As the gap between the demands for healthcare and the available resources is widening, setting priorities is becoming an inescapable and important task. The size of the elderly population and the average age is increasing, and advanced age is correlated with an increase in healthcare problems, co-morbidity and risks. It is therefore likely that the demand for healthcare services and complex and comprehensive services will increase in the coming decades. This will inevitably influence priority settings in healthcare and this is likely to affect the elderly in particular.

Prioritisations can be described as more or less conscious decisions to give some task or person priority and may within healthcare lead to postponed, reduced or shortened services for other patients. Still prioritisations might be legitimate due to the need to distribute limited resources—for example, budgets, time, manpower, or competence, in a fair way.1 Prioritisation might also be described as ranking in a sequential order, giving precedence, and making choices when the perceived need or demand exceeds available assets.2 The Norwegian guidelines for healthcare prioritisations stress the importance of an increased openness in setting priorities, as well as knowledge about the rationale behind prioritisations in clinical work.3 Still, qualitative research exploring clinical prioritisation is scarce. The present study is a part of a larger study of clinical prioritisation or “micro-allocation” in healthcare for older patients. The study consists of a quantitative part and a qualitative part. The quantitative sub-study is presented elsewhere.4

For a better understanding of how and why clinical prioritisations are made for older patients in healthcare services, it is important to explore the professionals’ self-understanding and their roles in such decision-making processes. This is the focus of the article.

A cross-European study of nurses’ opinions of their profession’s ethical codes and guidelines showed that most nurses have a poor understanding of their ethical codes. Most of the respondents believed the codes had little practical value because of extensive barriers to their use. Lacking awareness and interest, limited self-respect as professionals and insufficient motivation were considered internal barriers to an effective use of the codes. External barriers included inadequate financial and physical resources, time constraints and understaffing. The responding nurses also claimed that the actual standards of care were lower than those demanded by the codes.5 A study conducted by Woolhead et al revealed that, despite the awareness of good communication practices between professionals and older people, health and social care professionals often failed to live up to standards of good communication.6 Lack of time, scarcity of resources, regulation and bureaucracy, as well as lack of awareness and effort, were cited as barriers to the use of appropriate forms of address, listening, giving people choices, including them, respecting their need for privacy and politeness, and making them feel valued.

A significant problem concerned the difficulties involved in making morally acceptable decisions that would preclude too much or too little treatment.7 Among nurses, the primary concerns were lack of time to perform essential nursing tasks, addressing patients’ anxieties, fears and concerns, and giving patients and relatives information. Two elements of care closely associated with nursing, giving emotional support and bodily care, are most likely to be neglected when nurses are short of time.8 Quantitative data from our own study points to a tendency to disregard important needs of older patients, such as physical activity and communication, as well as psycho-social needs in healthcare.1 4

METHOD

The empirical basis for this study is qualitative, and semi-structured interviews were conducted with a total of 45 healthcare personnel during spring 2005. The study is a hermeneutical study with a hermeneutical and qualitative content analysis of the interviews. Of these 45 healthcare personnel there were 20 physicians and 25 nurses from different wards. The wards represented were dialysis and renal medicine (8 interviews), medical departments for patients suffering from heart conditions (12 interviews), orthopaedics wards (12 interviews) and from nursing homes (13 interviews).

There were 15 male physicians and five female, and two male nurses and 23 female. The physicians were aged from 32 to 63 years with work experience ranging from 3 to 35 years, with a median of 19 years experience as physicians. The nurses were aged from 26 to 59 years with work experience ranging from 1 to 34 years, with a median of 12 years experience as nurses. All informants were interviewed once and came from eastern, western and northern parts of Norway. The research group consisted of researchers and fellows at the section for medical ethics and section for nursing science, university of Oslo as well as from Oslo and Bodø University College

The semi-structured interview guide, started with an open question where the informants were asked to elaborate prioritisation dilemmas in their practice as healthcare workers. The interview guide also included questions on professional criteria for prioritisation as well as values inherent in the prioritisation decisions, and about participation and documentation procedures in clinical prioritisation.

Analysis

All 45 interviews were taped and transcribed verbatim before close readings. During the close readings the text was condensed, making it more compact without losing its meaning.9 Data were analysed qualitatively using hermeneutical content analysis.10 As a result of the first readings, an analysis guide with the most central themes in the interviews was developed by the research group. The analysis guide was used to condensate and to structure the findings. Coding was initially developed as a result of a naïve, inductive reading of the texts. In the next stage, coding was guided by the normative considerations central to the study as represented by the interview guide and informed by relevant ethical theoretical perspectives.

Ethical considerations

Each participant received written information about the study and gave their free informed consent to participate and for the taping of the interviews. The head of the department recruited, informed, and obtained consent from the informants before the researchers contacted them. Each informant gave written consent to participate. The informants were all health personnel, and a request to the Regional Ethical Committee was therefore not necessary, since the study did not include patients and was not within the mandate of the Norwegian Regional Ethics Committees. The study was approved by the Norwegian Social Science Data Services.

