Austerity, by its very nature, imposes constraints by limiting the options for action available to us because certain courses of action are too costly or insufficiently cost effective. In the context of healthcare, the constraints imposed by austerity come in various forms; ranging from the availability of certain treatments being reduced or withdrawn completely, to reductions in staffing that mean healthcare professionals must ration the time they make available to each patient. As austerity has taken hold, across the United Kingdom (...) and Europe, it is important to consider the wider effects of the constraints that it imposes in healthcare. Within this paper, we focus specifically on one theorised effect—moral distress. We differentiate between avoidable and unavoidable ethical challenges within healthcare and argue that austerity creates additional avoidable ethical problems that exacerbate clinicians’ moral distress. We suggest that moral resilience is a suitable response to clinician moral distress caused by unavoidable ethical challenges but additional responses are required to address those that are created due to austerity. We encourage clinicians to engage in critical resilience and activism to address problems created by austerity and we highlight the responsibility of institutions to support healthcare professionals in such challenging times. (shrink)

Background: Demographic trends indicate growth of population aged 65 and older in Western countries. One of the greatest challenges is to provide high-quality care for all. Technological solutions designed for older people, gerontechnology, can somewhat balance the gap between resources and the increasing demand of healthcare services. However, there are also ethical issues in the use of gerontechnology that need to be pointed out. Purpose: To describe what ethical issues are related to the use of gerontechnology in the care of (...) community-dwelling older people. Methods: A scoping review was performed to identify and analyse studies concerning ethical issues when using gerontechnology in the home care of older people. The literature search was limited to studies published after 1990 and addressed to the electronic databases CINAHL, PubMed, Cochrane, Medic, IEEE Explore and Web of Science. The search was performed in July−August 2018. Data from empirical studies were analysed using thematic analysis. Ethical considerations: This scoping review was conducted in accordance with good scientific practice. The work of other researchers was respected and cited appropriately. Results: A total of 17 studies were identified. Two main themes were found. ‘Balancing between the benefits of using gerontechnology and the basic rights of older people’, consisted of the subthemes safety, privacy and autonomy. The other main theme, ‘Gerontechnology as a risk of insecurity for older people’, included the subthemes fear of losing human contact and concern and fear. Surveillance and monitoring technologies were mainly studied. Conclusion: These results suggest that there may be ethical issues related to the use of gerontechnology and they must therefore be taken into consideration when implementing technology in the care of community-dwelling older people. (shrink)

The aim was to synthesize the findings of empirical research about the unmet nursing care needs of older people, mainly from their point of view, from all settings, focusing on (1) methodological approaches, (2) relevant concepts and terminology and (3) type, nature and ethical issues raised in the investigations. A scoping review after Arksey and O’Malley. Two electronic databases, MEDLINE/PubMed and CINAHL (from earliest to December 2019) were used. Systematic search protocol was developed using several terms for unmet care needs (...) and missed care. Using a three-step retrieval process, peer-reviewed, empirical studies concerning the unmet care needs of older people in care settings, published in English were included. An inductive content analysis was used to analyse the results of the included studies (n = 53). The most frequently used investigation method was the questionnaire survey seeking the opinions of older people, informal caregivers or healthcare professionals. The unmet care needs identified using the World Health Organization classification were categorized as physical, psychosocial and spiritual, and mostly described individuals’ experiences, though some discussed unmet care needs at an organizational level. The ethical issues raised related to the clinical prioritization of tasks associated with failing to carry out nursing care activities needed. The unmet care needs highlighted in this review are related to poor patient outcomes. The needs of institutionalized older patients remain under-diagnosed and thus, untreated. Negative care outcomes generate a range of serious practical issues for older people in care institutions, which, in turn, raises ethical issues that need to be addressed. Unmet care needs may lead to marginalization, discrimination and inequality in care and service delivery. Further studies are required about patients’ expectations when they are admitted to hospital settings, or training of nurses in terms of understanding the complex needs of older persons. (shrink)

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. (shrink)

