See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/26293626

Nurses' Perceptions of Ethical Issues in the Care of Older People

Article  in  Nursing Ethics · August 2009

DOI: 10.1177/0969733009104608 · Source: PubMed

CITATIONS READS

81 1,804

3 authors, including:

Lindy King
Flinders University
55 PUBLICATIONS   1,545 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Consumer reporting of patient deterioration View project

All content following this page was uploaded by Lindy King on 26 February 2015.

The user has requested enhancement of the downloaded file.

 Nurses’ Perceptions of Ethical
Issues in the Care of Older People
Jenny Rees, Lindy King and Karl Schmitz

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

Nursing Ethics 2009 16 (4) © The Author(s), 2009. 10.1177/0969733009104608

Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav
 Ethical issues in the care of older people 437

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.

Summary of selected studies

On reading the abstracts and in some cases the full texts of approximately 50 reports,
16 were found to meet the inclusion criteria. The reference lists of included reports
were also searched and provided one further report meeting the inclusion criteria.9
The final sample included 17 primary research reports relating to 11 major research
projects. Of these, five reports were presented as a series relating to one large-scale
research study collecting data from five European countries.4,10–13 Findings from the
Greek data collected within this large-scale study were reported in a separate article by
Lemondidou et al.14 Another two articles in the final sample reported different aspects
of the same study set in Sweden with some overlap in findings.15,16 The remaining nine
reports each related to nine separate research studies. Of these, one was set in Israel,5
one in the UK17 and seven in Scandinavian countries. 6–9,18–20 Tables 1 and 2 provide
details of the 17 reports.

Nursing Ethics 2009 16 (4)

 438

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

Nursing Ethics 2009 16 (4)

Tabak, 19985 encountered by nurses caring for people, 122 caring for adults and 117 Questionnaire (100% RR); ethical
adults only, elderly people only and caring for both) who participated issues defined within questionnaire
mixed-age groups, and to identify the in professional post-basic nursing
sources of dilemmas courses during 1994/1995
Lemonidou Greece To describe the perceptions of patients 144 nursing staff and 152 patients Cross-sectional exploratory and
et al., 200214 and nurses of the actualization of aged over 65 in 9 long term care correlational design with statistical
autonomy, informed consent and hospitals for elderly patients analysis
privacy (uses data from a large-scale Questionnaires for staff (66.1% RR)
study reported in series below) Structured interviews for patients
Leino-Kilpi Finland, First report in a series of five; general 887 nursing staff in health facilities Cross-sectional exploratory and
et al., 20034 Spain, overview: caring for elderly people and 573 correlational design with statistical
Greece To explore the issues of autonomy, patients aged 60 or over analysis
Germany, privacy and informed consent by Questionnaires for staff (65% RR)
UK examining nurses’ and patients’ Structured interviews for patients
perceptions
Scott et al., Finland Second report in a series of five: 887 nursing staff in health facilities Cross-sectional exploratory and
200313 Spain, To explore the realization of patient caring for elderly people and 573 correlational design with statistical
Greece autonomy by examining nurses’ and patients aged 60 or over analysis
Germany, patients’ perceptions Questionnaires for staff (65% RR)
UK Structured interviews for patients
Schopp Finland, Third report in a series of five: 887 nursing staff in health facilities Cross-sectional exploratory and
et al., 200311 Spain, To explore how privacy is protected caring for elderly people and 573 correlational design with statistical
Greece by examining nurses’ and patients’ patients aged 60 or over analysis
Germany, perceptions Questionnaires for staff (65% RR)
UK Structured interviews for patients
 Table 1 (Continued)

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.

