Aging 4.0? Rethinking the ethical framing of technology-assisted eldercare.

Technological approaches are increasingly discussed as a solution for the provision of support in activities of daily living as well as in medical and nursing care for older people. The development and implementation of such assistive technologies for eldercare raise manifold ethical, legal, and social questions. The discussion of these questions is influenced by theoretical perspectives and approaches from medical and nursing ethics, especially the principlist framework of autonomy, non-maleficence, beneficence, and justice. Tying in with previous criticism, the present contribution is taking these principles as a starting point and as a frame of reference to be critically re-examined. It thus aims to outline how existing ethical frameworks need to be extended or reconsidered to capture the ethical issues posed by technological developments regarding care for older people. In a first step, we provide a brief overview of assistive technologies in eldercare according to their purposes and functions. In the next step, we discuss how the questions and problems raised by new technologies in eldercare call for an expansion, re-interpretation, and revision of the principlist framework. We underline that the inclusion of ethical perspectives from engineering and computer science as well as a closer consideration of socio-political dimensions and fundamental anthropological and praxeological questions are needed.

Caring for elder patients: Mutual vulnerabilities in professional ethics.

BACKGROUND:: Neglect and abuse of elders in care institutions is a recurring issue in the media. Elders in care institutions are vulnerable due to their physical, cognitive, and verbal limitations. Such vulnerabilities may make them more susceptible to mistreatment by caregivers on whom they are heavily dependent. OBJECTIVES:: The goal was to understand caregivers' concerns about ensuring correct and proper treatment, as well as their experiences with neglect and abuse of older patients. This article examines resources and challenges of professional ethics within the care setting. RESEARCH DESIGN:: A study was conducted to explore the quality of care provided to older patients in nursing homes, geriatrics institutions, and ambulant care in the northwest region of Switzerland. PARTICIPANTS AND RESEARCH CONTEXT:: A total of 23 semi-structured interviews were conducted with nursing staff of varying experience levels. ETHICAL CONSIDERATIONS:: Ethical approval was granted by the competent regional ethics commission, Ethikkomission Nordwest-und Zentralschweiz EKNZ [Ethics Commission Northwest and Central Switzerland] (2014-015). FINDINGS:: Three themes emerged from our data analysis: professional identity, professional context, and professional relationships. Our findings indicate mutual vulnerabilities within these three themes, characterizing the interactions between nursing staff and older patients. Study participants believe that incidences of error, neglect, and abuse are consequences of their own vulnerability since they are not able to meet the demands of an overstraining work situation. DISCUSSION:: Different aspects of this mutual vulnerability are described and critically discussed as challenges for professional ethics. CONCLUSION:: Early education, continuous training as well as better management and response from the institution are necessary to maintain professionalism while handling mutual vulnerabilities.

Using Ethical Frameworks in Times of Transition and Uncertainty.

Health care policy is never easy and always fraught with concerns about quality, access, and cost. Currently, uncertainty abounds regarding new federal and state policies on the horizon for older adult care and quality. Empirics undergird most policy-making decisions regarding risk/benefit, cost, and knowing the best action to put in place for the best results. However, in times of great change in policy direction and political viewpoints, empirical knowledge must be combined with ethical knowledge for planning and implementation. Ethical and moral judgment has long been a mainstay of nursing practice and organizational leadership. Using ethical knowledge as a framework will be a crucial guide for nurses and health professionals and society to prioritize action and decisions in policy. [Journal of Gerontological Nursing, 43(3), 8-12.].

Manifestation of respect in the care of older patients in long-term care settings.

BACKGROUND: Respect is fundamental to ethical nursing practice. However, respect in the care of older people is seldom investigated from the perspective of patients and their next of kin. AIM: To describe the manifestation of respect in the care of older patients in long-term care settings from the perspective of older patients with memory disorders and their next of kin. DESIGN AND METHODS: A narrative inquiry on research methodology using open interviews was employed. Transcribed interviews were analysed using inductive content analysis, and from this analysis a typology was produced. SETTINGS: The study settings were patients' own homes supported by professional home care, and nursing homes in three cities in southern Finland. PARTICIPANTS: A purposeful sample (N = 40) of participants (older patient, n = 20 and their next of kin, n = 20) was recruited. Half of the older patient lived at home where they received professional care and the other half lived in nursing homes. RESULTS: Respect in long-term care settings is manifested in patient care through the being and doing of the nurse. A typology of nurses' being and doing described three ways nurses manifested respect: 'I'm here for you', 'I'm here for work' and 'I'm not here for you'. Patient's responses to the typology were as follows: sharing, exploring and withdrawing, respectively. CONCLUSIONS: The analysis and typology of nurses' being and doing increases the understanding of respect in patient care in long-term care settings. Furthermore, this knowledge of respect will make it possible to develop measureable respect indices for use in the evaluation of care.

