The Ethical Standpoints of Rehabilitation in the Nordic Countries-A Theoretical Study About Caring Sciences and Rehabilitation Vinje, Marianne Physical therapist, Master of Management Advicor, Organizational Development Ålesund Muncipality, Norway

Abstract

Purpose: The study's purpose is to argue from a theoretical perspective, the importance of an ethical foundation or ontology in rehabilitation. The study aims to create a theoretical model where ethics and rehabilitation form a synthesis. Method: The study is theoretical in the fields of rehabilitation and Caring Science. It follows a hermeneutic approach where the text is interpreted and analysed concerning context. Findings: A common opinion, based on our material, is that rehabilitation is a relationship rather than a separate activity area. No professional group can invoke a monopoly on rehabilitation. Who formulates clinical practice goals and determines the patients' needs? How is the rehabilitation process tailored to the theme of "what is right "and "what is best for the patient"? Conclusion: The theoretical model as it describes in this paper has opportunities to guide the ReHabilitering team against excellent ethical rehabilitation independent of clinical context.

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International Journal of Caring Sciences May-August 2018 Volume 11 | Issue 2| Page 645
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Special Article
Awareness of Ethical Challenges and Nursing Intensity in Care of Older People
Marianne Frilund, RNs, MNs, PhD
Associated Professor, Department of Health Sciences Aalesund, Norwegian University of Science and
Technology, Faculty of Medicine and Health Sciences, Aalesund Norway
Correspondence:
Marianne Frilund, RNs, MNs, PhDAssociated Professor, Department of Health Sciences
Aalesund, Norwegian University of Science and Technology, Faculty of Medicine and Health Sciences
Larsgardsvegen 2, 60030 Aalesund Norway Email: mafr@ntnu.no
Introduction
The article is an academic essay, a dialog between
different aspects of nursing intensity (NI) and theory of
Caritative Caring.(Eriksson, 2002a, K, 2003, Eriksson
and Lindström, 2009, Eriksson, 2007c, Eriksson,
2007a) The intentions are to reflect on ethically
defensible care (Frilund et al., 2013b, Frilund et al.,
2014, Frilund, 2013, Frilund and Fagerstrom, 2009,
Eriksson, 2007b) Ethically good care are not self-
evident. In clinical settings, we need consensus about
the criteria for “good ethical care”. (Frilund et al., 2014,
Larkin et al., 2017, Frilund, 2013). Consensus about
“good care” prevent service from becoming impersonal
and stereotypical and instead becoming care-based,
with ethical manners in the daily work. The syntheses
between the ethos of caring and nursing intensity
highlight new knowledge about realistic possibilities to
act in an ethical manners in praxis. (
Figure 1 A synthesis between ethos and nursing
intensity (Frilund and Fagerstrom, 2016)(Frilund and
Fagerstrom, 2016, Frilund, 2013)
I want to discuss, by dialog, how NI affects at quality of
care and the caregivers’ opportunities to provide “good
ethically care” for older people. As example on NI
measurement instrument was The RAFAELA system
used and this instrument includes both elements of to
"be with the patient" and to "do something for the
patient". (Fagerstrom, 1999, Morris et al., 2007)
Researches have stated that RAFAELA system
provides a realistic picture of the patients' care needs,
without trying to provide total accuracy. (Andersen et
al., 2014, Fagerstrom et al., 2000, Fagerstrom, 1999)
An important thing for meeting the needs of elderly
people are the caregivers’ averageness to own values
and attitudes toward the elderly, as well as knowledge
about geriatric and aging.(Wadensten and Carlsson,
2003b, Wadensten and Carlsson, 2003a) The Essay is a
continued dialog based on my thesis from 2013.
Background
Awareness of the good
An ethically aware caregiver strives to invite the patient
into a caring relationship that mediates strength as well
as respect for the integrity and wholeness of the human
being. An ethically aware caregiver strive to “do well”,
“do right” and “take responsibility”. Ethical values,
from a caring science perspective, describes in terms as
human love and mercy, caring relationships, human
dignity, autonomy and respect. (Frilund, 2016,
Eriksson, 2002, Eriksson, 2007 The essence of caring
is to alleviate the patient’s suffering, promote health
and wellbeing (Eriksson, 2010, Eriksson, 2007b,
Eriksson and Lindström, 2009).
Acting ethically exists in the moment when goodness
becomes an awareness choice for caregivers. An
awareness of “the good”, which cannot react to
practice, are for many caregivers, nurses as well as
other members of the team, burdensome. (Brodtkorb et
al., 2015) Previous research highlights, the fact that
caregivers most every day are meeting ethical
dilemmas and challenges. (Jakobsen and Sorlie, 2010,
Brodtkorb et al., 2015)
Synthesis between ethos and NI
The theoretically model (
Figure
1
) focus on ethical values- ethos, patients’
needs, expectations and wishes, ethical manners and
ethical leadership. The connection between the
different elements goes through ethical consensus,
ethical affirmation, ethical freedom and ethical
discussion and decision-making. The caregiver gives
life to the model, by her person. Her awareness of
ethical values, affirmation of them, willingness and
moral actions and responsibility are decisive prior to
how the daily work will be designed. (Frilund, 2013,
Frilund, 2015, Frilund and Fagerstrom, 2016)