Nursing Ethics 2009 16 (4)

Ethical issues in the care of older people 439

Table 2 Summary of qualitative research reports included in the review (date order)
Reference Location Research aim
Norberg Sweden To explore the differences in
Nursing Ethics 2009 16 (4)
et al., 19989 experience between doctors, RNs
and ENs in ethically difficult care
situations
Slettebø and Sweden To highlight strategies used by
Bunch, 200415 nurses to solve ethically difficult care
situations (uses data from the same
study as the report below)
Slettebo and Sweden To highlight strategies used by
Bunch, 200416 nurses to solve ethically difficult
care situations, and to provide a
supplement to principle-based ethics
(uses data from the same study as the
report above)
Enes and de UK To examine nurses’ experience of
Vries, 200417 disclosure and to determine other
ethical issues that nurses experience
Mauleon Sweden To illuminate what it means for
et al., 20056 anaesthetic nurses to be in ethically
problematic care situations
Sample and setting
20 RNs, 20 ENs and 10 doctors in one Narrative theory analysis
elderly care clinic in one large city Narrative interviews
14 RNs from 3 nursing homes
14 RNs from 3 nursing homes
53 RNs working in 13 elderly
persons’ care units
7 anaesthetic nurses in one
department of a large A&E care
hospital where the majority of
patients in the department were aged
60 or more
440
Design and method
J Rees et al.
Grounded theory analysis
Semistructured interviews and
observations
Grounded theory analysis
Semistructured interviews and
observations
Mixed method; however only the
qualitative findings were useful
Qualitative content analysis
Quantitative descriptive statistical
analysis
Semistructured questionnaires
(39.3% RR)
Interpretative phenomenological
method
Narrative interviews
 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.

Nursing Ethics 2009 16 (4)

Ethical issues in the care of older people 441
442 J Rees et al.

Critical appraisal of the studies

A critical analysis of the research reports was conducted to identify the strengths and
weaknesses of the research studies. The review included nine articles reporting the
findings of four quantitative studies (Table 1) and seven articles reporting the findings
of six qualitative studies (Table 2). There was also one mixed method study by Enes
and de Vries17 that provided both qualitative and quantitative findings, which were
assessed individually. However, analysis indicated that only the qualitative findings
from this study were useful to the aim of this review, and therefore the study is listed
with the qualitative reports in Table 2.
Differences between studies according to design and method can be found in Tables
1 and 2. The research aims of eight of the quantitative reports focused on nurses’ per-
ceptions of one or more ethical issues selected by the researchers, that is, autonomy,
informed consent, privacy, disclosure, exercise of power and conscience (Table 1). The
remaining quantitative report5 described perceptions of ethical dilemmas as defined
within the questionnaire used in the study. In this way the researchers used the de-
sign of the quantitative studies to determine what constituted an ethical issue. The
benefits of including quantitative studies in this review are that their findings can
provide accurate measures of what nurses think about selected ethical issues that are
transferable beyond their original settings. The research aims of the qualitative studies
and of the qualitative data in the mixed method study focused on nurses’ perceptions
of ethical issues in general terms. The design of these studies allowed participants to
identify for themselves what constituted an ethical issue, as well as to provide a nar-
rative description of the nature of the ethical issues identified.
Although the findings cannot be generalized beyond the group under study, quali-
tative research methods are particularly well suited to explore such sensitive issues
through in-depth narratives. The differences in methods, design and focus of the in-
cluded studies made the search for common themes more complex because the findings
were difficult to compare. However, as a whole, they provided a rich and informative
description of nurses’ perceptions of ethical issues, in keeping with the aim of this
review. As explained earlier, the review aim was intentionally broad in order to capture
a sufficient number of articles from an under-researched field.
The Critical Appraisal Skills Programme tool for assessing qualitative research21
was used to identify the strengths and weaknesses of the qualitative research studies.
A tool was developed by the first author for assessing the strengths and weaknesses of
the quantitative research studies by applying the criteria for assessing reliability and
validity described by Roberts and Taylor.22 Findings were clearly stated and the value
of the research adequately demonstrated for all the qualitative studies. Two qualitative
studies7,8 did not provide evidence of reflexivity within the research design, while an-
other two6,15,16 did not provide evidence of the inclusion of techniques to enhance the
credibility of the findings. Three studies (two qualitative and one quantitative) failed
to state whether approval had been sought for the research from the appropriate ethics
committees and also to discuss the ethical issues raised.5,9,17 This is a surprising obser-
vation in articles reporting research studies relating to ethical issues. The omission of
ethical considerations undermined the robustness of these three studies but this was
not so severe to require their exclusion from the review.
Overall, the trustworthiness of the qualitative studies was found to be sufficient for
all the seven qualitative articles plus the mixed-method article to be included in the
review, despite the weaknesses noted above. In addition, the reliability and validity of

Nursing Ethics 2009 16 (4)

 Ethical issues in the care of older people 443

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.

