This article provides a deeper understanding of how meaning can be created in everyday life at a nursing home. It is based on a primary study concerning dignity involving 12 older people living in two nursing homes in Sweden. A secondary analysis was carried out on data obtained from three of the primary participants interviewed over a period of time (18—24 months), with a total of 12 interviews carried out using an inductive hermeneutic approach. The study reveals (...) that sources of meaning were created by having a sense of: physical capability, cognitive capability, being needed, and belonging. Meaning was created through inner dialogue, communication and relationships with others. A second finding is that the experience of meaning can sometimes be hard to realize. (shrink)

Six case studies on nursing home staff attitudes to patient autonomy have been analysed. The case studies are based on six polarities within autonomy, as developed by Collopy. In total, 189 professional caregivers, comprising the staff of 13 nursing homes in the county of Stockholm, Sweden, responded to questions based on the case studies. Results show that the attitudes within each professional category had a high level of internal correspondence. Nurses consistently supported patient preferences to the highest (...) degree, followed by assistant nurses and auxiliary staff. Nurses' aides ranked lowest in supporting patient preferences. In only one of the cases were background variables of significance. (shrink)

Background Making the right decisions, while simultaneously showing respect for patient autonomy, represents a great challenge to nursing home staff in the issues of life-prolonging treatment, hydration, nutrition and hospitalisation to dying patents in end-of-life. Objectives To study how physicians and nurses protect nursing home patients' autonomy in end-of-life decisions, and how they justify their practice. Design A qualitative descriptive design with analysis of the content of transcribed in-depth interviews with physicians and nurses. Participants Nine physicians and ten (...) nurses in 10 nursing homes in Norway. Results and interpretations Assessment of the patient's competence to consent to treatment is almost absent. The physicians build their practice on the principles of beneficence and nonmaleficence. Nurses tend to trust the patients' rejection of life support, even when the patients have difficulty speaking or suffer from dementia. Relatives were, according to the health personnel, included in decision-making processes to a very limited extent. However, futile life support is sometimes provided contrary to the physicians' judgement of what constitutes the patient's best interest on occasions when they are pressurised by next of kin. Conclusions The study reveals a need to improve decision-making routines according to ethical ideals and legislation. Conflicts between relatives and healthcare professionals in the decision-making process deflect the focus from searching for the best possible treatment for the terminal patient. Further discussion is required as to whether the concept of autonomy is applicable in situations in which the patient is impaired and dying. (shrink)

In this article we report findings from a qualitative study that explored how doctors and nurses in nursing homes describe professional collaboration around dying patients. The study also examined the consequences this can have for the life-prolonging treatment of patients and the care of them and their relatives. Nine doctors and 10 nurses from 10 Norwegian nursing homes were interviewed about their experience of decision-making processes on life-prolonging treatment and care. The findings reveal that the frameworks (...) for the professional collaboration and organization of physicians and nurses prevent patient treatment and care complying with ethical considerations and the law. These conditions have a challenging impact on the care of dying patients and their relatives. (shrink)

Background Family involvement in nursing homes is generally recognized as highly valuable for residents, staff and family members. However, family involvement continues to be challenging in practice. Aim To contribute to the dialogue about family involvement and develop strategies to improve family involvement in the nursing home. Methods This interpretative synthesis consists of a thematic analysis and care ethical interpretation of issues regarding family involvement from the perspective of families in nursing homes reported in literature. (...) Findings This study reveals the complexities of family involvement in the nursing home by drawing attention to the moral dimension of the issues experienced by families, as seen through the theoretical lens of Baier’s care ethical concept of trust as a theoretical lens. The synthesis of literature resulted in a thematic categorization of issues reported by families, namely, family–staff relationship, psychosocial factors and organizational circumstances. The care ethical interpretation of the synthesis of literature showed that the concept of trust resonates with all reported issues. Trust evolves over time. Early issues are mostly related to getting to know each other. Secondly, families want to experience that staff are competent and of good will. Difficult feelings families may have, such as guilt or loneliness, and dealing with the deterioration of the loved one puts families in a vulnerable position. This power imbalance between family and staff impedes a trusting relationship. Issues related to organizational circumstances, such as understaffing, also undermine families' trust in staff and the nursing home. Discussion and conclusion Baier’s theoretical concept of trust provides a deeper insight into the moral dimension of family involvement from the perspective of families in the nursing home. To improve family involvement in practice, we propose to aim future interventions at reinforcing trust in the relationship between family and staff as well as in the organizational context in which these care relationships occur. (shrink)

