Berit Støre Brinchmann

In quest of justice? Clinical prioritisation in healthcare for the aged

Background: A fair distribution of healthcare services for older patients is an important challenge, but qualitative research exploring clinicians’ consideration in daily clinical prioritisation in healthcare services for the aged is scarce. Objectives: To explore what kind of criteria, values, and other relevant considerations are important in clinical prioritisations in healthcare services for older patients. Design: A semi-structured interview-guide was used to interview 45 clinicians working with older patients. The interviews were analysed qualitatively using hermeneutical content analysis and template organising style. Participants: 20 physicians and 25 nurses working in public hospitals and nursing homes in different parts of Norway. Results and interpretations: Important dilemmas relate to under-provision of community care and comprehensive approaches, and over-utilisation of certain specialised services. Overt ageism is generally not reported, but the healthcare services for the aged seem to be inadequate due to more subtle processes, for example, dominating considerations and ideals and operating conditions that do not pay sufficient attention to older patients’ needs and considerations of justice. Clinical prioritisations are described as being dominated by adapting traditional biomedical approaches to the operating conditions. Many of the clinicians indicate that there is a potential for improving end of life decisions and for reducing exaggerated use of life-prolonging treatment and hospitalisations. Conclusion: The interviews in this study indicate that considerations of justice and patients’ perspectives should be given more attention to strike a balance between specialised medical approaches and more general and comprehensive approaches in healthcare services for older patients.

When the Home Becomes a Prison: living with a severely disabled child

The aim of this study was to generate knowledge about how parents who have been part of an ethical decision-making process concerning a son or daughter in a neonatal unit experience life with a severely disabled child. A descriptive study design was chosen using 30 hours of field observations and seven in-depth interviews, carried out over a period of five months with parents who had been faced with ethical decisions concerning their own children in a neonatal unit. Strauss and Glaser’s constant comparative method was used for the analysis. The findings seem to indicate that these parents have an extremely tough life. Their relationships with their children are somewhat ambivalent. The children are very dependent on their parents, who in some ways both love and hate them. Too little rest and sleep and feeding the children are the most serious problems. The parents require respite facilities. The home can seem like a prison, from which it is impossible to escape. It is like having a baby who never grows up.

Clinical prioritisations of healthcare for the aged—professional roles

Background: Although fair distribution of healthcare services for older patients is an important challenge, qualitative research exploring clinicians’ considerations in clinical prioritisation within this field is scarce. Objectives: To explore how clinicians understand their professional role in clinical prioritisations in healthcare services for old patients. Design: A semi-structured interview-guide was employed to interview 45 clinicians working with older patients. The interviews were analysed qualitatively using hermeneutical content analysis. Participants: 20 physicians and 25 nurses working in public hospitals and nursing homes in different parts of Norway. Results and interpretations: The clinicians struggle with not being able to attend to the comprehensive needs of older patients, and being unfaithful to professional ideals and expectations. There is a tendency towards lowering the standards and narrowing the role of the clinician. This is done in order to secure the vital needs of the patient, but is at the expense of good practice and holistic role modelling. Increased specialisation, advances and increase in medical interventions, economical incentives, organisational structures, and biomedical paradigms, may all contribute to a narrowing of the clinicians’ role. Conclusion: Distributing healthcare services in a fair way is generally not described as integral to the clinicians’ role in clinical prioritisations. If considerations of justice are not included in clinicians’ role, it is likely that others will shape major parts of their roles and responsibilities in clinical prioritisations. Fair distribution of healthcare services for older patients is possible only if clinicians accept responsibility in these questions.

Priority dilemmas in dialysis: the impact of old age

Aim: This study explores priority dilemmas in dialysis treatment and care offered elderly patients within the Norwegian public healthcare system. Background: Inadequate healthcare due to advanced age is frequently reported in Norway. The Norwegian guidelines for healthcare priorities state that age alone is not a relevant criterion. However, chronological age, if it affects the risk or effect of medical treatment, can be a legitimate criterion. Method: A qualitative approach is used. Data were collected through semistructured interviews and analysed through hermeneutical content analysis. The informants were five physicians and four nurses from dialysis wards. Findings: Pressing priority dilemmas centre around decision-making concerning withholding and withdrawal of dialysis treatment. Advanced age is rarely an absolute or sole priority criterion. It seems, however, that advanced age appears to be a more subtle criterion in relation with, for example, comorbidity, functional status and cognitive impairment. Nurses primarily prioritise specialised dialysis care and not comprehensive nursing care. The complex needs of elderly patients are therefore often not always met. Conclusions: Clinical priorities should be made more transparent in order to secure legitimate and fair resource allocation in dialysis treatment and care. Difficult decisions concerning withholding or withdrawal of dialysis ought to be openly discussed within the healthcare team as well as with patients and significant others. The biomedical focus and limitations on comprehensive care during dialysis should be debated.

