Ethical consciousness in nursing homes

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Ethical consciousness in nursing homes
E.Merethe Solum Faculty of Health
Science Vestfold University College
Esbjerg June 2006
2
Background

• Preconceptions
• Ethically difficult situations often occur in
  nursing homes
• Frequent lack of awareness and dialogue on how to
  reach the best moral course of action.

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Research questions

• To what extent do caregivers use dialogue-based
  discourse and reflection in ethically difficult
  situations?
• Sub questions
• Is there presence of dialogue about ethically
  difficult situations?
• What is emphasized in the dialogue between
  caregivers?
• Do caregivers take the patients rights into
  consideration?

4
Methods and materials

• 2 long term units 13 patients x 2
• 4 weeks observation during staff-meetings.
• Semi-structured qualitative interviews with 7
  caregivers.

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Theoretical framework

• Based on J.Habermas discourse ethics
• Common sense in arguments to achieve better
  judgement for moral actions
• Equal positions in dialogue
• Justice and the perspective of solidarity

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Results

• All the situations could be linked to the
  patients rights.
• 1.The right to not be violated
• 2.The right to co-determination
• 3.The right to holistic care

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1.The right to not be violated

• Elise (88) is a restless and demanding patient.
  She does not give in before contact has been
  established. One year ago she had a stroke, she
  is often quite unhappy.

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Not listening

• Interview data
• One day Elise was very upset and restless. One
  of the assistant nurses came and asked me to give
  her tranquillizers.
• I asked her if she had tried to understand what
  Elise wanted. No, she replied. Its
  impossible. Please give her two pills. I went
  and sat down to speak with Elise, and she told me
  that she wanted to have an appointment at a
  pedicurist.
• I fixed that for her, and she was calm the rest
  of the day.

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Attributing motives

• Interview data
• When we have got a lot to do, and its like
  boiling around us, she is even more excited
  than ever, because it is attention she wants.
• Sometimes we take her to her room in her
  wheelchair so she doesnt disturb the other
  patients. But it is not good for her, it somehow
  affects her.

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Not believing in the patient

• Observation data
• Maybe Elise really has to go to the toilet
  when she says so. It is impossible to divert her
  attention, and she gets very frustrated. Today
  she became totally calm after I helped her to the
  toilet
• Another caregiver says
• We do not talk enough about what we can do to
  improve her situation.

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2 The right to co-determination

• Bjarne (90) does not have dementia, he sits in a
  wheel-chair, has a strong will and prefers to
  lie in bed because of back pain

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Attributing motives

• Observation data
• But he has such a good wheelchair that can be
  tilted backwards, so its just bullshit that he
  gets pain from sitting up all day.

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Mistrust

• Interview data
• I suggested to Bjarne that he could go to bed
  for an hour after breakfast, then we could help
  him up again. He thought it was a good idea, but
  he was sure that we would forget to come and help
  him out of bed again
• I think he was right about that

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Bad chemistry

• Interview data
• Very few of us like him much or have good
  chemistry with him. Some of us have no patience
  with Bjarne. We often exchange negative comments
  about him and we try to avoid him. Therefore no
  one helps him, or listens to what he wants

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3 The right to holistic care

• Karsten (70), does not have dementia, sits in a
  wheel-chair, wants to smoke after breakfast.
• He must be helped to the smoking room.

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Attitudes

• Observation data
• One of the nurses stated that she couldn't
  imagine becoming old in a nursing home.
  Previously we had time for a hug, a chat and a
  cigarette with the elderly. And a hug is much
  better than sleeping pills. Just think about
  Karsten. No one has the time to go to the smoking
  room with him
• Another nurse says But, he has been permitted
  to smoke in his room, and when he doesnt want
  that, he can just sit there and be grumpy.

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Conclusions

• Hardly any dialogue-based discourse and
  reflection on ethically difficult situations
  during report at the staff meetings
• More focus on technical-rational tasks in care,
  than on how to reach moral course of actions
• The patients rights are not emphasized in the
  dialogue
• Caregivers are aware of ethically difficult
  situations
• Moral problems were disclosed
• The caregivers perform actions they know are
  unethical

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Challenges

• Are these findings specific to this nursing home
  or are these problems frequent in other nursing
  homes as well?
• How can common reflection and dialogue in
  ethically difficult situations be strengthened?
• Can dialogue-based discourse ensure better
  judgement so caretakers dont become socialized
  into unethical attitudes and bad habits?

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Literature

• Solum, E.Merethe (2004) Etisk bevissthet i
  sykehjem Hvordan anvender pleiere i sykehjem
  dialog og refleksjon når de blir stilt ovenfor
  etisk vanskelige situasjoner Hvordan kan dialog
  bidra til utvikling av et godt skjønn?
  Masteroppgave i profesjonsetikk og diakoni-
  studieretning profesjonsetikk. Teologisk
  fakultet, Universitet i Oslo.
• Ot.prp. nr 12 (1998) Lov om pasientrettigheter
  (pasientrettighetsloven). Oslo Departementet.
• Ot.prp. nr 13 (1998) Om lov om helsepersonell m
  v (helsepersonelloven). Oslo Departementet.
• Norsk Helse- og sosialforbund (2003)
  Yrkesetiske retningslinjer for hjelpepleiere og
  omsorgsarbeidere, Oslo Fagforbundet.
• Norsk Sykepleierforbund (2001a) Yrkesetiske
  retningslinjer for sykepleiere ICNs etiske
  regler. Oslo Norsk Sykepleierforbund.
• Malmedal, Wenche (1999) Sykehjemmets skyggesider
  når beboere i sykehjem utsettes for krenkelser
  og overgrep. Oslo Kommuneforl.
• Slettebø, Åshild (2002a) Strebing mot pasientens
  beste. En empirisk studie om etisk vanskelige
  situasjoner i sykepleiepraksis ved tre norske
  sykehjem. Doktoravhandling. Oslo Universitetet
  i Oslo.
• Samuelsen, Anne Gerd. 2003. Samspill mellom
  pasient og pleier i et morgenstell- hva skjer?
  Hva uttrykker pasienten og på hvilken måte tar
  pleieren imot uttrykkene? Hovedfagsoppgave thesis
  Oslo Universitetet i Oslo.
• Summer, Jane 2001, Caring in nursing a different
  interperation.Journal of Advanced Nursing, 35
  (6), 926 932. Blackwell Sience Ltd.

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Definitions

• An ethically difficult situation a situation
  where it is problematic to know what values shall
  be fulfilled, and thus what is right to do to
  reach the best solution for the patient (Slettebø
  2002).
• An ethical dilemma Is characterised by having to
  choose between two unwanted alternatives and that
  we are uncertain about which to choose (Slettebø
  2002).
• A moral problem We have a moral problem when we
  know what is right to do, but still do not act
  according to what we know (Henriksen og Vetlesen
  1997).

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Contexts of interpretations

• The interviewed persons self-understanding as it
  appears in the interviews and the observations.
• A broader critical understanding based on common
  sense.
• A context based on Habermas discourse theory