Presentation of the findings

Analysis of the reviewed studies was conducted through a process involving all three
authors. Guidance on the analysis procedure was given by the second author while the
first author applied a general inductive method to repeated readings of the findings
of the studies. The main concepts from each study’s findings were highlighted and
included on a list by the first author. Grouping of similar concepts then became themes
and subthemes that were confirmed through discussion between the first and third
authors. The analysis was tightly focused on the reported descriptions of nurses’ percep-
tions and did not seek more overt themes such as cultural or sociological influences.
Four common themes were identified relating to nurses’ perceptions of ethical issues in
the care of older people: 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. Table 3 presents the research reports in which these
themes were found.

Theme 1: Sources of ethical issues

This was the most frequently reported theme, being found in nine reports. It was sub-
divided into the six subthemes below.

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.

Nursing Ethics 2009 16 (4)


Table 3 Themes found in reviewed research reports
Theme
Nursing Ethics 2009 16 (4)
1) Sources of ethical issues for nurses
Doctors
Lack of financial and personnel
resources
Patients’ families
Societal and organizational attitudes
Routine-centred care
Relationship with peers
2) Differences in perceptions between nurses
and patients/relatives
3) Nurses’ personal responses to ethical issues 4
4) Patient–nurse relationship
444
No. research Research reports
reports with
J Rees et al.
this theme
9 Norberg et al., 19989; Wagner and Tabak, 19985; Palviainen et al. 200318; Enes and
de Vries, 200417; Slettebø and Bunch, 200416; Mauleon et al., 20056; Nordam et al.,
200519; Teeri et al., 20067; Schaffer, 20078
6 Norberg et al., 19989; Wagner and Tabak, 19985; Enes and de Vries, 200417; Mauleon
et al., 20056; Nordam et al., 200519; Schaffer, 20078
4 Enes and de Vries, 200417; Slettebø and Bunch, 200416; Nordam et al., 200519;
Schaffer, 20078
4 Wagner and Tabak, 19985; Enes and de Vries, 200417; Teeri et al., 20067; Schaffer
20078
4 Mauleon et al., 20056; Enes and de Vries, 200417; Nordam et al., 200519; Schaffer,
20078
2 Palviainen et al. 200318; Teeri et al., 20067
2 Norberg et al., 19989; Nordam et al., 200519
7 Lemonidou et al., 200214; Leino-Kilpi et al., 20034,10; Schopp et al., 200311,12; Scott et al.,
200313 (6 reports = 1 study); Teeri et al., 20067
Norberg et al., 19989; Mauleon et al., 20056; Nordam et al., 200519; Juthberg et al.,
200720
4 Norberg et al., 19989; Slettebø and Bunch, 200415,16 (1 study); Nordam et al., 200519
 Ethical issues in the care of older people 445

Moral outrage against doctors was reported to be evident in stories narrated by

registered nurses.9 However doctors’ stories reported in the same study contained
positive views regarding personnel and teamwork, suggesting discrepancies in percep-
tion between doctors and nurses. Such discrepancies are likely to add to nurses’ diffi-
culties in overcoming ethical issues.

Lack of financial and personnel resources

Lack of resources was reported as a source of ethical issues in the care of older people in
four reports. A lack of both financial and personnel resources was reported as the source
of ethical issues in two studies.8,16 The nurses in Nordam et al.’s study19 discussed the
low priority given to the care of older people in the allocation of budgetary resources in
favour of high technology areas. Inadequate staffing levels were perceived to cause
unethical practices such as the unnecessary use of coercion and restraints19 and older
people not always dying ‘well’; for example, patients without families were dying
alone.17

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.