RESULTS

The results will be presented according to two central themes, the healthcare personnels’ conception of their role responsibilities and an apparent conflict between role responsibilities and important professional and ethical demands in the clinical setting.

One of the emerging themes, central to the focus of this article was clinician’s professional role and relevant role conflicts in clinical prioritisations in healthcare for the aged. Other central themes are explored in other articles.1

Professional roles and role responsibilities

In general the physicians and nurses in this study define their professional role and responsibility in clinical prioritisations in healthcare services to older patients—primarily as providing high quality medical treatment and responding to the patients’ most vital medical needs. Other responsibilities emphasised by many of the physicians and nurses interviewed are palliation and the need not to limit their professional role to the “treatment imperative” in the care for seriously ill older patients:

If starting treatment of a seriously ill older patient only means prolonging the suffering, I think it is better not to treat. […] We are trained to treat and to treat. This may in many cases be right, but, with these patients, I actually think that we should treat in order to relieve pain and suffering and provide comfort and care. But, we are not supposed to provide meaningless life-prolonging treatment. (Orthopaedic surgeon).

Most of the interviewees stated that their primary responsibility is the individual patient encountered at any given moment, and not the general patient population, other parts of healthcare, or considerations of justice. Facing the patient’s need directly is regarded as important in clinical prioritisations. Some interviewees stated that this perspective is often lacking on the administrative levels. As one of them states:

We are standing in a one to one relation with our patient […] and I think it is difficult to just say that I can’t talk to you… and that I don’t have time to help you with a bath… and things like this. It’s about ethics and morals among us. (Nurse, nursing home).

Some of the interviewees consider it an important part of their role and responsibility to be an advocate for their patient or group of patients when resources are limited. One physician remarked that the struggle between the professionals about relevant priorities is the hardest and most demanding one.

After all, we see that much of our job… is to try to argue in order to get resources if we see a need. And […] that fight has to be among the politicians and us, […] the whole thing comes out in arguing well enough, so that people realise what we should have. But much of the struggle also happens within the system, so that you change the ways treatment is done… And that struggle is the worst, the one within the group of professionals. And, that’s when we need strong leaders. (Orthopaedic surgeon).

Some of the interviewees are worried that older patients’ needs or diagnoses may fall outside the advocates’ primary interest or competence, and that this group therefore would be given lower priority:

I’ve really noticed it with the stroke patients now, when we’ve only had a cardiologist, we’ve had an oncologist. […]Then there is no one who speaks for them, none of the doctors stand in the breach for these people. […] If you don’t have anyone with a passion for this group of patients, among the doctors, then one ends up at the bottom of the priority list. And that is a little scary, I think. […] This week we have a geriatric doctor, and then (laughing) things are going really well! (Nurse, internal medicine).

However, none mentioned the importance of influencing the national policy on allocating healthcare resources, nor did they seem to recognise any conflict between serving their particular patients or take any responsibility for influencing the national policy on prioritisations. Most of the physicians limit their primary responsibility to the medical needs of the individual patient. It did not seem that they took particular responsibility for issues of distributive justice or responsibility for the commons. This may in the longer run make the elderly patients even worse off regarding priorities to healthcare. Although, many physicians mention “softer” responsibilities—for example, clinical communication and rehabilitation, such tasks are often given lower priority or delegated to the nurses:

Time is what we have least of […] you don’t have enough time to finish the regular work during the days, and you have to do it in the evenings. […] I have to say that, time for care, that is among the doctors is basically minimal. […] But, as a rule, it is probably the nurse who, most of the time, has to provide the care, and they are the ones communicating too. (Doctor, renal medicine).

However, the nurses also tend to focus their role and primary responsibilities to the medical needs of the individual patient.

Everyone gets a basic fundamental care. But, you often feel that you don’t get done that little extra you wish you could do, you don’t have time to sit on the edge of the bed and chat a little. […] You have to do the most necessary, and then the other things, the things that aren’t about life and death, they have to be postponed […] maybe you don’t get to […] exercise with the patient […] you don’t get time to plan what to do next, those thing we have to postpone […] The things you have to prioritise are really the most basic needs of the patient. That’s the way it is. [….] They may get a washcloth in their face, and their medicine, but you don’t have time to sit down and help with food and things like that. (Nurse, internal medicine).

Physical training, rehabilitation, nutrition, clinical communication, psycho-social needs and care needs, are often peripheral or even outside of both the physicians’ and nurses’ primary responsibilities and attention. One could expect that other professionals could take care of some of these needs, but such staff are often scarce or not used. In order to cope with these conditions, some nurses report a tendency to develop minimalistic standards, rather than aiming at good or excellent practice in their work. It seemed that time pressure indeed resulted in limitation of patient care. Several mentioned that this was especially problematic in elderly care, as care for the older patient are more time consuming than for younger patients.

Role conflict and moral strain

Even though a few physicians do not regard clinical communication as an important part of their responsibility, the majority of the informants consider clinical communication an important part of their work;

Speaking with family or loved ones means so incredibly much; Just the fact that someone spends some time. […] Just the fact you are there as a doctor. Because, in a way, you’re a natural authority too. (Doctor, nursing home).