This paper applies a relational and familial ethic to address concerns relating to nursing home deaths and advance care planning during Covid‐19 and beyond. The deaths of our elderly in nursing homes during this pandemic have been made more complicated by the restriction of visitors even at the end of life, a time when families would normally be present. While we must be vigilant about preventing unnecessary deaths caused by coronavirus outbreaks in nursing homes, some (...) deaths of our elders are inevitable. Thus, it is essential that advanced care planning occurs in a way that upholds the familial and relational aspects of elders’ lives that often matter to them the most. We invoke concepts from feminist ethicists like Hilde Lindemann and Eva Kittay and introduce Avery Weisman and Thomas Hackett’s concept of “appropriate death” to suggest better ways of planning for those deaths of our elderly that cannot be avoided. Our hope is to allow for deaths that are as meaningful as possible for both the elderly and the family members who survive them. (shrink)

Background: Studies have demonstrated the extensive use of coercion in Norwegian nursing homes, which represents ethical, professional as well as legal challenges to the staff. We have, however, limited knowledge of the experiences and views of nursing home patients and their relatives. Objectives: The aim of this study is to explore the perspectives of nursing home patients and next of kin on the use of coercion; are there situations where the use of coercion can be defended, (...) and if so, under which circumstances? Methods: The data are based on individual interviews with 35 patients living in six nursing homes and seven focus group interviews with 60 relatives. Ethical considerations: Participation was based on written informed consent, and the study was approved by the Regional Committees for Medical and Health Research Ethics. Results: More than half of the patients and the majority of the relatives accepted the use of coercion, trusting the staff to act in the patient’s best interest. However, the acceptance of coercion is strongly related to the patients’ lack of understanding, to prevent health risks and to preserve the patient’s dignity. Conclusion: The majority of nursing home patients and relatives accepted the use of coercion in specific situations, while at the same time they emphasised the need to try alternative strategies first. There is still a need for good qualitative research on the use of coercion in nursing homes, especially with a closer focus on the perspectives and experiences of nursing home patients. (shrink)

The purpose of this study was to explore and interpret the meaning of relatives’ experiences of encounters with nurses when visiting residents in nursing homes. Thirteen relatives of residents in three nursing homes in Sweden were interviewed. The interviews were tape‐recorded and transcribed verbatim. The method used was hermeneutical text analysis. Four themes emerged in the analysis and interpretation of the whole text: ‘being paid attention to’, ‘being ignored’, ‘being involved’ and ‘being safe and secure’. A (...) further interpretation of the findings shows a deeper understanding of the meaning of relatives. This meaning was revealed as being invited into an encounter with nurses and gave a sense of community but the opposite was being ignored and left outside. This study gives a deeper understanding of the meaning of encounters between relatives and nurses in nursing homes; it also illuminates how these encounters also can affect the care of the residents. This new understanding can hopefully offer support for nurses during their encounters with relatives and optimise the ability to provide a positive outcome for residents in nursing homes. (shrink)

BackgroundEthically challenging critical events and decisions are common in nursing homes. This paper presents nursing home doctors’ descriptions of how they include the patient and next of kin in end-of-life decisions.MethodsWe performed ten focus groups with 30 nursing home doctors. Advance care planning; aspects of decisions on life-prolonging treatment, and conflict with next of kin were subject to in-depth analysis and condensation.ResultsThe doctors described large variations in attitudes and practices in all aspects of end-of-life decisions. In (...) conflict situations, many doctors were more concerned about the opinion of next of kin than ensuring the patient’s best interest.ConclusionsMany end-of-life decisions appear arbitrary or influenced by factors independent of the individual patient’s values and interests and are not based on systematic ethical reflections. To protect patient autonomy in nursing homes, stronger emphasis on legal and ethical knowledge among nursing home doctors is needed. (shrink)