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Figure 1 A synthesis between ethos and nursing intensity (Frilund and Fagerstrom, 2016)
Nursing Intensity
In Finland, a patient classification system called the
RAFAELA- system, has been under development in
hospital care since the 1990s (Frilund and Fagerstrom,
2009, Rauhala and Fagerstrom, 2004, Fagerstrom et al.,
2000, Fagerstrom, 1999).The system has been widely
used in Finland, Norway and in Sweden. RAFAELA
system consist of three parts: 1) The OPC instrument
and 2) daily nursing resources and 3) the Professional
Assessment of Optimal Nursing Care Intensity
(PAONCIL) method. The goals of RAFAELA system
are to make sure that personnel resources and patients'

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needs for care are in balance with each other.
Fagerstøm ( 2000, 1999) highlights that all dimensions
of the caring relationship not fully can be measured
planned or assessed. The patients’ care needs are both
measurable and unmeasurable. In order to get a more
comprehensive picture of the patients’ needs, the
assessment of the patient's care, also has to take into
account so called "indirectly" nursing. (Morris et al.,
2007)
.
Based on my preunderstanding and the aim with the
paper following hypothesis where formulated:
Awareness about ethical values, consensus about
criteria for good care and optimal resource allocation
make it possible to act ethically. Awareness and
consensus in case of ethic are the secrets behind good
ethically care and caregivers’ job satisfaction.
Dialog
Dialog I- Ethical consensus
Organizational and political changes of today
will easily be in conflict with the caregivers’
individual wishes to act ethically. Ethos is a
fundamental human value made visible in words,
needs and attitudes.(Frilund and Fagerstrom,
2016) Eriksson state that ethos stands for the
good as a potential. Something each nurse has
opportunities to choose or refrain (Eriksson,
2002b, Eriksson, 2007b, Eriksson, 2009,
Eriksson and Lindström, 2009). The majority of
nurses have an obvious picture about how the
daily care together with older people should be
designed (Nordman, 2006, Frilund et al., 2013b).
However, many nurses expire they lack realistic
opportunities to care in accordance with their
ethical ideals. (Nordstrom and Wangmo, 2017,
Larkin et al., 2017, Frilund and Fagerstrom,
2016)
My study from 2013 show that a number of
caregivers not necessary have an awareness
about what ethical values suppose us to be or do
in the daily work with older people. There will
be a gap between ideals and the caregivers’
ontological standpoint to act ethically. (Frilund et
al., 2013a, Frilund, 2013) What kind of ethical
manners or position healthcare professionals
show in the relation to the patient are depended
on which ethical values the caregivers have
affirmed and the opportunities the caregivers feel
they have to be ethically. (Frilund et al., 2014,
Frilund and Fagerstrom, 2016) Ability to be
ethically can be expired as challenging and
problematical.
In praxis different professions work together in
team. Different professions have their own
ethical codes and guidelines that can easily come
into conflict with each other. An important task
for the team members are to get consensus about
which ethical values the team are ready to
conform. If dignity, autonomy, respect
participation are values they agree with, how can
caregivers make them visible in the daily work?
Good ethically care are depended on how well
the ethical values have been operationalized to
understandable concepts with clinical evidence.
In addition, are the caregivers willing to act in
accordance with made agreements at the unit or
would the ethical level depends on each
caregivers’ own attitude? (Frilund et al., 2014,
Frilund et al., 2013b) Wecan stat that ethically
“good care” is dependent of ethical consensus
made at the unit, willingness to be ethical, ethical
freedom and ethical consensus. The consensus
would be a background for to stat optimal NI
level.
Optimal Nursing Intensity (NI) level is a concept
which describe how well available resources are
in balance with the patients’ needs of nursing.
(Frilund and Fagerstrom, 2009, Rauhala and
Fagerstrom, 2004) Many instruments used within
the care of older people measure primarily the
patients’ ability to manage in everyday life and
only to a limited extent take into consideration
the patients’ psychological, social and spiritual
needs. NI level affects personnel allocation and
thereby, the quality of care.(Frilund and
Fagerstrom, 2009, Sung et al., 2005)
Possibilities to be ethically needs an optimal NI
level. In accordance to RAFAELA- system, the
NI can be at different levels; the optimal level,
the lower level and the high level. An optimal
level describes a situation where the patients’
needs are in balance with available resources. In
this case, the patients’ care have been in
accordance with the criteria’s of good care that
the unit in case has defended.
If the NI is higher than the optimal level, the
patients’ needs are higher than the available
resources. In that case, a gap between needs and
possibilities to provide good care will occur.
Research has shown that high NI level under a
long period not only will be a risk for the quality
of care but also a health risk for the
caregivers.(Frilund and Fagerstrom, 2009, Sung
et al., 2005, Rauhala, 2008)

