Ethical issues experienced by healthcare workers in nursing homes

Decision-making

According to the Principles of Nursing Practice, informed decision-making regarding treatment and care should involve the full healthcare team, the resident and their family. ²⁵ Research suggests that nurses were more likely than doctors to include resident preferences in care decisions; ¹⁷ however, this often left them feeling stuck ‘in the middle’ of the resident, relatives and other health professionals in their attempt to provide individualised care. ²⁶

The degree of nurse involvement in decision-making varied greatly between studies. Some felt they were advocates for the resident, whereas others felt much more distanced and acted as a facilitator to assist residents and families in making their own decisions. ²⁶ While the majority of residents receiving care wanted to participate in treatment decisions, most did not achieve their desired level of involvement. ²⁷ On many occasions, the relatives and doctor made the decisions without input from the resident. ^17,28,29 Care-providers also reported a similar lack of involvement in decision-making. ²⁷

Residents were least involved in decision-making when their capacity was questionable. In such instances, the nurse saw themselves as a strong advocate for the resident’s wishes and consequently played a greater role in decision-making, for example, when dementia was present or they were too ill to verbally communicate their desires. ²⁸ In these instances, the care-providers questioned who should make treatment-related decisions which caused conflict, especially when there were concerns that the resident may become confused or distressed. ³⁰ Even when resident capacity was present, including the resident in decision-making was still found to be challenging, particularly when the resident was unwilling to acknowledge readiness for death ²⁸ or when the health professionals had a ‘paternalistic’ attitude towards care. ^13,30

While some papers reported limited inclusion of relatives, ¹⁷ most papers reported some level of shared decision-making. ²⁴ Schaffer ²⁸ found that ethical issues arose when managing relatives’ over- or under-treatment requests which may not have been in the resident’s best interest. The fear of relatives contacting the media if they were unsatisfied with care provision had resulted in futile treatments being offered and the resident’s views being overlooked. ¹⁷ Residents being overruled by relatives was also reported by McClement et al. ²⁹ and has been highlighted as an ethical issue.

Despite these issues, nurses were committed to the coordination of decision-making processes for life prolonging treatment and care, ³¹ suggesting that care-providers are aware of the importance of decision-making inclusive of both care-providers and recipients even if it can result in conflicting situations.

Restraint

The issue of using restraint was repeatedly raised as an ethical issue for staff. ⁹ Restraint has been defined as any action which restricts physical or psychological freedom, can be chemical or mechanical and may apply some form of physical or mental violence. It could be experienced positively, for example, when it provided safety or protection, when staff were protected from liability and when wellbeing was promoted. ³² However, issues arose when it was used inconsistently or as part of daily routine without explanation. In particular, the use of chemical restraints, such as sedation, was problematic and left staff feeling guilty. ^12,33 Despite a desire to minimise restraint use, nurses were conflicted between the desire to preserve resident autonomy and ensure safety and comply with institutional policy. A discrepancy was found between professional values of nursing staff and their perception of the actual use of restraints in daily practice. ³⁴

Communication with other healthcare professionals

Communication within the healthcare team ³⁰ has been reported as a common ethical issue. A lack of communication or intervention during painful situations, and when a colleague requested the nurse to carry out an ethically questionable task, was experienced as ethically conflicting for nurses. ¹⁹ Breakdowns in communication resulted in feelings of ‘not being heard’, which led to a sense of anger, powerlessness and bad conscience, and consequently increased staff turnover rate.

Communication with the resident and their relatives

Nurses reported their role as a ‘middleman’ or facilitator of communication between families, residents and healthcare professionals. ³⁵ Conversations with the family and resident centred around pain management, avoiding unnecessary hospital admissions, life prolonging treatments and practical arrangements, both during the preliminary and terminal phases. ³⁶ Healthcare Aides felt they were more aware of the resident’s true wishes than the family as they spent more time together. ²⁹ Therefore, if the relative’s wishes were not reflective of the Healthcare Aide’s believed wishes, this resulted in an ethical issue. Disagreements between the nurse and the family have arisen when next-of-kin wanted to continue life prolonging treatment contrary to staff opinion. ³⁶ Ethical issues associated with informing relatives were experienced frequently by 55% of nursing assistants and 68% of nurses, ²⁴ leading to a desire to increase ethical competence and a request for issues to be dealt with more systematically.