The overall purpose of this cross-country Nordic study was to gain further knowledge about maintaining and promoting dignity in nursing home residents. The purpose of this article is to present results pertaining to the following question: How is nursing home residents’ dignity maintained, promoted or deprived from the perspective of family caregivers? In this article, we focus only on indignity in care. This study took place at six different nursing home residences in Sweden, Denmark and Norway. Data (...) collection methods in this part of this study consisted of individual research interviews. Altogether, the sample consisted of 28 family caregivers of nursing home residents. The empirical material was interpreted using a hermeneutical approach. The overall theme that emerged was as follows: ‘A feeling of being abandoned’. The sub-themes are designated as follows: deprived of the feeling of belonging, deprived of dignity due to acts of omission, deprived of confirmation, deprived of dignity due to physical humiliation, deprived of dignity due to psychological humiliation and deprived of parts of life. (shrink)

Nursing homes' ethics committees play a role in designing policies to assure ethical care. The administrative structure of nursing homes is not as large as that of hospitals. Nursing home staff and administration can respond to medical accidents in a way that treats family unethically and does serious harm to the facility. This paper describes incidents in which nursing homes attempted to conceal accidental deaths. It describes how such incidents are discovered, and the (...) consequences of such efforts, and suggests ways to prevent such incidents.This paper presents a retrospective review of a convenience sample of eight cases in which it was discovered that a nursing home attempted to conceal an accidental death. The effort to conceal an accidental death requires a coordinated effort to: [1] limit dissemination of information about the accident by staff and records, [2] decrease suspicion about the death, and [3] decrease the likelihood that an inquiry, if launched, will succeed. This effort begins as a reflexive, emotional and defensive response to the accident and consolidates as an institutional strategy to conceal both the accident and the concealment. The effort is coordinated by administrators who coerce cooperation from front line staff, alter medical records, and fail to follow reporting procedures. The attempt to conceal a lethal accident adversely affects the facility and the healthcare system. Ethics committees should work with professional organizations and administrator to assure proper management and disclosure of harmful accidents. (shrink)

ZusammenfassungDerzeit gibt es in Österreich kein in allen Bundesländern einheitlich etabliertes Betreuungsmodell eines „Heimarztes“ für Pflegeheime. Im Bundesland Wien werden seit mehr als 100 Jahren chronisch Kranke und hochgradig pflegebedürftige Menschen in den städtischen Pflegeeinrichtungen und in einigen Institutionen geistlicher Träger rund um die Uhr von angestellten geriatrisch versierten ÄrztInnen betreut. Die Rechtsform dieser Häuser entspricht prinzipiell der einer „Pflegeanstalt für Chronisch Kranke“ nach dem Österreichischen Krankenanstaltengesetz. Aber auch andere Träger in Wien und Niederösterreich beschäftigen angestellte ÄrztInnen an Bettenstationen von (...) Pflege- und Wohnheimen. Der Bedarf nach einer kontinuierlichen, fachlich spezialisierten ärztlichen Betreuung ergibt sich vor allem aus der Notwendigkeit der Therapie psychiatrischer Erkrankungen im hohen Alter mit Psychopharmaka, der komplexen Multimorbidität und Polypharmazie, sowie aus dem Bedarf nach rehabilitativen Maßnahmen bzw. palliativer Begleitung am Lebensende. Mit dieser Aufgabenstellung sind geriatrisch nicht adäquat ausgebildete bzw. nicht in den Pflegeheimen integrierte ÄrztInnen häufig überfordert. Die Konsequenzen davon sind häufige Spitalseinweisungen bzw. suboptimale ärztliche Betreuung. Als notwendige Maßnahmen zur Qualitätssicherung in geriatrischen Pflegeeinrichtungen ist daher bundesweit die Implementierung von qualifizierten HeimärztInnen nach niederländischem Vorbild zu fordern. (shrink)