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Ethical consensus is thereby critical for the unit's
criteria of good ethically care. Are the criteria of
good care in accordance with the ideals as
dignity, caring relationship, closeness and
distance, safety, autonomy and participation?
Dialog II -Optimal nursing intensity and patients’
care needs
Patients have become older, their care needs
have increased, and this has consequences for
working conditions within primary health care.
(Frilund et al., 2009, Frilund et al., 2013a,
Frilund et al., 2013b) Personnel dimensioning
(staff allocation) as well as the personnel's level
of competence is something quite different today
than it was for 20 years ago (Sundler et al., 2016,
Mahlin, 2010) NI level in primary health care is
high and national recommendations for nurse-to-
patient ratios have not been implemented,
because of economic conditions. (Murphy, 2007,
Frilund and Fagerstrom, 2009). Still, there is an
increased need for instruments that measure NI
level and state the optimal NI level per nurse
within primary health care.(Fagerstrom et al.,
2014)
Assessment of nursing intensity (NI) with
RAFAELA system has proven to be a useful
method to reveal the relationship between NI and
available resources, and find out the optimal
level of NI at the unit.(Frilund and Fagerstrom,
2009, Frilund et al., 2014) Balance between
patients’ needs of care and available staff support
caregivers to develop nursing compatible with
Theory of Caritative Care. (Eriksson and
Lindström, 2009, Eriksson, 2009, Eriksson,
2007b) RAFAELA system gives sufficient
attention to psychological, social and spiritual
needs.(Murphy, 2007) and thereby support the
theory of caritative caring.
Consensus about the criteria for good ethical care
and an optimal nursing intensity level gives the
patient opportunities to “be met” with ethical
manners and morality. (Frilund and Fagerstrom,
2009, Frilund et al., 2014, Rauhala and
Fagerstrom, 2004) However, it is not self-evident
that consensus about ethical values turn into
ethical manners in the daily work with older
people.(Frilund et al., 2014, Suhonen et al.,
2013) Conflicts between the healthcare
provider's ideals of ethical care and their
experiences of realistic possibilities to act
ethically can lead to different adverse effects for
both the patients’ quality of care (Frilund et al.,
2013a, Frilund et al., 2013b) and the caregivers’
job satisfaction (Glasberg.A-L., 2007, Førde and
Aasland, 2013). Nordstrom and Wangmo (2017)
show in their study a tension between the nursing
staffs’ ideals and values and their actual work
context. Their informants described a deep
willingness to serve the patients in order to
promote well-being.(Nordstrom and Wangmo,
2017) Lindström and Lindholm(Lindstrom and
Lindholm, 2003) warns that every sentence
context can turn into futility and fragmentation.
Nurses and other healthcare providers become
carriers of values, which praises productivity,
efficiency and impact, in praxis the
meaninglessness and fragmentation emerges as
ethical dilemmas and challenges. (Jakobsen and
Sorlie, 2010)
Are the patients’ needs, wishes’ and expectations
in balance with available resources?
Dialog III- Ethical manners
The caregivers must have realistically
opportunities to meet the patients’ needs, and it
will be a main task for the leaders to argue for
balance between patients’ needs and available
resources. (Frilund and Fagerstrom, 2016,
Frilund, 2015)
A holistic view of caring, individual treatment of
the elderly, efforts to preserve the autonomy of
the elderly, encourage to actively make it
possible for the older person to participate in
their own care, are generally expectations or
wishes to day. However, might the level of
participation and autonomy be embraced
different within the working group? One obvious
problem is the conflict between economic
principles and ethical ideals, between
effectiveness and relations, between my opinion
and the patients’ opinion.
Within the team are expectations, which not
necessary will be consistent with the patient's
and/or family's expectations. The patient want to
participate in his/her own care, be a part of the
decision – making process, and feel dignity and
safety. Healthcare professions has theoretically
the same opinion, but in clinical settings, the
situation will be something else. We do not have
time is a common statement. Can we derby feel
free to decide without asking the patient about
his/ her opinion? Dignity, participation, safety
integrity are common values in the community to
day. What do these values impose us to be or do?
(Sundler et al., 2016, Sung et al., 2005,
Nordstrom and Wangmo, 2017, Frilund, 2015)

