municipality A, 74% of service hours were allotted to home health nursing, 12% to practical assistance, and 14% to support contact; in Municipality B, the distribution was 73%, 19%, and 8%, respectively. Both municipalities allocated home health services with no service end date (41% and 85% of the total services, respectively). Among recipients of “expired” services, 25% in Municipality A and 7% in Municipality B continued to receive assistance.

Conclusions

Our findings reveal that the municipalities adhered to the goal for home care recipients to remain at home as long as possible before moving into a nursing home. The findings also indicate that the system for allocating home healthcare services may not be fair, as the municipalities lacked procedures for revising individual decisions. Our findings indicate that local authorities should closely examine how they design individual decisions and increase their awareness of how long a service should be provided.

Nurses’ emotional challenges in providing home care in Norway

The aim of this study was to examine registered nurses’ experiences of emotional challenges when providing home care for older patients. Previous studies have shown that home care nurses encounter increased responsibilities and emotional challenges when caring for older patients with multiple diagnoses. However, to date, what these emotional challenges consist of has been insufficiently investigated. A qualitative study, inspired by a phenomenological approach, was conducted. Eleven registered nurses employed in home care services in Norway were selected for semi-structured interviews, and three main challenges were identified using meaning condensation: time pressure, feeling provoked by the behaviour of a patient and feeling overpowered by emotions when a patient was in the terminal stage of his or her illness. Our conclusion is that when nurses are confronted with a patient’s vulnerability, they are also confronted with their own vulnerability.

Older Patients’ and Next of Kin’s Perspectives on Continuity in Long-Term Home Health Care

The study explored how 125 older patients and 92 next of kin experienced and assessed continuity in long-term home health care. Data were collected by means of structured interviews. A majority of the patients indicated that having a high number of health care personnel involved in their care was not problematic. For patients, informed and skilled health personnel along with knowing the visiting personnel may compensate for a high number of personnel. For next of kin, accepting a high number of personnel was related to the carers being informed about the patient’s situation. This study indicates that, in terms of patient satisfaction, the overall quality of care is more important than the number of people providing the care.

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.

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.

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.

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.

Rationing home-based nursing care: professional ethical implications

The purpose of this study was to investigate nurses' decisions about priorities in home-based nursing care. Qualitative research interviews were conducted with 17 nurses in home-based care. The interviews were analyzed and interpreted according to a hermeneutic methodology. Nurses describe clinical priorities in home-based care as rationing care to mind the gap between an extensive workload and staff shortages. By organizing home-based care according to tight time schedules, the nurses' are able to provide care for as many patients as possible. Furthermore, legal norms set boundaries for clinical priority decisions, resulting in marginalized care. Hence, rationing care jeopardizes important values in the nurse-patient relationship, in particular the value of individualized and inclusive nursing care. The findings are highly relevant for clinical practice, since they have major implications for provision of nursing care. They revive debates about the protection of values and standards of care, and nurses' role and responsibility when resources are limited.