Objectives: Efficient procedures for obtaining informed (proxy) consent may contribute to high influenza vaccination rates in nursing homes. Yet are such procedures justified? This study’s objective was to gain insight in informed consent policies in Dutch nursing homes; to assess how these may affect influenza vaccination rates and to answer the question whether deviating from standard informed consent procedures could be morally justified. Design: A survey among nursing home physicians. Setting & Participants: We sent a (...) questionnaire to all (356) nursing homes in the Netherlands, to be completed by one of the physicians. Results: We received 245 completed questionnaires. As 21 institutions appeared to be closed or merged into other institutions, the response was 73.1% (245/335). Of all respondents 81.9% reported a vaccination rate above 80%. Almost 50% reported a vaccination rate above 90%. Most respondents considered herd immunity to be an important consideration for institutional policy. Freedom of choice for residents was considered important by almost all. Nevertheless, 106 out of 245 respondents follow a tacit consent procedure, according to which vaccination will be administered unless the resident or her proxy refuses. These institutions show significantly higher vaccination rates (p < 0.03). Conclusions: In our discussion we focus on the question whether tacit consent procedures can be morally justifiable. Such procedures assume that vaccination is good for residents either as individuals or as a group. Even though this assumption may be true for most residents, there are good reasons for preferring express consent procedures. (shrink)

Background: Ought nursing homes to establish clinical ethics committees? An answer to this question must begin with an understanding of how a clinical ethics committee might be beneficial in a nursing home context – to patients, next of kin, professionals, managers, and the institution. With the present article, we aim to contribute to such an understanding. Aim: We ask, in which ways can clinical ethics committees be helpful to stakeholders in a nursing home context? We describe (...) in depth a clinical ethics committee case consultation deemed successful by stakeholders, then reflect on how it was helpful. Research design: Case study using the clinical ethics committee’s written case report and self-evaluation form, and two research interviews, as data. Participants and research context: The nursing home’s ward manager and the patient’s son participated in research interviews. Ethical considerations: Data were collected as part of an implementation study. Clinical ethics committee members and interviewed stakeholders consented to study participation, and also gave specific approval for the publication of the present article. Findings/results: Six different roles played by the clinical ethics committee in the case consultation are described: analyst, advisor, support, moderator, builder of consensus and trust, and disseminator. Discussion: The case study indicates that clinical ethics committees might sometimes be of help to stakeholders in moral challenges in nursing homes. Conclusions: Demanding moral challenges arise in the nursing home setting. More research is needed to examine whether clinical ethics committees might be suitable as ethics support structures in nursing homes and community care. (shrink)

McCLOSKEY R. Nursing Inquiry 2011; 18: 154–164The ‘mindless’ relationship between nursing homes and emergency departments: what do Bourdieu and Freire have to offer?This paper explicates the long-standing and largely unquestioned adversarial relationship between nurses working in the nursing home (NH) and the emergency department (ED). Drawing on the author’s own research on resident ED transfers, this paper reports on the conflict and tension that can arise when residents transfer between the two settings. The theoretical concepts of (...) mindlessness, habitus, social capital and oppression are deployed to understand the contextual nature of the social relations that exist between NH and ED practitioners and between practitioners and residents. This theoretical discussion offers the potential to uncover the social relations that give rise to problematic transfers which may lead to alternative and more productive NH to ED transfers. (shrink)

Background:Ethical issues are increasingly being reported by care-providers; however, little is known about the nature of these issues within the nursing home. Ethical issues are unavoidable in healthcare and can result in opportunities for improving work and care conditions; however, they are also associated with detrimental outcomes including staff burnout and moral distress.Objectives:The purpose of this review was to identify prior research which focuses on ethical issues in the nursing home and to explore staffs’ experiences of ethical issues.Methods:Using (...) a systematic approach based on Aveyard (2014), a literature review was conducted which focused on ethical and moral issues, nurses and nursing assistants, and the nursing home.Findings:The most salient themes identified in the review included clashing ethical principles, issues related to communication, lack of resources and quality of care provision. The review also identified solutions for overcoming the ethical issues that were identified and revealed the definitional challenges that permeate this area of work.Conclusions:The review highlighted a need for improved ethics education for care-providers. (shrink)

Patients in nursing homes sometimes give accounts of episodes in which they feel their autonomy and/or self-respect are violated as a result of the care they receive from nursing staff. In these ethically difficult care situations nurses use strategies such as negotiation, explanation and, in some cases, restraint. This study investigates how nurses apply these strategies to resolve ethical dilemmas in such a way that patients experience respect rather than violation. Critical issues that will be discussed include (...) the definition of ethically difficult care situations in nursing homes and the identification of strategies for resolving such situations. Examples of the use of three strategies are presented. The use of negotiation, restraint and explanation are discussed in order to ensure respect for patients’ autonomy and thus to optimize health care outcomes. (shrink)

