Care-managers' professional choices: ethical dilemmas and conflicting expectations

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.

´You are not yourself anymore´: The place of the ethical demand in a practical home care context

THE STUDY'S RATIONALE

The Scandinavian nursing tradition is based on caring science as the ontological backdrop. This means that meeting the patient with openness and respect is essential in care. The experiences of an elderly woman receiving home nursing provide insight into a world many healthcare workers need to understand; meaning what is important in the encounter with the fragile old patient whose voice is not often heard in the society nor in research. Caring science with its person-oriented care clashes with the New Public Management's ideal for municipal health care in Norway, at the expense of the needs of the elderly patients.

AIMS AND OBJECTIVES

This article aims to express the phenomenon of lived experience as presented by an elderly woman, more specifically her experience of care in home nursing run according to the principles of new public management.

METHODOLOGICAL DESIGN

The article is based on an empirical narrative in the form of an individual qualitative research interview.

FINDINGS

The patient has needs that cannot be defined without the nurse having an ethical understanding of what may be important in the patient´s lifeworld. The core findings are: Feeling disregarded as a human being, Broken agreements, Surrendering in anonymous relationships and Each day is a different day with altered needs.

CONCLUSION

The system of New Public Management sets a strain on the time at hand for the nurse to develop a relationship that acknowledges and supports the patient´s life courage. The ethical demand and care ethics can explain how the patient´s will to live can be preserved, and provide knowledge of how the caregiver can best attend to the patient's ways of expressing what is important to her. Nevertheless, within the time at disposal, the nurse has an opportunity to either marginalize or strengthen the old person´s dignity.

A qualitative study of purchaser unit employees’ experiences of patient pathways from specialist healthcare to primary healthcare in Norway

Introduction

Understanding the purchaser–provider split model in the patient pathway is important. The purchaser is a key player in managing the flow between specialist and municipal healthcare services. A smoother patient transfer has been a priority in Norway, but also challenging. Accordingly, this study aims to describe and explain how the purchasers operate as liaisons during patient transfers from specialist to primary healthcare services.

Methods

Eleven interviews were conducted with employees at purchaser units in primary healthcare in Norway. The interviewees’ professional backgrounds were in nursing and physiotherapy, as well as casework, and management. The interviews took place in 2018–2019 and analyzed with Graneheim and Lundman's content analysis strategy.

Results

The interviewees’ views reflected the changes they experienced in the wake of healthcare reforms in specialist healthcare services and municipal healthcare institutions. Three themes emerged from the analyses: (1) increased efficiency requirements after the Coordination Reform, (2) better reporting systems and the need for role clarifications in contact with hospitals, and (3) the need for good assessments for safe transfer to the municipality.

Discussion

Purchaser unit employees’ experiences with patient pathways point towards a need for certain changes. There is a need for increased efficiency requirements for purchasing units, even with new electronic tools, as well as a growing need for better reporting systems and a common understanding between the service levels about what patients can expect in the municipalities.

Implementation of nursing case management to improve community access to care: A scoping review

Background

Case management is an approach used to help patients locate and manage health resources as well as to enhance effective communication among patients, families, and health systems. Nurses' role as case managers has been proven effective in reducing healthcare costs among patients with chronic diseases. However, little is known about its implementation in improving access to care in community-based settings.

Objectives

This scoping review aimed to examine the components of nursing case management in improving access to care within community settings and to identify the issues of community-based nursing case management for future implications.

Design

This study was conducted following the framework of scoping review.

Data Sources

The authors systematically searched five electronic databases (CINAHL, PubMed, Science Direct, Scopus, and Google Scholar) for relevant studies published from January 2010 to February 2021. Only original studies involving nurses as one of the professions performing case management roles in the community-based settings, providing 'access to care' as the findings, were included.

Review Methods

The article screening was guided by a PRISMA flowchart. Extraction was performed on Google Sheet, and synthesis was conducted from the extraction result.

Results

A total of 19 studies were included. Five components of nursing case management to improve access to care were identified: 1) Bridging health systems into the community, 2) Providing the process of care, 3) Delivering individually-tailored health promotion and prevention, 4) Providing assistance in decision making, and 5) Providing holistic support. In addition, three issues of nursing case management were also identified: 1) Regulation ambiguity, 2) High caseloads, and 3) Lack of continuing case management training.

Conclusion

Care coordination and care planning were the most frequent components of nursing case management associated with access to care. These findings are substantial to improve nurses' ability in performing the nursing process as well as to intensify nurses' advocacy competence for future implications.

Moral competence, moral teamwork and moral action - the European Moral Case Deliberation Outcomes (Euro-MCD) Instrument 2.0 and its revision process

Background

Clinical Ethics Support (CES) services are offered to support healthcare professionals in dealing with ethically difficult situations. Evaluation of CES is important to understand if it is indeed a supportive service in order to inform and improve future implementation of CES. Yet, methods to measure outcomes of CES are scarce. In 2014, the European Moral Case Deliberation Outcomes Instrument (Euro-MCD) was developed to measure outcomes of Moral Case Deliberation (MCD). To further validate the instrument, we tested it in field studies and revised it. This paper presents the Euro-MCD 2.0 and describes the revision process.