Societal and organizational attitudes

The prevailing attitudes of society, or of the organizations in which nurses work, were
highlighted in four reports as ethical issues in the care of older people. Anaesthetic nurses
reported the dilemma of watching each patient treated as ‘a commodity’.6 These nurses
perceived that the drive for efficiency and productivity within the setting of the study
conflicted with the ethical treatment of the patients concerned. In another study, nurses
regarded the ‘system’ in which they worked as being unethical, not only in its effect on
the treatment of older people but also in its dealings with the workforce.19 In the same
study, nurses expressed their awareness of a wider disrespect towards older people in
society and in the health care services.19 This was perceived as a cultural bias towards
‘an ideal of youth, richness and independence’ (p. 1252) and an attitude that old people
had outlived their usefulness.19
The cultural taboo in modern western society towards death and dying was iden-
tified as an ethical issue in relation to the care of older people in two studies.8,17 Nurses’

Nursing Ethics 2009 16 (4)

446 J Rees et al.

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

Relationship with peers

Relationships with other nurses were raised as an ethical issue in the care of older people
in two reports. Frustration with nurses on other wards and in the primary health care
system was expressed as a source of ethical difficulty by nurses working on wards
delivering care to older people.19 Enrolled nurses reported that overwhelming peer
pressure from other enrolled nurses and nursing aides prevented them from intervening
to protect older people from incidents of neglect or abuse by others.9

Theme 2: Differences in perceptions between nurses and patients/

relatives
The second theme related to the differences found between nurses’ and patients’/
relatives’ perceptions of ethical issues in the care of older people and was found in
seven reports covering two studies. These two studies revealed notable differences
when comparing the perceptions of nurses with those of patients4,10–14 and with the per-
ceptions of both patients and relatives7.
Although many common ethically problematic experiences were reported by nurses,
patients and relatives in the study by Teeri et al.,7 there were additional categories of
experiences encountered by patients and relatives, but not by nurses. One of these
was a main category relating to social integrity, which included the loneliness of pati-
ents and their isolation from the outside world. In addition, patients and relatives
reported two separate subcategories of ethical problems not noted by nurses. First,
patients and relatives reported lack of information as an ethical problem, in that nurses
failed to explain their daily nursing interventions to patients or give regular updates
and opportunities for discussion to relatives. Second, physical abuse was reported by
patients and relatives, which involved disrespectful physical handling of patients, caus-
ing them pain and loss of dignity.
The other study in which this theme was identified described the perceptions
of nurses and patients across five European countries in relation to the concepts of

Nursing Ethics 2009 16 (4)

 Ethical issues in the care of older people 447

autonomy (defined as information received by patients/given by nurses, and decision

making by patients), informed consent and privacy.4,10–14 Nurses were found to have
more positive perceptions than patients of the realization of autonomy in all five
countries13 and of informed consent in four of the five countries.12 For the purposes of
this large-scale study and for this review, results with a P-value below 0.05 were con-
sidered statistically significant. The above differences in perceptions between nurses
and patients were statistically significant for information received/given in all five
countries (P < 0.0002);13 for decision making in two countries (P = 0.0001);13 and for
informed consent in four countries (P = 0.0001).12 In relation to the realization of privacy,
perceptions of nurses and patients were similar in three of the five countries, although
statistically significant differences in perceptions between nurses and patients were
found in the other two countries (P < 0.013),11 with the perceptions of the nurses being
more positive than those of the patients. A report focusing solely on the perceptions
of Greek nurses and patients in relation to autonomy, informed consent and privacy
revealed that nurses’ perceptions of adherence to all three of these ethical concepts
were consistently higher than those of patients.14 These differences were statistically
significant (P < 0.001) for information received, informed consent and privacy.

Theme 3: Nurses’ personal responses to ethical issues

Nurses’ perceptions of their personal responses to ethical issues were described in four
reports. They reflected that they were capable of overriding treatment decisions they
thought were unethical in two studies.9,19 They based these decisions on professional
knowledge and experience, described as a concept of ‘trusting oneself’ in one study.19
However, when nurses were faced with unresolvable ethical issues they expressed guilt,
frustration and a sense of powerlessness.19 Another study revealed the moral anguish
felt by nurses who had not adhered to their personal values.6 A quantitative study
by Juthberg et al.20 explored the relationship between perceptions of conscience and
stress caused by a troubled conscience. A strong correlation was found between stress
caused by conscience and the perception that conscience has to be deadened in order
to continue to work in health care. Although only 22% of the participants admitted that
they had to deaden their conscience for this reason, being forced to ignore their con-
science caused moral stress for these nurses. Moral outrage was expressed by nurses
in relation to ethical issues caused by doctors.9 The depth of emotion shown in relation
to ethical issues in these studies revealed that the personal and moral well-being of
nurses as individuals was dependent on the ability to resolve ethical issues in the care
of older people.