Validation of the Hospital Ethical Climate Survey for older people care.

BACKGROUND: The exploration of the ethical climate in the care settings for older people is highlighted in the literature, and it has been associated with various aspects of clinical practice and nurses' jobs. However, ethical climate is seldom studied in the older people care context. Valid, reliable, feasible measures are needed for the measurement of ethical climate. OBJECTIVES: This study aimed to test the reliability, validity, and sensitivity of the Hospital Ethical Climate Survey in healthcare settings for older people. DESIGN: A non-experimental cross-sectional study design was employed, and a survey using questionnaires, including the Hospital Ethical Climate Survey was used for data collection. Data were analyzed using descriptive statistics, inferential statistics, and multivariable methods. PARTICIPANTS AND RESEARCH CONTEXT: Survey data were collected from a sample of nurses working in the care settings for older people in Finland (N = 1513, n = 874, response rate = 58%) in 2011. ETHICAL CONSIDERATIONS: This study was conducted according to good scientific inquiry guidelines, and ethical approval was obtained from the university ethics committee. RESULTS: The mean score for the Hospital Ethical Climate Survey total was 3.85 (standard deviation = 0.56). Cronbach's alpha was 0.92. Principal component analysis provided evidence for factorial validity. LISREL provided evidence for construct validity based on goodness-of-fit statistics. Pearson's correlations of 0.68-0.90 were found between the sub-scales and the Hospital Ethical Climate Survey. DISCUSSION: The Hospital Ethical Climate Survey was found able to reveal discrimination across care settings and proved to be a valid and reliable tool for measuring ethical climate in care settings for older people and sensitive enough to reveal variations across various clinical settings. CONCLUSION: The Finnish version of the Hospital Ethical Climate Survey, used mainly in the hospital settings previously, proved to be a valid instrument to be used in the care settings for older people. Further studies are due to analyze the factor structure and some items of the Hospital Ethical Climate Survey.

The associations among the ethical climate, the professional practice environment and individualized care in care settings for older people.

AIM: To investigate the associations among the ethical climate, professional practice environment and individualized nursing care in care settings for older people. BACKGROUND: The quality of care provision is affected by organizational environments, such as ethical climate and professional practice environment. Although, the association between professional practice environment and individualized nursing care has been pointed out, we know that little is known about how ethical climate is associated with the level of individualized nursing care delivery. DESIGN: A cross-sectional explorative and correlational survey design. METHODS: The study was conducted in 62 units in the vicinity of a Finnish city using a sample of nurses (N = 874, response rate 58%) who worked clinically with older people in different care settings in 2012. Survey data were collected using the Hospital Ethical Climate Survey, Revised Professional Practice Environment scale and Individualised Care Scale-B. Data were analysed statistically using descriptive statistics, correlation coefficients (Pearson) and multiple stepwise regression analyses. RESULTS: Statistically significant correlations were found among the variables, ethical climate and individualized care and between individualized care and all professional practice environment sub-scales. Multiple stepwise regression showed associations among individualized care, ethical climate and internal work motivation, control over practice and leadership and autonomy. CONCLUSIONS: The study provided better understanding of the complex concept of individualized care by taking into consideration the ethical climate and the practice environment and their associations. To increase individualization in care provision, efforts need to be directed towards organizational aspects requiring the support of nursing leaders.

Three dialogues concerning robots in elder care.

The three dialogues in this contribution concern 21st century application of life-like robots in the care of older adults. They depict conversations set in the near future, involving a philosopher (Dr Phonius) and a nurse (Dr Myloss) who manages care at a large facility for assisted living. In their first dialogue, the speakers discover that their quite different attitudes towards human-robot interaction parallel fundamental differences separating their respective concepts of consciousness. The second dialogue similarly uncovers deeply contrasting notions of personhood that appear to be associated with respective communities of nursing and robotics. The additional key awareness that arises in their final dialogue links applications of life-like robots in the care of older adults with potential transformations in our understandings of ourselves - indeed, in our understandings of the nature of our own humanity. This series of dialogues, therefore, appears to address a topic in nursing philosophy that merits our careful attention.

Re-examining the basis for ethical dementia care practice.

Ethical nursing practice is an important component of quality dementia care. To be ethically competent, and to acquire the language, knowledge and skills required to explore and resolve ethical dilemmas in practice, the nurse needs an understanding of ethics and of the theory behind ethical decision-making. Traditional theories of ethics and ethical principles are commonly used to explore the dilemmas faced in dementia care practice. While these theories remain influential in healthcare practice, more contemporary ethical theories are equally relevant to the examination of the ordinary and extraordinary ethical dilemmas that present in conditions such as dementia. In this article, the ethical considerations central to effective dementia care nursing will be examined.