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In recent years, professional identity, ethics and
ethical issues and their impact on health of the
caregivers have been subject to numbers of
studies.(Manomenidis et al., 2017, Ahlin et al.,
2015, Orrung Wallin et al., 2015)
Ethical
awareness that cannot be realize through an
ethical approach, differently affect caregivers.
The phenomena can be described as "a good
intention goes wrong" with the patients’
autonomy and dignity are been overlooked.
Studies demonstrate correlations between
conscience stress and burnout, which can lead to
emotional exhaustion. The caregivers are forced
to numb their conscience for to manage their
situation or they have to leave the health care.
(Manomenidis et al., 2017, Ahlin et al., 2015,
Orrung Wallin et al., 2015) One of the reasons
for conscience stress can be a consequence of
high nursing intensity. The caregivers felt they
not could live up to patients’ expectations. They
felt they did not have a supporting team or
leaders around. In combination with luck of inner
strength, they decided to live the area of
caring.(Frilund et al., 2013b, Frilund and
Fagerstrom, 2009)
Moral anxiety and stress also occurs when the
career’s experience of ethical and moral
responsibilities towards patients came into
conflict with organizational expectations, and the
expectations from the team. Frilund (2013)
believe that with the help of reflection and
discussion in the working Group, it will be
possible to find optimal solutions to ethical
problems.
Consensus
Back to the hypothesis, Awareness about ethical
values, consensus about criteria for good care
and optimal resource allocation make it possible
to act ethically. Awareness and consensus in
case of ethic are the secrets behind good
ethically care and caregivers’ job satisfaction.
A new understanding for awareness of ethical
challenges and NI in care of older people has
been born. Ethical values need to be discussed;
they need to be taken seriously and they need to
be made visible as criteria for good care. The
clinical settings need measurement tools for to
measure the working load at the unit. New
questions have been born under the writing
process that we have to answer in future
research. Thereby, we have opportunities to
develop the theoretical model described above
and promote a model with clinical evidence.
(Figure 1)
Future research questions for relevance
• Are the criteria of good care in
accordance with the ethically ideals as
dignity, relations, closeness and distance,
safety, autonomy and participation?
• Are the patients’ needs, wishes’ and
expectations in balance with available
resources?
• What are the caregivers’ realistic
opportunities to act ethically in the daily
work? What is the NI level at the unit?
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