Theme 4: Patient–nurse relationship

The role of the patient–nurse relationship in resolving ethical issues was identified as a
theme in four reports covering three studies. Knowledge of the patient was identified
as an essential aspect of the relationship in two studies. One of these described the
strategies of negotiation and explanation used to resolve ethically difficult situations,
both of which required discussion with the patient and knowledge of the patient.15,16
Nurses talked about building relationships of respect and getting to know patients,
and regarded their meetings with older people as exciting and valuable experiences for
themselves.19 Respecting the individuality of older patients was perceived as critical

Nursing Ethics 2009 16 (4)

448 J Rees et al.

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

Discussion and implications for practice

Ageism in both society and health care organizations was clearly identified in the find-
ings as one of the sources of ethical issues in the care of older people. However, the
insidious nature of ageism may cause effects wider than those immediately identifiable
by nurses. Ageism is likely to underpin other sources of ethical issues identified in this
review, such as conflict with doctors, the lack of financial and staff resources, and conflict
with peers who harbour ageist views. In fact, ageism is probably the major source
of ethical issues in the care of older patients. Fundamental changes in attitude towards
older people in our society are clearly required. One way to change ageist attitudes
is through awareness and education,1 which can begin within the nursing profession
itself. Many nursing undergraduates express the view that nursing older people is
uninteresting or unchallenging. This viewpoint shows a failure to appreciate what it is
to be old. Nursing an older person involves more than catering for physical needs; it also
requires an understanding of the psychological, sociological, cultural and ethnic needs
of a person who has lived through loss and adversity as well as good times. This can be
a rich and enlightening experience for undergraduates who are open to learning from
older people. Including the care of older people as a compulsory topic in the nursing
curriculum would have the dual purpose of engaging disinterested students and
preparing nurses for an inevitable future of nursing older people as this population
increases.
There is insufficient detail in the reviewed studies to determine whether the re-
ported conflicts between doctors and nurses regarding the treatment of older people
were due to the doctors’ lack of respect for older people, or for the nurses, or for both.
Certainly, such conflict between doctors and nurses is generally well recognized in
other articles.24 The reality of medical dominance goes hand in hand with doctors failing
to value nurses’ opinions and recognize their professional status. However, nurses’
anecdotes also support the theory that doctors prioritize patients by age, for example,
by being quicker to respond to emergencies involving children and younger adults
than older people. Doctors who are focused on cure can tend to regard older people as
less deserving of their attention than younger patients. More focus should be given to
effective pain management in older people and good palliative care so that unnecessary
investigations are avoided. These two topics should become mainstream courses in
both nursing and medical education as the population of older people increases.
Nursing practice must continue to move towards individual care plans tailored
to older people’s needs, particularly in the age-related residential care sector. This
involves giving patients the choice and does not necessarily mean the removal of rout-
ines for those older people who prefer routines. However, the lack of financial and
personnel resources, already identified as a source of ethical issues, inevitably prevents
the transition from routine-centred care to patient-centred care. The ageist attitudes of
health care organizations are responsible for the failure to adequately resource the care
of older people, and must be overcome. Nurses can influence the values of society by
using their voices to challenge health care policies that they believe are unethical.25

Nursing Ethics 2009 16 (4)