The ethical dimension of care work is less explored in Chinese long-term care (LTC) settings. This paper accentuates care ethics embodied by direct care workers (DCWs) from an ethnographic study of care at Sunlight Nursing Home in central China. I include the notion of xiao (filial piety) to construe care ethics by engaging both feminist and intersectional approaches. Empirical findings highlight the narrative of mei banfa (‘there is nothing you can do about it’) in revealing the complexity of caregiving (...) in a commercialised environment where both physical and emotional care intertwine. Mei banfa compels DCWs to invoke their agency in care practice despite inadequate support from the nursing home and negative social portrayals of care work. It is a cognitive coping strategy of DCWs to harness their energy in upholding care ethics for both the elderly residents and their own family members. Such commitment is unlikely to be sustained if structural barriers continue to impede the recognition of care labour as part of social production. Arguably, an ethically informed approach to both policymaking and care practice gives voice to human interdependency in care work and affords ways to reimagine a caring future. (shrink)

Families frequently act as substitute decisionmakers for their older members who suffer from diminished mental capacity to make and express their own medical choices. Substitute decisionmaking takes on particular ethical and legal urgency within the nursing home environment, especially when choices concern potential medical treatment near the end of the nursing home resident's life. This article examines current legal mechanisms in the United States that enable a family to make substitute medical decisions, the ethical underpinnings of those mechanisms, (...) and specific ethical and legal considerations implicated by their application to the nursing home setting. The article offers advice to nursing home professionals, including physicians, in working with families as substitute decisionmakers. (shrink)

Our 2021 article, "Dying Well in Nursing Homes During COVID-19 and Beyond: The Need for a Relational and Familial Ethic," addresses the response to the COVID-19 pandemic within nursing homes and the impact it had on the lives of residents, care providers, and families. We acknowledge that, at the height of the pandemic, when infection and death rates were soaring in these facilities, extreme "lockdown" measures may have been justified; but these measures resulted in significant relational (...) costs. The collateral damage caused by these lockdown measures included extreme isolation, loss of community, and experiences of confusion, depression, and mental decline for the elderly residents that... (shrink)

Background:Palliative care is acknowledged as an appropriate approach to support older people in nursing homes. Ethical issues arise from many aspects of palliative care provision in nursing homes; however, they have not been investigated in this context.Aim:To explore the ethical issues associated with palliative care in nursing homes in the United Kingdom.Design:Exploratory, sequential, mixed-methods design.Methods:Semi-structured interviews with 13 registered nurses and 10 healthcare assistants (HCAs) working in 13 nursing homes in the United (...) Kingdom were used to explore ethical issues in palliative care. The ‘Ethical Issues in Palliative Care for Nursing Homes’ instrument was used to measure the frequency and level of distress arising from ethical issues through a cross-sectional survey with 69 registered nurses and 129 healthcare assistants. Data collection occurred between December 2014 and November 2015.Ethical considerations:Ethical approval was granted by Queen’s University’s School of Nursing and Midwifery Research Ethics Committee and governance sought from each nursing home’s manager.Findings:The interviews revealed three themes: ethical issues in practice; relational issues; and organisational issues. No significant differences between registered nurses and healthcare assistants were evident, confirming the patterns emerging from the interviews. Relational issues, primarily issues with residents and families, occurred most frequently and caused greater distress.Conclusion:The shared environment is key in the experience of ethical issues; therefore, multidisciplinary education is needed for ethical decision making in palliative care. Addressing staff knowledge and service organisation may reduce ethical issues locally and provide a benchmark for global change. (shrink)