The concept of missed care refers to an irrefragable truth that required nursing care, which is left undone, occurs in the delivery of health care. As a technical concept, missed care offers nurses the opportunity to articulate a problematic experience. But what are we to make of missed care from an ethical perspective? Can nurses be held morally responsible for missed care? Ethically speaking, it is generally accepted that if a person has a moral obligation to do something, s/he needs (...) to have the capacity to do it. If a person does not have the capacity to fulfil a moral obligation, then s/he cannot be held responsible for failing to do so. This is captured by the “ought implies can” (OIC) principle. This paper brings the OIC principle to the forefront of the discussion on missed care. It is contended that nurses – qua moral agents – may be discharged from a moral obligation to carry out a required caring act because of some inability that is not of their making and therefore may not be morally responsible for missed care. However, the OIC principle may not be applied to all situations of missed care depending on their causes. In addition, following in the thought of Sapontzis (The Southern Journal of Philosophy, 1991, XXIX, 383–393) it is contended that when an original obligation to deliver a required act of care cannot be fulfilled, other obligations may be generated as summed up in the “Principle of Making Amends” and the “Principle of Appropriate Feeling.” It is the view of this paper that these further principles could prevent the OIC principle from being used to simply excuse omissions of care from a normative standard and could support the view that nurses continue to have alternative obligations to make amends and to respond with appropriate feelings to missed care. (shrink)

BackgroundRationing of care in nursing is nurses' inability to complete all care activities for patients because of scarcity in time and resource. Literature suggests that rationing of care is closely related to patient safety and quality of care. The phenomena have been defined and studied from varied perspectives and contexts. A systematic review of studies related to the concept was aimed at identifying and synthesizing the finding.MethodsThe review followed Preferred Reporting Items for Systematic Reviews and Meta‐analysis guidelines, and literature searches (...) were conducted in MEDLINE, CINAHL, PsycInfo, Web of Science and EMBASE databases. Fifty‐seven quantitative studies were included in the review.FindingsThe review observed that nursing activities addressing the emotional, educational, mobility and hygiene needs of the patients were commonly rationed. Antecedents of rationing included resource inadequacy and organizational work environment. Rationing influenced patient satisfaction, mortality and a number of adverse events and was associated with decreased job satisfaction, increased intention to leave and high turnover among nurses.DiscussionsThis review concludes that rationing in nursing is ubiquitous, embedded in the work environment and poses a threat to the professional health and philosophical base of nursing in addition to having serious implications on patients' safety. Strategies to reframe and reconsider organizational traits, and open discussion with other healthcare stakeholders can reduce rationing of nursing care. The review suggests future researchers adopt different methodological layout to study rationing. (shrink)

Care left undone, interchangeably referred to as missed care, unfinished nursing care and task incompletion, is pervasive in contemporary healthcare systems. Care left undone can result in adverse outcomes for the patient, nurse and organization. The rhetoric that surrounds care left undone infers it is a contemporary nursing phenomenon; however, a seventeenth‐century Spanish nursing treatise, Instruccion de Enfermeros (Instructions for Nurses), challenges this assumption. Instruccion de Enfermeros was an instructional guide that was written for members of the Congregation of Bernardino (...) de Obregon who worked as nurses at the Madrid General Hospital. The treatise provides a historical commentary on the daily roles, responsibilities and working conditions of the Obregonian nurses. Its content and context suggest the Obregonian nursing resource was consistently time poor due to a confluence of internal and external stressors. Consequently, the Obregonians were under considerable role strain resulting in inferior patient care. This article explores the antecedents of care left undone through a historical lens using exemplars from the 1625 edition of Instruccion de Enfermeros. Factors contributing to care left undone in Obregonian nursing will then be examined to offer insights into the similarities between what a nurse suffered 400 years ago and what exists in contemporary nursing practice. (shrink)