 Ethical issues in the care of older people 449

Nursing education needs to focus on workplace skills such as conflict management

and assertiveness to assist nurses to deal with the types of ethical issues encountered
in the care of older people. This is fundamentally about enabling nurses to be patients’
advocates. In the first author’s experience nursing undergraduates are continually
reminded of this role, but insufficient instruction is given on how to achieve this in
practice.
In addition, nursing management should provide workplace forums for nurses to
discuss and share strategies for overcoming ethical issues in the care of older people.
The focus of these forums should be on questions relating to skills, such as: How could
I have been a better advocate for the patient? How could I have better enabled the
patient to determine his or her own treatment? If nurses are afraid to speak out when
they see abuse of older people occurring, better avenues for reporting abuse are needed
to put an end to this unacceptable and often criminal behaviour. At the same time, nurs-
ing management must recognize the emotional stress on nurses as they endeavour to
resolve ethical issues in the care of older people, and offer appropriate support. Organ-
izations can and should develop more effective dialogue between professional groups
in relation to these ethical issues.
It is interesting that some nurses placed great emphasis on understanding patients,
while others underestimated the size and scope of ethical issues, suggesting a lack of
common understanding. In practice, little attention is focused on patient feedback, de-
spite feedback forms being left at the bedside in some hospitals. Research has shown
that patients avoid speaking out for fear of being labelled as difficult and consequently
receiving poor care.26 The increased vulnerability of older people on entering hospital
or age-related residential care2 may make them more fearful of these consequences
than younger people. However, older people can express their views without prejudice
through participation in clinical research. If nurses are to understand and respect older
people properly, further research on older people’s perceptions of ethical issues is
required.

Limitations of the review

Limitations of this review and of the existing research in this area are acknowledged by
the authors. First, only one of the included studies5 explored the difference in nurses’
perceptions of ethical dilemmas in the care of older people compared with care of other
age groups. Thus the current review does not identify which of its findings, with the ob-
vious exception of ageist attitudes, are unique to, or are more prevalent in, the care of
older people. Although this was not an aim of the review, an understanding of these
aspects would be useful in terms of implementing the findings.
Second, this review focused on nurses’ perceptions in order to understand what
aspects of ethical issues were important to them. However, findings from studies ex-
cluded from this review, such as those using third party observation of ethical issues,
may also provide insight into nurses’ ethical perceptions. In addition, excluded studies
whose settings were outside the care of older people may also offer insights that are
transferable to this research aim.
Third, the failure in the literature to define older people consistently, or sometimes
at all, makes it difficult to apply the findings to a specific group in practice. Future
research should explore the question of whether to define older people by a specific age
or indeed by other criteria.

Nursing Ethics 2009 16 (4)

450 J Rees et al.

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.

These conclusions provide important messages for nursing education, management,

practice and research. The most important messages are derived from the first finding.
Action must be taken to resolve ethical issues at their source, particularly the most
insidious underlying source: ageism. Education is a key tool for changing ageist atti-
tudes and for otherwise preparing health professionals for resolving ethical issues.
This review revealed to the authors a significant and disappointing lack of research
in the field of ethics in the care of older people. This is perhaps a reflection of society’s
lack of focus on older people to date. It is likely that this will change not only in response
to the increasing size of the population of older people, but also as a response to their
changing nature as the baby-boomer and following generations grow old. These gen-
erations are generally expected to be more demanding and assertive than previous
older generations because of their comparative life-styles and wealth. The ageing of
the nursing workforce in many countries in tandem with that of the general population
is acknowledged as creating an additional strain on existing nurse shortages.27 It is
imperative that the nursing profession and nurse researchers respond today to the
harsh realities of the changing global demography. Further research and changes to
education and practice can equip new nursing graduates to meet the challenges of
resolving ethical issues in the care of older people.

Nursing Ethics 2009 16 (4)

 Ethical issues in the care of older people 451

Acknowledgement
With thanks to Chris Walton, for support given as clinical mentor to the first author
during the initial phases of this review.

Conflict of interest statement

None declared.

Jenny Rees, Lindy King and Karl Schmitz, Flinders University, Adelaide, South Australia.