Why does the provision of home mechanical ventilation vary so widely

There is wide variation in the provision of home mechanical ventilation (HMV) throughout Europe, but the provision of home mechanical ventilation can also vary within countries. In 2008, the overall prevalence of HMV in Norway was 19.9/100,000, and there were huge regional differences in treatment prevalence. The aim of this study is to find explanations for these differences. We gathered multidisciplinary respondents involved in HMV treatment from five hospitals in five different counties to six focus group conversations to explore respondents’ views of their experiences systematically. We based the analysis on grounded theory. We found that uneven distribution of ‘‘enthusiasm’’ between hospitals seems to be an important factor in the geographical distribution of HMV. Furthermore, we found that the three subcategories, ‘‘high competence,’’ ‘‘spreading competence,’’ and ‘‘multidisciplinary collaboration,’’ are developed and used systematically in counties with ‘‘enthusiasm.’’ This culture is the main category, which might explain the differences, and is described as ‘‘wise enthusiasm.’’ The last subcategory is ‘‘individual attitudes’’ about HMV among decision-making physicians. The most important factor is most likely the uneven distribution of highly skilled enthusiasm between hospitals. Individual attitudes about HMV among the decision makers may also explain why the provision of HMV varies so widely. Data describing regional differences in the prevalence of HMV within countries is lacking. Further research is needed to identify these differences to ensure equality of provision of HMV.

“Values That Vanish into Thin Air”: Nurses' Experience of Ethical Values in Their Daily Work

The objective of this study was to examine how nurses experience ethical values as they are expressed in daily practice in a Norwegian hospital. A growing focus in Western healthcare on effectiveness, production, and retrenchment has an influence on professional nursing standards and nursing values. Lack of resources and subsequent ethically difficult prioritizations imply a strain on nurses. This study is qualitative. Data collection was carried out by conducting 4 focus group interviews. The data was analyzed using content analysis. The results are presented in two main themes: (1) values and reflection are important for the nurses; (2) time pressure and nursing frustrations in daily work. The results demonstrate that nurses believe the ethical values to be of crucial importance for the quality of nursing; however, the ethical values are often repressed in daily practice. This results in feeling of frustration, fatigue, and guilty conscience for the nurses. There is a need for changes in the system which could contribute to the development of a caring culture that would take care of both patients and nurses. In an endeavour to reach this goal, one could apply caritative leadership theory, which is grounded on the caritas motive, human love, and mercy.

Ethical challenges in home mechanical ventilation: A secondary analysis

The aim of this study was to explore the ethical challenges in home mechanical ventilation based on a secondary analysis of qualitative empirical data. The data included perceptions of healthcare professionals in hospitals and community health services and family members of children and adults using home mechanical ventilation. The findings show that a number of ethical challenges, or dilemmas, arise at all levels in the course of treatment: deciding who should be offered home mechanical ventilation, respect for patient and family wishes, quality of life, dignity and equal access to home mechanical ventilation. Other challenges were the impacts home mechanical ventilation had on the patient, the family, the healthcare services and the allocation of resources. A better and broader understanding of these issues is crucial in order to improve the quality of care for both patient and family and assist healthcare professionals involved in home mechanical ventilation to make decisions for the good of the patient and his or her family.

‘They have to Show that they can Make it’: Vitality as a Criterion for the Prognosis of Premature Infants

In this article, the vitality of premature infants will be described and discussed. Vitality was one of the main factors in a grounded theory study in which the aim was to generate knowledge concerning the ethical decision-making processes with which nurses and physicians are faced in a neonatal unit. Which assessments underlie decisions about whether to start, continue or stop medical treatment of very sick premature babies? A descriptive study design, including 120 hours of field observations and 22 qualitative in-depth interviews with doctors and nurses, was chosen. Strauss and Glaser’s comparative method was used to analyse the field observations and interviews. The findings indicate that life-and-death decisions are somewhat ambivalent; experience does not always make them easier. In situations of ambiguity, decisions also seem to be based upon the vitality of the babies concerned.

The challenge of integrating justice and care in neonatal nursing

The aim of this study was to explore neonatal nurses’and mothers of preterm infants’experiences of daily challenges. Interviews took place asking for good, bad and challenging experiences. Data were analysed using qualitative content analysis and findings were clustered in two categories: good and challenging experiences, each containing three themes. The good experiences were: managing with success as a nurse, small things matter for mothers, and a good day anyhow for mothers and nurses. The challenging experiences were: mothering in public, being pulled between responsibilities, and adverse things stick under the nurses’skin. The study shows that small daily clinical matters become big issues and could lead to moral distress, and that nurses integrate ethics of justice and ethics of care while mothers are concerned about health and well-being of their specific infant only. The challenge for nursing to integrate fairness and sensitive care in family-oriented neonatal care is discussed.

Evidence-based care and childbearing : a critical approach

Developing the best care for clients and patients is a paramount aim of all health care practices, which therefore, should be based on best evidence. This is also crucial for care during the childbearing period here defined as pregnancy, childbirth, and infancy. However, due to dominance of the evidence-based medicine (EBM) model, health care practice has encountered problems especially regarding its relationship to qualitative research. In this article, we analyze and discuss how research based on a lifeworld perspective fits with evidence-based care (EBC), and how a circular model instead of a hierarchy is suitable when attributing value to knowledge for EBC. The article focuses on the history of EBM and EBC, the power of the evidence concept, and EBC from a narrow to a broad view. Further qualitative research and its use for developing EBC is discussed and examples are presented from the authors’ own lifeworld research in the Nordic childbearing context. Finally, an alternative circular model of knowledge for EBC is presented. In order to develop evidence-based care, there is need for multiple types of scientific knowledge with equal strength of evidence, integrated with clinical experience, setting, circumstances and health care resources, and incorporating the experiences and clinical state of the childbearing woman and her family.