Implicit and explicit clinical ethics support in The Netherlands: a mixed methods overview study.

Internationally, the prevalence of clinical ethics support (CES) in health care has increased over the years. Previous research on CES focused primarily on ethics committees and ethics consultation, mostly within the context of hospital care. The purpose of this article is to investigate the prevalence of different kinds of CES in various Dutch health care domains, including hospital care, mental health care, elderly care and care for people with an intellectual disability. A mixed methods design was used including two survey questionnaires, sent to all health care institutions, two focus groups and 17 interviews with managing directors or ethics support staff. The findings demonstrate that the presence of ethics committees is relatively high, especially in hospitals. Moral case deliberation (MCD) is available in about half of all Dutch health care institutions, and in two-thirds of the mental health care institutions. Ethics consultants are not very prominent. A distinction is made between explicit CES forms, in which the ethical dimension of care is structurally and professionally addressed and implicit CES forms, in which ethical issues are handled indirectly and in an organic way. Explicit CES forms often go together with implicit forms of CES. MCD might function as a bridge between the two. We conclude that explicit and implicit CES are both relevant for clinical ethics in health care. We recommend research regarding how to combine them in an appropriate way.

Keep quiet or act? Challenges in integrating ethical theory into gerontological nursing care during students' first clinical rotation: A discussion paper.

AIM: The aim of the paper is twofold: 1. To present observations based on first-year nursing students' narratives during clinical rotation in gerontological nursing care; and 2. Explore a nursing educator's reflections on these observations in relation to the didactic and ethical challenges that occurred. BACKGROUND: The teaching of ethics is included in nurse education worldwide. Students are in their first clinical placement in residential care of older persons confronted with the moral complexities of gerontological care, where they get little possibility to share emotions and thoughts about ethically challenging nursing situations with a supervising registered nurse. DESIGN: A critical discussion paper. METHOD: The educator's reflections in this discussion paper are based on a narrative assignment in ethics where first-year nursing students reflect on and describe a nursing situation during their clinical rotation in the residential care of older persons. RESULTS: Most students were acting as mere spectators in the described nursing situation where an older person, ethical standards, or evidence-based care was violated. Some students acted as advocates to the older person and intervened in the situation and a few as inspirers showing alternative ways of handling ethically challenging situations. CONCLUSIONS: Educators in nursing programs at the undergraduate level require time for student-centered formative guidance to foster moral courage and practice. During first-year students' clinical rotation, the learning goals in long-term residential care of older persons are focused on evidence-based basic nursing care. In this, students are confronted with ethically challenging situations, where the possibility to learn from a critical reflective practice is rare. When observing situations where an older person is subjected to unethical or unsafe nursing care it is common that the students take the spectators' role, not knowing how to deal with what is observed. Some students are taking an intervening role by trying to alleviate the vulnerability of the older person. A few are showing moral courage by directly intervening when experiencing unethical or unsafe nursing care or conduct. In this the student can inspire fellow students or staff during their clinical rotation in alternative ways of handling ethically challenging situations. As older persons are the largest demographic group that nurses will experience, educators need a sound knowledge of ethics as well as gerontological care to be able to meet and nurture students' ethical reflections during clinical practice and to foster practical wisdom in nursing.

Aspects of indignity in nursing home residences as experienced by family caregivers.

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.

How to avoid and prevent coercion in nursing homes: a qualitative study.

In many Western countries, studies have demonstrated extensive use of coercion in nursing homes, especially towards patients suffering from dementia. This article examines what kinds of strategies or alternative interventions nursing staff in Norway used when patients resist care and treatment and what conditions the staff considered as necessary to succeed in avoiding the use of coercion. The data are based on interdisciplinary focus group interviews with nursing home staff. The study revealed that the nursing home staff usually spent a lot of time trying a wide range of approaches to avoid the use of coercion. The most common strategies were deflecting and persuasive strategies, limiting choices by conscious use of language, different kinds of flexibility and one-to-one care. According to the staff, their opportunities to use alternative strategies effectively are greatly affected by the nursing home's resources, by the organization of care and by the staff's competence.

The ethics of coercive treatment of people with dementia.

The aim of the present study was to describe how registered nurses in nursing homes ensure legal security, good and safe nursing care and uphold the dignity of nursing home residents with severe dementia without violating residents' integrity. Semi-structured interviews were conducted with 10 charge nurses in a county in central Sweden. The transcribed interviews were examined using manifest and latent content analyses. The manifest analysis identified actual local routines involving coercive treatment and registered nurses' descriptions of complications and alternative measures. The latent analysis resulted in three themes describing nursing strategies: one with coercive treatment, one with coercive treatment under specific circumstances and one to prevent coercive treatment. Interpretations of legal terms regarding coercive treatment and inadequate gerontological nursing training and understaffing seem to preserve the use of coercive treatment.