References
1 World Health Organization. Missing voices: views of older persons on elder abuse. 2002. Retrieved
16 September, 2007, from: http://whqlibdoc.who.int/hq/2002/WHO_NMH_VIP_02.1.pdf
2 Irurita VF. The problem of patient vulnerability. Collegian 1999; 6: 10–15.
3 World Health Organization. 10 facts on ageing and the life course. 2007. Retrieved 16 September,
2007, from: http://www.who.int/features/factfiles/ageing/en/index.html
4 Leino-Kilpi H, Välimäki M, Dassen T et al. Perceptions of autonomy, privacy and informed
consent in the care of elderly people in five European countries: general overview. Nurs Ethics
2003; 10: 18–27.
5 Wagner N, Tabak N. The old get equal care: myth or reality? Int J Nurs Pract 1998; 4: 234–39.
6 Mauleon AL, Palo-Bengtsson L, Ekman S-L. Anaesthesia care of older patients as experienced
by nurse anaesthetists. Nurs Ethics 2005; 12: 263–72.
7
Teeri S, Leino-Kilpi H, Välimäki M. Long-term nursing care of elderly people: identifying
ethically problematic experiences among patients, relatives and nurses in Finland. Nurs Ethics
2006; 13: 116–29.
8 Schaffer MA. Ethical problems in end-of-life decisions for elderly Norwegians. Nurs Ethics
2007; 14: 242–57.
9
Norberg A, Uden G, Andren S. Physicians’, registered nurses’ and enrolled nurses’ stories
about ethically difficult episodes in the care of older patients. Eur Nurse 1998; 3: 3–13.
10 Leino-Kilpi H, Välimäki M, Dassen T et al. Perceptions of autonomy, privacy and informed
consent in the care of elderly people in five European countries: comparison and implications
for the future. Nurs Ethics 2003; 10: 58–66.
11
Schopp A, Leino-Kilpi H, Välimäki M et al. Perceptions of privacy in the care of elderly people
in five European countries. Nurs Ethics 2003; 10: 39–47.
12 Schopp A, Välimäki M, Leino-Kilpi H et al. Perceptions of informed consent in the care of
elderly people in five European countries. Nurs Ethics 2003; 10: 48–57.
13 Scott PA, H Välimäki M, Leino-Kilpi H et al. Perceptions of autonomy in the care of elderly
people in five European countries. Nurs Ethics 2003; 10: 28–38.
14
Lemonidou C, Merkouris A, Leino-Kilpi H et al. Nurses’ and elderly patients’ perceptions
regarding autonomy, privacy and informed consent in nursing interventions in Greece. Rev
Clin Gerontol 2002; 12: 191–204.
15
Slettebø Å, Bunch EH. Solving ethically difficult care situations in nursing homes. Nurs Ethics
2004; 11: 543–52.
16
Slettebø Å, Bunch EH. Ethics in nursing homes: experience and casuistry. Int J Nurs Pract 2004;
10: 159–65.
17
Enes SPD, de Vries K. A survey of ethical issues experienced by nurses caring for terminally ill
elderly people. Nurs Ethics 2004; 11: 150–64.
18 Palviainen P, Hietala M, Routasalo P, Suominen T, Hulpi M. Do nurses exercise power in basic
care situations? Nurs Ethics 2003; 10: 269–80.
19 Nordam A, Torjuul K, Sørlie V. Ethical challenges in the care of older people and risk of being
burned out among male nurses. J Clin Nurs 2005; 14: 1248–56.

Nursing Ethics 2009 16 (4)

452 J Rees et al.
20 Juthberg C, Eriksson S, Norberg A, Sundin K. Perceptions of conscience in relation to stress of
conscience. Nurs Ethics 2007; 14: 329–43.
21 Public Health Resources Unit. Critical Appraisal Skills Programme (CASP): making sense of
evidence: 10 questions to help you make sense of qualitative research. 2006. Retrieved 17 September,
2007, from: http://www.phru.nhs.uk/Doc_Links/Qualitative%20Appraisal%20Tool.pdf
22 Roberts K, Taylor B. Nursing research processes: an Australian perspective, second edition. South
Melbourne: Nelson, 2002: 64–68.
23 National Health and Medical Research Council. How to use the evidence: assessment and application
of scientific evidence. 2000. Retrieved 19 December, 2008, from: http://www.nhmrc.gov.au/
publications/synopses/cp69syn.htm
24 Blue I, Fitzgerald M. Interprofessional relations: case studies of working relationships between
registered nurses and general practitioners in rural Australia. J Clin Nurs 2002; 11: 314–21.
25 Leino-Kilpi H. We need more nursing ethics research [Guest editorial]. J Adv Nurs 2004; 45:
345–46.
26 Henderson S. Power imbalance between nurses and patients: a potential inhibitor of partnership
in care. J Clin Nurs 2003; 12: 501–508.
27 International Council of Nurses. An ageing nursing workforce. 2008. Retrieved 28 April, 2008,
from: http://www.icn.ch/matters_ageing_Workforce.htm

Nursing Ethics 2009 16 (4)

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

View publication stats