Lack of knowledge and education

Knowledge was seen to facilitate understanding of all perspectives ¹⁴ and as a means of assisting in risk identification for residents with dementia. ¹⁵ Doctors were more confident in nurses who received additional training in geriatric or palliative care, improving the overall quality of the coordination of care. ³¹ While an increase in formal education was suggested by staff to improve confidence during emotionally challenging end-of-life conversations, ³⁶ inadequate knowledge was associated with unsatisfactory care. Increased knowledge of ethics was seen as a means of reducing challenges, ¹⁸ which may explain why a professional need for knowledge was experienced. ³⁰

However, evidence suggests that nurses were often unaware of empirical information in various aspects of care. ³⁵ Furthermore, a lack of knowledge by short-term temporary staff, younger nurses and untrained staff has been associated with a lack of humane treatment which threatens the resident’s integrity. ³⁸ Lack of knowledge is associated with the prior and ongoing education of care-providers which may need to be addressed to improve this situation. Knowledge of the scope of nurse responsibility was also lacking, for example, their role as resident advocate, ¹⁷ in providing spiritual care, ²⁸ in feeding decisions or discussing treatment risks, ³⁵ individual responsibility for moral judgements and actions that comport with morality, ³⁵ and what to do when their professional responsibility is undermined. ²⁴ Unmet needs and unclear boundaries regarding duty of care contributed to the ethical issues associated with managing a personal response to care. ^16,28 A lack of ethical education was suggested to result in professional needs being overlooked, such as the need for knowledge and education, and the need to address the emotional aspect of caring. ^28,30,36

Lack of time

Studies considering time ethics found that talking together, finding calmness, meeting the person in their own time and knowing the person’s life history were meaningful aspects of good care provision; however, a lack of time would threaten this aspect of care. ³⁹ Juthberg et al. ⁴⁰ found that Finnish nursing staff did not feel they had sufficient time to provide adequate care, and this contributed most significantly to a troubled conscience. A lack of time due to insufficient resources and involvement in tasks other than direct care reduced the ability to provide stability and attention to residents. ³⁷ Understaffing caused tension between getting work done quickly and in an individualised manner as time allocation per resident was reduced. ⁴¹

Access to doctors

Many benefits were reported in nursing homes in Norway when access to physicians was high. In nursing homes where physicians held higher percentage posts, advanced directives were more likely to be discussed on admission, medical records were up to date, residents were involved in decision-making where possible and the roles and responsibilities of the healthcare team were clearly defined. ³¹ When doctor visits averaged 4 to 6 times a week, a position of good coordination of care was described. By increasing the doctor–patient ratio, Gjerberg et al. ³⁶ found an increase in the presence of guidelines for conversing with next of kin when the residents were in an end stage of life phase. However, despite the importance of a doctor’s presence, many studies revealed that access to a doctor was not always possible. Dreyer et al. ³¹ found that 80% of nursing homes in Norway had one doctor visit per week which was deemed very limiting when issues regarding life prolonging treatment were raised. Decision-making appeared less inclusive of the resident and the doctor did not know the resident sufficiently to reach a satisfactory level of individualised care, sudden illness was not planned for, and this resulted in an increase of unplanned admissions. Despite doctors being formally in charge of treatment decisions, nurses saw themselves as spending more time with the resident and having a better understanding of their wishes. ¹⁷ Poor resident–doctor communication was also witnessed due to limited doctor availability. ²⁸

Lack of finance

The lack of financial support could encompass all previous resource issues. Lacking financial resources was experienced as a major limiter of achieving best care ³³ and limited the beds available causing strain during nursing home placement. ²³ Nursing homes are unable to pay for more staff which would alleviate many of the other ethical issues associated with limited resources. Improving how current resources are used and reducing the pressure on care-providers may help to ease the financial issues reported.

Inability to meet individual needs

A consequence of limited resources was often the inability to meet individual needs of the residents and balance the needs of multiple residents. The nursing home structure reflects a system-driven process which has little time for individualised, resident-centred care. ⁴² This approach has resulted in ethical issues for care-providers who strive to provide high-quality, individualised care while conforming to the structure and culture of the organisation. Van der Dam et al. ⁴³ reflected upon the organisational context, within nursing homes and care homes, of scarcity of staff and space, multiple demands, a mismatch between the care needed and provided and the social climate as areas requiring moral deliberation.