Nurses' ethical reasoning in cases of physical restraint in acute elderly care: a qualitative study.

In their practice, nurses make daily decisions that are ethically informed. An ethical decision is the result of a complex reasoning process based on knowledge and experience and driven by ethical values. Especially in acute elderly care and more specifically decisions concerning the use of physical restraint require a thoughtful deliberation of the different values at stake. Qualitative evidence concerning nurses' decision-making in cases of physical restraint provided important insights in the complexity of decision-making as a trajectory. However a nuanced and refined understanding of the reasoning process in terms of ethical values is still lacking. A qualitative interview design, inspired by the Grounded Theory approach, was carried out to explore nurses' reasoning process in terms of ethical values. We interviewed 21 acute geriatric nurses from 12 hospitals in different regions in Flanders, Belgium in the period October 2009-April 2011. The Qualitative Analysis Guide of Leuven was used to analyse interview data. Nurses' decision-making is characterized as an ethical deliberation process where different values are identified and where the process of balancing these values forms the essence of ethical deliberation. Ethical decision-making in cases of physical restraint implies that nurses have to choose which values receive priority in the process, which entails that not all values can be respected to the same degree. As a result, decision making can be experienced as difficult, even as a dilemma. Driven by the overwhelming goal of protecting physical integrity, nurses took into account the values of dignity and justice more implicitly and less dominantly.

Development and psychometric evaluation of the Moral Competence Scale for Home Care Nurses in Japan.

PURPOSE: The purpose of this study was to evaluate the validity and reliability of the Moral Competence Scale for Home Care Nurses (MCSHCN). METHODS: A self-administered questionnaire that included the preliminary MCSHCN (90 items) was distributed to home care nurses (HCNs) in Japan. Usable data (from 1,961 questionnaires) were analyzed. RESULTS: Item and exploratory factor analysis for the MCSHCN revealed 45 items that loaded on 5 factors. This 5-factor model showed reasonable fit to the data by confirmatory factor analysis (root mean square error of approximation [RMSEA] = 0.070). Thus, the model closely corresponded to the theoretical components of moral competence. Cronbach's alpha ranged from .78 to .93. CONCLUSIONS: The construct validity and internal consistency reliability were supported. Further research is needed to refine this scale to increase the generalizability.

"Here's my dilemma". Moral case deliberation as a platform for discussing everyday ethics in elderly care.

Our study presents an overview of the issues that were brought forward by participants of a moral case deliberation (MCD) project in two elderly care organizations. The overview was inductively derived from all case descriptions (N = 202) provided by participants of seven mixed MCD groups, consisting of care providers from various professional backgrounds, from nursing assistant to physician. The MCD groups were part of a larger MCD project within two care institutions (residential homes and nursing homes). Care providers are confronted with a wide variety of largely everyday ethical issues. We distinguished three main categories: 'resident's behavior', 'divergent perspectives on good care' and 'organizational context'. The overview can be used for agendasetting when institutions wish to stimulate reflection and deliberation. It is important that an agenda is constructed from the bottom-up and open to a variety of issues. In addition, organizing reflection and deliberation requires effort to identify moral questions in practice whilst at the same time maintaining the connection with the organizational context and existing communication structures. Once care providers are used to dealing with divergent perspectives, inviting different perspectives (e.g. family members) to take part in the deliberation, might help to identify and address ethical 'blind spots'.

Morality in the mundane: specific needs for ethics support in elderly care.

Ethics support is called for to improve the quality of care in elderly institutions. Various forms of ethics support are presented, but the needs for ethics support remain unknown. Using a mixed-methods design, this article systematically investigates the specific needs for ethics support in elderly care. The findings of two surveys, two focus groups and 17 interviews demonstrate that the availability of ethics support is limited. There is a need for ethics support, albeit not unconditionally. Advice-based forms of ethics support are less appropriate as they are removed from practice. Ethics support should be tailored to the often mundane and easily overlooked moral issues that arise in long-term care. Attention should also be given to the learning styles of nurses who favour experiential learning. Raising awareness and developing a climate of openness and dialogue are the most suitable ways to deal with the mundane moral issues in elderly care.

Undertreatment of pain in older adults: an application of beneficence.

Inadequate pain control, especially in older adults, remains a significant issue when caring for this population. Older adults, many of whom experience multiple acute and chronic conditions, are especially vulnerable to having their pain seriously underassessed and inadequately treated. Nurses have an ethical obligation to appropriately treat patients' pain. To fulfill their ethical obligation to relieve pain in older patients, nurses often need to advocate on their behalf. This article provides an overview of the persistent problem of undertreated pain in older adults and explores how nurses can meet this ethical duty through the application of Beauchamp and Childress' three principles of beneficence.