Nurses' Perceptions of Ethical Issues in The Care of Older People
Nurses' Perceptions of Ethical Issues in The Care of Older People
Nurses' Perceptions of Ethical Issues in The Care of Older People
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Key words: ageism; elderly; ethics; nurses’ perceptions; nursing; older people
The aim of this thematic literature review is to explore nurses’ perceptions of ethical issues
in the care of older people. Electronic databases were searched from September 1997 to
September 2007 using specific key words with tight inclusion criteria, which revealed 17
primary research reports. The data analysis involved repeated reading of the findings and
sorting of those findings into four themes. These themes are: sources of ethical issues for
nurses; differences in perceptions between nurses and patients/relatives; nurses’ personal
responses to ethical issues; and the patient–nurse relationship. The findings reveal that
ageism is one of the major sources of the ethical issues that arise for nurses caring for older
people. Education and organizational change can combat ageist attitudes. Wider training is
required in the care of older people, workplace skills, palliative care and pain management
for older people. The demands of a changing global demography will necessitate further
research in this field.
Introduction
Globally, older people may experience ageist attitudes and be considered of lesser value
than younger and healthier people.1 At the same time, the population of older people
is growing throughout both developed and developing nations.1 When they enter
hospitals or age-related residential care they become particularly vulnerable owing
to loss of control and ageist attitudes.2 In these circumstances, particular emphasis
on matters of ethics is required. The care of older people should be the concern of
everybody because older people’s todays are potentially our tomorrows.
The purpose of this literature review is to explore ethical issues in the care of older
people from a nursing perspective. The contradictory behaviours of nurses to older
people witnessed by the first author during clinical practice stimulated an interest in
this area of nursing research. In particular, an incident in which an older woman was
forced into the shower against her will provoked highly distressing feelings. The nurse
involved later stated to the first author that she loved working with older people.
The original aim was to investigate nurses’ perceptions of the thin line between
acting in older people’s best interests and bullying them. This may also be seen as the
Address for correspondence: Jenny Rees, South Coast District Hospital, Bay Road,
Victor Harbor, SA 5211, Australia. Tel: +61 (0)8 8552 0500; Fax: +61 (0)8 8552 0507;
E-mail: jenandder@yahoo.co.uk
conflict between the ethical principles of patient autonomy and beneficence. When it
became clear that there was very little research in this area, the main aim was broadened
to explore nurses’ perceptions of ethical issues in the care of older people.
Achieving this aim through a review of the relevant research literature may inform
both undergraduate and continuing nursing education. Such programmes guide stu-
dents and nurses in their formulation of ethical behaviours and approaches to the care
of older people. The findings may also inform nursing practice and lead to the intro-
duction of changes to support nurses in their endeavours to resolve ethical issues in
the care of older people.
Method
Sample
A comprehensive literature review was conducted using the following online databases:
MEDLINE, Cumulative Index of Nursing and Allied Health Literature (CINAHL),
Blackwell Synergy, Proquest and EBSCO. The key words used to search were: ethics,
nursing ethics, ethical issues, aged, elderly, nurse, nursing, nurses’ perceptions and
nurse–patient relations. The search was limited to primary research studies published
in the English language during the 10 years prior to September 2007 by using the fol-
lowing inclusion criteria: nursing staff defined as registered nurses, enrolled nurses
and various nomenclatures for nursing staff without professional qualifications; per-
ceptions or experiences, as reported by nurses, relating to ethical issues, dilemmas or
questions; and health care facilities defined in the literature as settings for the provision
of nursing care to older people. Where nursing staff without professional qualifications
were included as participants, the study was checked to ensure it included at least one
registered nurse as a participant to maintain the relevance of the research to nursing
graduates. No definition of older people by reference to a specific age was applied
because most of the studies did not define older people in these terms. However, the
World Health Organization defines older people for their purposes as people aged
60 years or over.3 Three of the studies included in the review defined older people by
reference to the World Heath Organization’s minimum age,4–6 two used criteria of over
657 and over 758, while the remaining six studies made no reference to a specific age.
Table 1 Summary of quantitative research reports included in the review (date order)
Reference Location Research aim Sample and setting Design and method
J Rees et al.