Methods

The revision process comprised an iterative dialogue among the authors as Euro-MCD-project team, including empirical findings from six Euro-MCD field-studies and input from European experts in CES and theory. Empirical findings contained perceptions and experiences of MCD outcomes among healthcare professionals who participated in MCDs in various settings in Norway, Sweden and the Netherlands. Theoretical viewpoints on CES, literature on goals of CES and MCD and ethics theory guided the interpretation of the empirical findings and final selection of MCD outcomes.

Results

The Euro-MCD 2.0 Instrument includes three domains: Moral Competence, Moral Teamwork and Moral Action. Moral Competence consists of items about moral sensitivity, analytical skills and virtuous attitude. Moral Teamwork includes open dialogue and supportive relationships and Moral Action refers to moral decision-making and responsible care. During the revision process, we made decisions about adding and reformulating items as well as decreasing the number from 26 to 15 items. We also altered the sentence structure of items to assess the current status of outcomes (e.g. ‘now’) instead of an assumed improvement over time (e.g. ‘better’) and we omitted the question about perceived importance.

Conclusions

The Euro-MCD 2.0 is shorter, less complex and more strongly substantiated by an integration of empirical findings, theoretical reflections and dialogues with participants and experts. Use of the Euro-MCD 2.0 will facilitate evaluation of MCD and can thereby monitor and foster implementation and quality of MCD. The Euro-MCD 2.0 will strengthen future research on evaluation of outcomes of MCD.

Important outcomes of moral case deliberation: a Euro-MCD field survey of healthcare professionals' priorities

BACKGROUND

There is a lack of empirical research regarding the outcomes of such clinical ethics support methods as moral case deliberation (MCD). Empirical research in how healthcare professionals perceive potential outcomes is needed in order to evaluate the value and effectiveness of ethics support; and help to design future outcomes research. The aim was to use the European Moral Case Deliberation Outcome Instrument (Euro-MCD) instrument to examine the importance of various MCD outcomes, according to healthcare professionals, prior to participation.

METHODS

A North European field survey among healthcare professionals drawn from 73 workplaces in a variety of healthcare settings in the Netherlands, Norway and Sweden. The Euro-MCD instrument was used.

RESULTS

All outcomes regarding the domains of moral reflexivity, moral attitude, emotional support, collaboration, impact at organisational level and concrete results, were perceived as very or quite important by 76%-97% of the 703 respondents. Outcomes regarding collaboration and concrete results were perceived as most important. Outcomes assessed as least important were mostly about moral attitude. 'Better interactions with patient/family' emerged as a new domain from the qualitative analysis. Dutch respondents perceived most of the outcomes as significantly less important than the Scandinavians, especially regarding emotional support. Furthermore, men, those who were younger, and physician-respondents scored most of the outcomes as statistically significantly less important compared with the other respondents.

CONCLUSIONS

The findings indicate a need for a broad instrument such as the Euro-MCD. Outcomes related to better interactions between professionals and patients must also be included in the future. The empirical findings raise the normative question of whether outcomes that were perceived as less important, such as moral reflexivity and moral attitude outcomes, should still be included. In the future, a combination of empirical findings (practice) and normative reflection (theories) will contribute to the revision of the instrument.

Field-testing the Euro-MCD Instrument: Experienced outcomes of moral case deliberation

BACKGROUND

Moral case deliberation is a form of clinical ethics support to help healthcare professionals in dealing with ethically difficult situations. There is a lack of evidence about what outcomes healthcare professionals experience in daily practice after moral case deliberations. The Euro-MCD Instrument was developed to measure outcomes, based on the literature, a Delphi panel, and content validity testing. To examine relevance of items and adequateness of domains, a field study is needed.

AIM

To describe experienced outcomes after participating in a series of moral case deliberations, both during sessions and in daily practice, and to explore correlations between items to further validate the Euro-MCD Instrument.

METHODS

In Sweden, the Netherlands, and Norway, healthcare institutions that planned a series of moral case deliberations were invited. Closed responses were quantitatively analyzed. The factor structure of the instrument was tested using exploratory factor analyses.

ETHICAL CONSIDERATIONS

The study was approved in Sweden by a review board. In Norway and the Netherlands, data services and review boards were informed about the study.

RESULTS

The Euro-MCD Instrument was completed by 443 and 247 healthcare professionals after four and eight moral case deliberations, respectively. They experienced especially outcomes related to a better collaboration with co-workers and outcomes about individual moral reflexivity and attitude, both during sessions and in daily practice. Outcomes were experienced to a higher extent during sessions than in daily practice. The factor structure revealed four domains of outcomes, which did not confirm the six Euro-MCD domains.

CONCLUSION

Field-testing the Euro-MCD Instrument showed the most frequently experienced outcomes and which outcomes correlated with each other. When revising the instrument, domains should be reconsidered, combined with theory about underlying concepts. In the future, a feasible and valid instrument will be presented to get insight into how moral case deliberation supports and improves healthcare.