Moral case deliberation (MCD) is a specific form of clinical ethics, aiming to stimulate ethical reflection in daily practice in order to improve the quality of care. This article focuses on the implementation of MCD in nursing homes and the questions how and where to organize MCD. The purpose of this study was to evaluate one way of organizing MCD in two Dutch nursing homes. In both of these nursing homes the MCD groups had (...) a heterogeneous composition and were organized apart from existing institutional communication structures. As part of a naturalistic evaluation, systematic observations, interviews and focus groups were completed. The findings indicate that the heterogeneous composition and MCD meetings separate from existing structures have benefits. However, the participants also reported negative experiences. This gives rise to the question whether a mixed MCD group which meets separately is an effective way to embed MCD as an instrument for reflection on moral issues in daily practice. We conclude that there is no single answer to that question. In the end, the two implementation strategies (i.e. within existing communication structures and a mixed MCD group) can be complementary to each other. (shrink)

This paper reports on a mail survey of Jewish nursing homes nationally regarding their compliance with the federal Patient Self-Determination Act that became effective in December, 1991. Data is presented about the extent to which institutions' religious affiliation has influenced their advance directive policies and the procedures they have adopted to implement those policies. A content analysis of written advance directive policies used in Jewish nursing homes is presented also.

Aging has become a serious social problem in China. Traditional informal long-term care is hard to sustain because of the reduction in family size and elders’ children migration to big cities. The institution offering services for the disabled elders has been a tendency. There exists a strange phenomenon: some nursing homes are difficult to enter for most disabled elders, while the other ones must search for elders to maintain operation. Therefore, for the evaluation of nursing homes, (...) two problems should be considered: selecting suitable nursing homes for disabled elders; obtaining the key factors influencing the selection of elders and helping nursing homes improve their services based on the key factors. First, we propose a new DEMATEL method for PLTSs to solve the second problem. Then, we present a novel PROMETHEE method to rank the alternatives and make a sensitivity analysis for criteria. Finally, we illustrate our proposed methods to an evaluation problem in Zhenjiang City by a case study. Based on the case study, we can obtain that our proposed methods are effective and practicable. (shrink)

This study aims to present culturally situated artefacts as depicted in nursing home environments and to analyse the underlying understandings of disciplining structures that are manifested in these kinds of places. Our personal geographies are often taken for granted, but when moving to a nursing home, geographies are glaringly rearranged. The study design is archival and cross‐sectional observational, and the data are comprised of 38 photographs and 13 videos showing environments from nursing homes. The analysis was (...) inspired by the methodological steps in Roper's and Shapira's description of conducting ethnography. The results are presented in four categories: (i) public areas, (ii) orderliness, (iii) staff's places and (iv) devices. The rearrangement of geography implies a degrading of agency and loss of authority over one's place. The places should be understood in their relation to the agents and their temporarily claims upon them. The material and immaterial artefacts, that is the items, people and behaviours, transform the nursing staff into ‘space invaders’. Future inquiries may take into consideration the ways that space invasion in participative space intersect and construct the identities of the agents it invades upon. (shrink)

This study investigates what professional caregivers working in nursing homes consider to be a good life for residents suffering from dementia. Ten caregivers were interviewed; special attention was paid to the way in which they deal with conflicting values. Transcripts of the interviews were analysed qualitatively according to the method of grounded theory. The results were compared with those from a similar, earlier study on ideals found in mission statements of nursing homes. The concepts that were (...) mentioned by most interviewed participants as important for a good life were ‘peace and quiet’, ‘going along with subjective experience’ and ‘no enforcement: the way the resident wants it’. A considerable overlap was found between the interviews and the mission statements; however, when compared with the mission statements, the interviews put less emphasis on individuality and on giving meaning, and more on offering residents pleasant activities. When faced with conflicting values, caregivers tend to make pragmatic and more or less intuitive decisions. Although this has its merits, it may be desirable to stimulate conscious reflection regarding conflict between different values. (shrink)

Discussion about a dignified death has almost exclusively been applied to palliative care and people dying of cancer. As populations are getting older in the western world and living with chronic illnesses affecting their everyday lives, it is relevant to broaden the definition of palliative care to include other groups of people. The aim of the study was to explore the views on dignity at the end of life of 12 elderly people living in two nursing homes in (...) Sweden. A hermeneutic approach was used to interpret the material, which was gathered during semi-structured interviews. A total of 39 interviews were transcribed. The analysis revealed three themes: (1) the unrecognizable body; (2) fragility and dependency; and (3) inner strength and a sense of coherence. (shrink)