Nursing home residents share a communal living space with its own rhythms and structured activities which may interfere with individual preferences. ⁹ Nurses have been provided with a set routine,. and any deviations could sometimes be perceived as problematic. As a result, the provision of perfunctory care was evident as care-providers were just ‘going through the motions’. ^29,38

Ethical issues arose when choosing between acting in one resident’s best interests and preventing other residents from coming to harm, ¹² when using restraints to prevent harm, ¹⁹ when all residents want something at once or when a resident expects staff to focus more attention on them than others. ¹⁶ Balancing multiple residents’ wellbeing was problematic when it conflicted with the concept of patient-centred care, for example, if a relative made a request which would compromise the wellbeing of other residents. ^10,32 Reports of not taking responsibility for a resident’s wellbeing ¹² were also drawn out from the literature. Staff members did not feel responsible for facilitating a resident’s request to smoke out of his room which reflected a lack of responsibility to a resident’s self-determination.

Quality of person-centred care

Care within the nursing home aims to be individualised and person-centred, meeting their needs on a physical, social, spiritual and psychological level; however, some of the studies reported difficulties in fulfilling each of these types of care. The presence of a poor psychosocial environment resulted in anxiety, restlessness and inadequate psychosocial care in one Scandinavian nursing home study. ^15,18 The inability to provide spiritual care caused further ethical issues for nurses in a Norwegian nursing home who believed it was part of their practice. ¹²

The challenge of providing individualised care increases further when the resident resists care, for example, when a resident has dementia. ⁹ Restraint was suggested as appropriate when a resident resists an activity that they usually enjoy and this aims to get them started on the activity; however, restraint was often an issue for staff and could lead to mistrust. ³³ Egede-Nissen et al. ³⁹ found time to be an important method to avoid coercion when residents resisted care.

Quality of death was identified as a source of ethical issues. Decisions concerning life prolonging treatment, hydration, nutrition, euthanasia and stopping treatment were a frequently reported source of conflict. ³⁰ Residents complained their needs were not being met, ³⁷ for example, limited and insufficient pain management, which was distressing for care-providers. ^{28,29,36,41,44}

Preserving integrity and dignity

Integrity incorporates privacy, autonomy, self-respect and the values the person espouses, and ethical issues resulted when nurses felt the resident’s integrity was not respected. Teeri et al. ^38,44 highlighted three ethically problematic subtypes of integrity: psychological, physical and social. Psychological integrity was compromised when short-term or younger staff failed to show humane treatment resulting in human dignity being overlooked. Staff shortages led to a lack of individualised care and a risk of physical abuse which prevented physical integrity from being respected. Finally, upholding social integrity was difficult due to time pressures and staff shortages, causing nurses to downplay the importance of resident interaction with the outside world. The resident’s social integrity was impacted through isolation from the outside world, ^24,38 for example, not taking patients on day trips in case they exhibit difficult behaviour. ¹² Additionally, Johansson et al. ¹⁵ found that balancing integrity with other principles such as resident autonomy, in a situation when falls were a risk, provided further issues. These violations may be linked to the culture and resources of the nursing home.

The research suggests a struggle between balancing individual wellbeing and respecting other residents’ wellbeing, and the potentially detrimental impact on dignity, for example, when a resident’s family requested that they were moved to an open ward despite the staff concluding that they were better suited in a private ward. ¹⁰ While nurses understood that dignity could be upheld via caring by advocacy, ¹⁴ respecting dignity became more challenging when the culture of the nursing home involved open use of restraint, a system-driven approach to care and overlooking resident wishes. ³⁸ Furthermore, understaffing and the feeling of chaos, resulting from multiple resident groups being simultaneously cared for, compromised individual resident’s dignity. ¹⁹

Ethics environment

The organisation’s ethical structure has clear implications for staff and the residents’ experiences of ethical issues. McDaniel et al. ⁴⁵ found a positive correlation between the ethics environment in long-term care and the residents’ opinion on care and mental health status, making it a crucial factor to consider when exploring the organisational structure and quality-of-care provision.