Ethical challenges related to elder care. High level decision-makers' experiences

Decision Inertia in Critical Incidents

Abstract. When presented with competing options, critical incident decision makers often struggle to commit to a choice (in particular when all options appear to yield negative consequences). Despite being motivated to take action in disasters, terrorism, major investigations, and complex political interventions, decision makers can become inert, looping between phases of situation assessment, option generation, and option evaluation. This “looping” is functionally redundant when it persists until they have lost the opportunity to take action. We define this as “decision inertia”: the result of a process of (redundant) deliberation over possible options and in the absence of any further useful information. In the context of critical incidents (political, security, military, law enforcement) we have discovered that rather than disengaging and avoiding difficult choices, decision makers are acutely aware of the negative consequences that might arise if they failed to decide (i.e., the incident would escalate). The sensitization to possible future outcomes leads to intense deliberation over possible choices and their consequences and, ultimately, can result in a failure to take any action in time (or at all). We (i) discuss decision inertia as a novel psychological process of redundant deliberation during crises; (ii) define the concept and discuss the emerging studies in support of our tentative hypotheses regarding how the cognitively active process of deliberation can result in complete behavioral inactivity; and (iii) suggest recommendations and interventions for combatting inertia.

Ethical challenges

Introduction:

To meet and take care of people with dementia implicate professional and moral challenges for caregivers. Using force happens daily. However, staff also encounter challenges with the management in the units. Managing the caretaking function is also significant in how caretakers experience working in dementia care.

Purpose:

The purpose of this study is to explore the caregiver’s experiences with ethical challenges in dementia care settings and the significance of professional leadership in this context.

Method:

The design is qualitative, and data appear through narrative interviews. A total of 23 caretakers participated in the study. The transcribed interviews were subjected to a phenomenological-hermeneutical interpretation.

Ethical considerations:

The respondents signed an informed consent for participation prior to the interviews. They were assured anonymity and confidentiality in the publication of the data. Ricoeur’s method for interpretation ensures anonymity as the researcher relates to the data as one collective text. The study is part of a larger research project in ethics, in its entirety approved in line with the Helsinki Convention.

Results:

The findings show that the caretakers experienced inadequacy. Some of them described a negative work atmosphere where they experienced that their leaders did not take them seriously. Because of this, informal negative sub-groups functioned as an exclusive debriefing arena. Some of the informants described the opposite experience where the leaders actively supported them.

Discussion:

The analyses of the findings are discussed in light of the concepts of trust and mistrust in leadership.

Conclusion:

There is a correlation between the leadership and the caregivers’ experience of being in difficult situations.

Swedish politicians’ view of obstacles when dealing with priority settings in health care

Purpose

– The purpose of this paper is to identify and describe main obstacles for politicians when dealing with healthcare priority setting.

Design/methodology/approach

– The study had an exploratory descriptive design based on interviews with 18 politicians from two different county councils in Sweden. The interviews were analyzed using inductive qualitative content analysis.

Findings

– The politicians highlighted the importance of, and difficulties in, communicate political missions; the politicians in this study saw the media as not always being fair watchdogs, implying that possibly important but unpopular prioritizing decisions were not made because of the risks of being badly reported and therefore not re-elected. Breaking up established structures in care practice is difficult and change takes time, partly because of existing higher level financing and rules and the system’s traditional separation of facilities and services. Although the politicians highlighted their limited power to influence and control resource allocation they could give small and “lower profile”, low-prioritized disciplines control of their own budgets and base payments on the results the disciplines accomplished.

Originality/value

– This study highlights the difficulties that politicians experience, for example, having to take unpleasant decisions and thereby run the risk of being scrutinized by media, which in turn could influence how effectively tax money is being used.

