Background:In the face of scarcity, nurses may inevitably delay or omit some nursing interventions and give priority to others. This increases the risk of adverse patient outcomes and threatens safety, quality, and dignity in care. However, it is not clear if there is an ethical element in nursing care rationing and how nurses experience the phenomenon in its ethical perspective.Objectives:The purpose was to synthesize studies that relate care rationing with the ethical perspectives of nursing, and find the deeper, moral meaning (...) of this phenomenon.Research design:A systematic review and thematic synthesis of qualitative studies was used. Searching was based on guidelines suggested by Joana Brigs Institute, while the synthesis has drawn from the methodology described. Primary studies were sought from nine electronic databases and manual searches. The explicitness of reporting was assed using consolidated criteria for reporting qualitative research. Nine studies involving 167 nurse participants were included. Synthesis resulted in 35 preliminary themes, 14 descriptive themes, and four analytical themes. Discussion of relationships between themes revealed a new thematic framework.Ethical consideration:Every effort has been taken, for the thoroughness in searching and retrieving the primary studies of this synthesis, and in order for them to be treated accurately, fairly and honestly and without intentional misinterpretations of their findings.Discussion:Within limitations of scarcity, nurses face moral challenges and their decisions may jeopardize professional values, leading to role conflict, feelings of guilt, distress and difficulty in fulfilling a morally acceptable role. However, more research is needed to support certain relationships.Conclusions:Related literature is limited. The few studies found highlighted the essence of justice, equality in care and in values when prioritizing care—with little support to the ethical effects of rationing on nurses. Further research on ethical dimension of care rationing may illuminate other important aspects of this phenomenon. (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)

Driven by interests in workforce planning and patient safety, a growing body of literature has begun to identify the reality and the prevalence of missed nursing care, also specified as care left undone, rationed care or unfinished care. Empirical studies and conceptual considerations have focused on structural issues such as staffing, as well as on outcome issues – missed care/unfinished care. Philosophical and ethical aspects of unfinished care are largely unexplored. Thus, while internationally studies highlight instances of covert rationing/missed care/care (...) left undone – suggesting that nurses, in certain contexts, are actively engaged in rationing care – in terms of the nursing and nursing ethics literature, there appears to be a dearth of explicit decision-making frameworks within which to consider rationing of nursing care. In reality, the assumption of policy makers and health service managers is that nurses will continue to provide full care – despite reducing staffing levels and increased patient turnover, dependency and complexity of care. Often, it would appear that rationing/missed care/nursing care left undone is a direct response to overwhelming demands on the nursing resource in specific contexts. A discussion of resource allocation and rationing in nursing therefore seems timely. The aim of this discussion paper is to consider the ethical dimension of issues of resource allocation and rationing as they relate to nursing care and the distribution of the nursing resource. (shrink)

Objective The objective of this article is to provide an ethical analysis of a high-risk, advanced treatment case where the patient received transcatheter aortic valve insertion, for aortic valve stenosis. Particular emphasis will be placed upon the significance of evidence and the implications for priority setting. Method One paradigmatic case involving a TAVI patient from a large university hospital in Norway is described and analysed. The method used was ethical case analysis modified after Kymlicka by Miljeteig et al. Perioperative mortality (...) risk was estimated using the Euroscore risk-logarithm and the Society of Thoracic Surgeons’ risk model, STS. These predict the risk of operative mortality and morbidity associated with adult cardiac surgery. GRADE, the Grading of Recommendations Assessment, Development and Evaluation, was used to evaluate the evidence. Results In the case analysis, we found that it would be ethically justifiable not to recommend TAVI treatment for this patient. Although the patient had a severe condition in need of treatment, the expected improvement was marginal, the quality of evidence was low and the opportunity costs for other patients and society were higher than usually deemed appropriate. Conclusions Decision-making in the absence of high quality evidence from randomized trials is a complex process involving difficult ethical judgments. Novel high-risk devices often enter the European market with limited clinical evidence. Transparency and improved clinical evaluation are required so patient safety is not jeopardized. We argue that implementation of high risk, high cost interventions should be better regulated at a national level. Background All clinical decisions imply priority setting and therefore indirectly affect other patients and other patient groups. The use of expensive, innovative health technologies has an affect on individual patients as well as on other patient groups competing for the same resources. (shrink)

This article addresses some ambiguities and normative problems with the concept of mature care in professional relationships and in health care priorities. Mature care has recently been introduced in the literature on care ethics as an alternative to prevailing altruistic conceptions of care. The essence of mature care is an emphasis on reciprocity, where the mature agent has the ability to balance the concerns of self with those of others and act from a principle of not causing harm. Our basic (...) claim is that the prevailing concept of mature care does not capture the real nature of professional relationships and role obligations in health care. As the focus of attention in professional care is and must be the patient’s particular medical and care needs, such care must principally be altruistic. Furthermore, we argue that mature care cannot adequately address moral conflict in health care without accepting some more principle-based approaches and a richer notion of partiality. (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)

This research aims to identify the ethical issues perceived by intensive care nurses in their everyday practice. It also aims to understand why these situations were considered an ethical issue and what interventions/strategies have been or are expected to be developed so as to minimize them. Data were collected using a semi-structured interview with 15 nurses working at polyvalent intensive care units in 4 Portuguese hospitals, who were selected by the homogenization of multiple samples. The qualitative content analysis identified end-of-life (...) decisions, privacy, interaction, team work, and health-care access as emerging ethical issues. Personal, team, and institutional aspects emerge as reasons behind the experience of these issues. Personal and team resources are used in and for solving these issues. Moral development and training are the most significant strategies. (shrink)