Wagner and Israel To identify ethical dilemmas 330 RNs (91 caring for elderly Statistical analysis
Reference Location Research aim Sample and setting Design and method
Schopp et al., Finland, Fourth report in a series of five: 887 nursing staff in health facilities Cross-sectional exploratory and
200312 Spain, To explore the realization of informed caring for elderly people and 573 correlational design with statistical
Greece consent by examining nurses’ and patients aged 60 or over. analysis
Germany, patients’ perceptions Questionnaires for staff (65% RR)
UK Structured interviews for patients
Leino-Kilpi Finland, Fifth report in a series of five 887 nursing staff in health facilities Cross-sectional exploratory and
et al., 200310 Spain, – discusses the implications of the caring for elderly people and 573 correlational design with statistical
Greece findings of the series: patients aged 60 or over analysis
Germany, To explore the issues of autonomy, Questionnaires for staff (65% RR)
UK privacy and informed care by Structured interviews for patients
examining nurses’ and patients’
perceptions
Palviainen Finland To describe nurses’ opinions about the 174 nursing staff from 5 acute care Statistical analysis
et al., 200318 exercise of power in both acute and wards in district hospitals and 127 Questionnaire using Likert scale (65%
long term care nursing staff from 5 geriatric units RR)
and 1 nursing home
Nursing staff included unit managers,
RNs, health care assistants and others
Juthberg Sweden To explore the relationship between 146 nursing staff (50 RNs and 96 Statistical analysis and multivariate
et al., 200720 perceptions of conscience and stress nursing aides/ENs) working in canonical correlation analysis
related to a troubled conscience housing for elderly people in one Questionnaires using Likert format
among care providers municipality (87% RR)
RN, registered nurse; RR, response rate; EN, enrolled nurse.
Table 2 Summary of qualitative research reports included in the review (date order)
Reference Location Research aim Sample and setting Design and method
J Rees et al.
Norberg Sweden To explore the differences in 20 RNs, 20 ENs and 10 doctors in one Narrative theory analysis
Slettebø and Sweden To highlight strategies used by 14 RNs from 3 nursing homes Grounded theory analysis
Bunch, 200415 nurses to solve ethically difficult care Semistructured interviews and
situations (uses data from the same observations
study as the report below)
Slettebo and Sweden To highlight strategies used by 14 RNs from 3 nursing homes Grounded theory analysis
Bunch, 200416 nurses to solve ethically difficult Semistructured interviews and
care situations, and to provide a observations
supplement to principle-based ethics
(uses data from the same study as the
report above)
Enes and de UK To examine nurses’ experience of 53 RNs working in 13 elderly Mixed method; however only the
Vries, 200417 disclosure and to determine other persons’ care units qualitative findings were useful
ethical issues that nurses experience Qualitative content analysis
Quantitative descriptive statistical
analysis
Semistructured questionnaires
(39.3% RR)
Mauleon Sweden To illuminate what it means for 7 anaesthetic nurses in one Interpretative phenomenological
et al., 20056 anaesthetic nurses to be in ethically department of a large A&E care method
problematic care situations hospital where the majority of Narrative interviews
patients in the department were aged
60 or more
Table 2 (Continued)
Reference Location Research aim Sample and setting Design and method
Nordam Norway To explore ethical problems for 5 male nurses working in gerontology Phenomenological hermeneutical
et al., 200519 health professionals, elderly people wards at one university hospital method
and family members in end-of-life Interviews
decision making
Teeri et al., Finland To identify and describe ethically 9 nurses (5 RNs, 4 ENs), 10 patients Content analysis
20067 problematic care-related experiences aged 71 to 84 (criterion aged over 65) Essays written by nurses and relatives
of patients, relatives and nurses and 17 relatives, from 1 long-term and open interviews with patients
care institution
Schaffer, Norway To explore ethical problems for 25 health professionals (17 nurses, Ethical analysis framework
20078 health professionals, elderly people 4 doctors, 3 ministers and 1 social Semistructured interviews
and family members in end-of-life worker) involved with end-of-life
decision making care for elderly people in different
settings; 6 elderly people; 5 relatives
RN, registered nurse; EN, enrolled nurse; RR, response rate.
all quantitative findings relevant to the review aim were found to be adequately demon-
strated and thus all nine quantitative articles were also incorporated in the review. It is
interesting to note that, when the authors considered the National Health and Medical
Research Council’s (NHMRC) levels of evidence framework,23 none of the included
studies fell within the NHMRC’s study design guidelines. Nevertheless, all included
studies have relevant findings to incorporate in this review.
Doctors
In six reports, nurses perceived doctors as a source of ethical issues in the care of older
people. In one quantitative study, 78% of the nurses caring for older people regarded
doctors to be the main source of ethical dilemmas.5 Specific ethical issues relating to doc-
tors reported in the studies were: their lack of availability to discuss issues;8 poor
decision making;19 inadequate pain management, and over- and under-treatment of
patients;9 focusing on cure and being unable to attend to patients’ wider needs; and a
lack of knowledge about palliative care.17
In addition, direct conflict between nurses and doctors was revealed in two studies.