The concept of equality is subject to many different interpretations, and it is closely connected to similar concepts such as equity, justice, fairness, and human rights. As an ideal, equality entails many aspects that are untenable. For instance, genetic and social inequalities may never be extinct, but they can both be ameliorated by proper distribution of society's resources. Likewise, within the context of health care, equality can be promoted by proper rationing of health resources, amongst which nursing care stands out. (...) In the field of nursing, the principle of equality presents itself in various forms of ethical and deontological mandates. However, beyond good intentions and abstract notions, there is a need to examine the ways in which nurses enforce this principle in practice, within the reality of modern health systems. Although there is scarcity of qualitative evidence in the nursing care rationing literature, existing studies suggest that fair treatment pertains to a largely intuitive sense of equality which involves subjective perceptions and judgements about rationing. Nurses’ initial predisposition is to view all patients as equal and treat them in an equal manner; yet, on an individual basis, each patient has a different starting point, different needs and different prospects that render rationing decisions complex and uncertain. Equality should be accepted with its unavoidable limitations in practice and be further examined within the context of nursing care rationing, in the hope that it can be advanced in a consistent way, despite the idealistic nature in many of its aspects. (shrink)

Midwives and nurses play a critical role in safeguarding the lives of women in resource-constrained African countries. Working within the context of scarce resources may undermine their moral agency and hinder their ability to care. The purpose of this paper is to understand the influence of resource scarcity on midwifery and nursing care and practice. A critical ethnography was conducted in the obstetric department of three tertiary-level facilities in Ghana. Purposive sampling was used to recruit 30 midwives and nurses and (...) semistructured interviews, field notes and documentary materials were used to generate in-depth understanding. Ethical approval was granted from Canada and Ghana and written, and ongoing informed consent was obtained from the participants. Five conceptual themes depicting the impact of scarce resources on midwifery and nursing care were discovered: compromised care, constrained care, dehumanized care, missed care and disengaged care. Improving the maternal health of women and averting avoidable maternal morbidity and mortality require governments and institutions to invest in health infrastructure that will support the delivery of ethical and safe midwifery care for women in their most vulnerable period. (shrink)

Background The international health workforce crisis had led to an increasing shortage of nurses, which has substantial implications for the quality of patient care. This shortage potentially results in nurse-perceived time pressure, which can be particularly challenging for nurses who provide care for older persons. Objective This study aimed to show how geriatric nurses experience working under time pressure, perceive its impact on care and deal with time pressure in daily care. Research design A qualitative descriptive interview design was used. (...) Participants and research context Purposive sampling led to the inclusion of 11 nurses from three geriatric nursing wards in two general hospitals in Flanders (Belgium). Data were collected using semi-structured in-depth interviews and analysed using the QUAGOL (Qualitative Analysis Guide of Leuven). Ethical considerations The study protocol was approved by the Ethics Committee of the University Hospitals Leuven (Ethics committee of the University Hospitals Leuven). Findings In all interviews, time pressure was described as ubiquitous in the daily care of older persons. A sense of failure in providing care was the common thread in many interviews. Nurses felt compelled to ‘reduce’ good-quality care to basic care by focusing on the physical and visible aspects of care. Nevertheless, personal experiences with time pressure and strategies to cope with it differed among the interviewees. These variations were related to the working environment and the nurses themselves. They underscored the importance of nurses’ perspectives for a good understanding of the phenomenon of time pressure. Discussion and conclusion Working under time pressure in the care of older persons leads to various important challenges for nursing ethics. The findings show that providing care that promotes the human dignity of older persons in busy working environments in which care is rationed is an important ethical challenge. As such, our study offers a baseline for further research and discussion on how to support nurses working under time pressure. (shrink)

This article draws attention to the nature and importance of public policy. It argues that if nurses are to influence the quality of healthcare effectively, they must be engaged with policymakers to get nursing care issues on the policy agenda. There is an ethical imperative to do so, driven by the advocacy role of the nurse and rooted in the values base of nursing. In addition, it is argued that if one takes the role of patient advocacy seriously, as core (...) to the nursing role, two things are required of nurses: We must (a) broaden the conceptualisation of patient advocacy beyond the individual patient to the system of healthcare resourcing and provision and (b) see systemic change as important as change at the bedside. (shrink)

This paper revisits a 2003 publication in Nursing Philosophy: The need for accurate perception and informed judgement in determining the appropriate use of the nursing resource: hearing the patient's voice. The author suggests that the basic ideas and focus of this 16‐year‐old paper are still topical and relevant in considerations of nursing care. However, it is also suggested that greater attention to the importance of the nurse–patient relationship in considerations of resource allocation, and potential rationing of nursing care, would have (...) strengthened the original paper. (shrink)