Assessment of ethical ideals and ethical manners in care of older people

The aim of this study is to establish structured clusters and well-defined ontological entities (nodes) describing ethical values as both ideal and opportunity for ethical manner as perceived by thecaregiver.In this study, we use Bayesian Belief Networks (BBNs) to analyse ethical values (ethos) and ethical manners in daily work with older people. Material is based on questionnaire data collected by the instrument for the self-assessment of individual ethos in the care of older people(ISAEC) in spring 2007 in a municipality in Western Finland. This study is unique in its kind, both concerning the selected approach and methodological questions. BBNs have not been used significantly in nursing research, nor are there any studies that examine the ethical possibilities with focus on the probable effects upon changing conditions.

Dignity of older people in a nursing home: narratives of care providers

The purpose of this study was to illuminate the ethically difficult situations experienced by care providers working in a nursing home. Individual interviews using a narrative approach were conducted. A phenomenological-hermeneutic method developed for researching life experience was applied in the analysis. The findings showed that care providers experience ethical challenges in their everyday work. The informants in this study found the balance between the ideal, autonomy and dignity to be a daily problem. They defined the culture they work in as not supportive. They also thought they were not being seen and heard in situations where they disagree with the basic values of the organization. The results are discussed in terms of Habermas's understanding of modern society. Care settings for elderly people obviously present ethical challenges, particularly in the case of those suffering from dementia. The care provider participants in this study expressed frustration and feelings of powerlessness. It is possible to understand their experiences in terms of Habermas's theory of modern society and the concept of the system's colonization of the life world.

Malnutrition in elder care: qualitative analysis of ethical perceptions of politicians and civil servants

BACKGROUND

Few studies have paid attention to ethical responsibility related to malnutrition in elder care. The aim was to illuminate whether politicians and civil servants reason about malnutrition in elder care in relation to ethical responsibility, and further about possible causes and how to address them.

METHOD

Eighteen elected politicians and appointed civil servants at the municipality and county council level from two counties in Sweden were interviewed. They worked at a planning, control and executive level, with responsibility for both the elder care budget and quality of care. Qualitative method was used for the data analysis.

RESULTS

Two themes emerged from their reasoning about malnutrition related to ethical responsibility. The theme assumed role involves the subthemes quality of care and costs, competent staff and govern at a distance. Old and ill patients were mentioned as being at risk for malnutrition. Caregivers were expected to be knowledgeable and stated primary responsible for providing adequate nutritional care. Extended physician responsibility was requested owing to patients' illnesses. Little was reported on the local management's role or on their own follow-up routines. The theme moral perception includes the subthemes discomfort, trust and distrust. Feelings of discomfort concerned caregivers having to work in a hurried, task-oriented manner. Trust meant that they believed for the most part that caregivers had the competence to deal appropriately with nutritional care, but they felt distrust when nutritional problems reappeared on their agenda. No differences could be seen between the politicians and civil servants.

CONCLUSION

New knowledge about malnutrition in elder care related to ethical responsibility was illuminated by persons holding top positions. Malnutrition was stressed as an important dimension of the elder care quality. Governing at a distance meant having trust in the staff, on the one hand, and discomfort and distrust when confronted with reports of malnutrition, on the other. Distrust was directed at caregivers, because despite the fact that education had been provided, problems reappeared. Discomfort was felt when confronted with examples of poor nutritional care and indicates that the participants experienced failure in their ethical responsibility because the quality of nutritional care was at risk.

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

The purpose of the study was to investigate nurses' priority decisions and the provision of home-based nursing care services. Interviews were conducted with 17 nurses in various positions in this service. The data were interpreted and analyzed according to interpretive hermeneutic methodology. The authors particularly address the nurses' descriptions of the role of the patient and his or her family members for the provision of home-based care. Cooperative patients and family members represent an important resource for care and can make it possible for nurses to provide services for all the patients on an egalitarian basis and to prioritize those who live alone. However, demanding and resourceful patients and family members may "rule" the service at the expense of other patients who also have legitimate care needs--a practice that the nurses describe as unfair. In this article, the authors discuss how a fair and impartial distribution of common benefits can be achieved without some parties being unjustly treated.