Anaesthetic nurses (described in this Swedish study as nurse anaesthetists) disclosed
their ethical struggle when medical professionals did not share their point of view.6
Nurses on wards delivering care to older people described how valuable time was
diverted from providing good nursing care to defending their professional opinions
to the doctors.19 These nurses disclosed that sometimes they chose to override doctors’
medication orders, particularly in relation to pain management when doctors were
perceived to withhold pain relief and sedation. This is a significant finding in that it
shows that nurses are willing to act unlawfully in order to overcome ethical issues in
the care of older people.
this theme
Patients’ families
Conflicting interests in the families of older people were reported by nurses as the
source of ethical issues in four reports. Wagner and Tabak’s quantitative study5 iden-
tified patients’ family members to be the second most common source of ethical
dilemmas after doctors, and were reported by 72.5% of the nurses in the study. Ethical
conflict arose from the gap between relatives’ needs and patients’ needs.7,17 Examples
related to a patient’s decision to stop eating, where a relative wanted to feed the patient
by force, or to situations where relatives sought extreme forms of treatment regardless
of patients’ suffering or their own wishes.7 Examples given in relation to end-of-life
decision making for older people were of families who did not accept that their relative
was dying and wanted to continue invasive treatment, and of families who did not
wish important information to be disclosed to their relative.17 Another study reported
ethical issues arising from family members disagreeing not only with the patient but
also with health professionals regarding appropriate treatment, and with each other.8
The highest number of ethical issues reported by health professionals in this study
related to family members.
perceptions in one study were that contemporary society had placed death in the clin-
ical realm of doctors, leaving people unable to discuss it openly and accept the fact
of dying.17 This perspective was reiterated in a study in which nurses expressed the
difficulties of raising the subject of death with patients and families.8
Routine-centred care
The concept of routine-centred care in contrast to patient-centred care was identified in
two reports that focused on the long term care of older people. The study by Palviainen
et al.18 explored the use of power by nurses in both acute and long term care: 59% of
long term care nurses stated that they adhered strictly to the bathing list; 16% required
patients to go to the toilet according to the unit’s schedule; and about 33% required pati-
ents to go to bed at the same time each evening. These findings showed that long term
care nurses perceived that sometimes they exercised power over their patients when
routines took preference over individual needs. In the second study, long term care
nurses openly expressed the view that care delivery was sometimes determined by
schedules rather than by patients’ needs, leaving staff with feelings of failure because
they had not acted in their patients’ best interests.7
to resolving ethical issues.19 The stories narrated by enrolled nurses about being in
ethically difficult care situations showed great empathy with a focus on relationships
and patient centredness.9
Fourth, the findings of the reviewed studies showed that nurses are committed to
resolving ethical issues in the care of older people, yet they also demonstrated that nurses
perceived that nurse colleagues are not so committed and can themselves be a source
of ethical issues. This may demonstrate further limitations of the research studies,
such as that only those nurses committed to resolving ethical issues took part or that
participants gave the answers they thought the researchers wanted to hear. It may
also reflect the fact that the definition of an ethical issue remains subjective and
individual to each nurse. What one nurse believes to be the ethically correct thing to
do in accordance with the relevant professional code of ethics may not be the same for
another nurse working alongside. There are cultural and sociological influences on
nurses’ perceptions of ethical issues that have not been investigated in this review.
Finally, from an international perspective, it is important to note that the studies
included in this review were conducted in several European countries and in Israel
(Tables 1 and 2). Research in other countries with different health care structures,
cultural values, educational systems and/or geographical influences is needed to
understand the impact of these differences on the findings.
Conclusion
The findings of this review can be summarized as follows:
• Nurses experienced multiple sources of ethical issues in the care of older people;
• A comparison of nurses’ perceptions with older people’s and relatives’ perceptions
revealed that nurses underestimated the size and scope of ethical issues in the care
of older people;
• Nurses experienced strong personal responses to ethical issues in the care of older
people;
• Nurses believed that understanding and respecting older people was essential in
resolving ethical issues.
Acknowledgement
With thanks to Chris Walton, for support given as clinical mentor to the first author
during the initial phases of this review.
Jenny Rees, Lindy King and Karl Schmitz, Flinders University, Adelaide, South Australia.
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