However, clinical communication is often reported to be inadequate due to the time constraints. Some of the physicians are deeply concerned about the lack of time for communication and holistic approaches in the care for older patients, while other physicians prefer a more limited role.

We’ve worked a lot with attitudes in this department, and that being an orthopedicist and a surgeon means not only being able to handle a knife, that relating to the patient is important… and if you, in one way or another, don’t care about people, then it really doesn’t matter if you’re technically skilled. Well, it does matter… but, it’s not enough […] I feel we have some colleagues who do this very naturally, and then we have one or two where we have the sense that this is not their task. (Orthopaedic surgeon).

Many nurses, both in hospitals and nursing homes, describe a continuous role conflict, being bound to concentrate on satisfying the most urgent medical needs, while other needs and tasks are neglected:

I feel that I don’t prioritise the social and relational aspect of patient care. It’s more about, if something is medically wrong with the patients then… Due to resources…. cutbacks, I feel that, that we… You really feel guilty. Because, you feel that it’s been a long time since you sat down and chatted with the resident about just everyday things… where they get the feeling that they can see a bit more of us, the staff. (Nurse, nursing home).

Many nurses and physicians are concerned that lack of time may also result in neglecting medical needs, due to symptoms not being noticed. Some of the interviewees point out that lack of time and attention may increase the risk for mishaps and neglect; “When you run and run between people, you might not notice that person lying there coughing, something you might have noticed otherwise.” (Nurse, dialysis). There is a need for both scrupulous and caring clinicians, since older patients may be too modest, frail or confused to complain.

And I feel like I have 100 balls—eggs—in the air and if I turn away for just a second, they crash to the floor behind me, and I would be in big trouble if I then discovered that I had contributed to someone having a terribly worsened or shortened life, because of me not managing to take time to do the job properly… small mishaps happen all the time [...] we do have competent co-workers and they stretch themselves very far, and we’re also fortunate that we haven’t seen more…. but clearly, there’s a lot of things we don’t know about, patients who are sent home […] and then we never hear about it. (Doctor, internal medicine).

The same physician reports that you are “eaten up” if you are available for the patients and nurses on the ward. For that reason some physicians withdrew from the ward and even turn off the beeper. Both doctors and nurses appear to be worried about their lack of time for more comprehensive approaches to medical care and nursing care. Both nurses and doctors take time constraints and extensive working pressure to be a significant personal burden in their daily work. However, as mentioned, some doctors being aware of lack of opportunity doing clinical communication etc. said that this was the responsibility of nurses. It is notable that nurses become increasingly focused towards biomedical tasks, and we see that their role and possibilities to perform good nursing care also becomes increasingly limited.

DISCUSSION

This is a qualitative study based on interviews with physicians and nurses working in hospital wards (internal medicine or orthopaedics) or nursing homes in Norway, where the publicly funded healthcare services are considered to be of relatively high quality.11 However, the physicians’ and nurses’ interviewed, in various ways portray their roles and primary responsibility as having to do with attending to vital needs and providing sound medical treatment to the individual patient. These role descriptions cohere with the descriptions of what is given higher and lower priority in a national survey of priorities in care and treatment for the elderly sick patient.4 It seems that the humanistic and holistic clinician is under strain. Possibly, increased specialisation in healthcare, advances and increase in available medical interventions, economical incentives, and organisational structures, may contribute to a narrowing of the clinicians’ role, despite the steady increase of healthcare budgets and number of healthcare personnel. Some of the clinicians interviewed are concerned that patients’ groups that fall outside healthcare professionals’ prime interests or competence—for example, older patients with comprehensive needs, are given lower priority. Although the numbers of older patients are increasing and their needs are growing, there is little evidence of corresponding organisational and professional role adjustments in the descriptions of the healthcare services given in the interviews.

Many of the physicians interviewed still adhere to the idea that the nurses’ primary role is a holistic approach to care and clinical communication, and that this role may balance the physician’s biomedical role. However, the nurses’ role and priorities are largely framed by a biomedical discourse. This may seal off important values in healthcare, such as holistic care, empathy and dignity. The undermining of holistic professional roles may pose a serious challenge in healthcare services, in particular to older patients. A “void” may be created due to the lack of comprehensive and adjusted healthcare services. The low priority given to psychosocial needs, physical therapy, rehabilitation, nutrition and clinical communication are important examples of this tendency which was also prominent in the survey part of this study.1 4

The physicians and nurses define their role within a moral reality of illness and operating conditions which they cannot escape. Many struggle with not being able to do enough, not attending to the comprehensive needs of older patients, or the sapping of one’s own professional role and expectation in daily work life. Some describe a tendency to lower the standards and narrowing the role of the clinician. This is done in order to secure the vital needs, but is felt to counter good practice and holistic role modelling. How to secure holistic professional roles and to attend to older patients comprehensive needs remains an inescapable and important challenge—to professional associations, educators and healthcare institutions—as the biomedical possibilities and costs seem to increase rapidly.

In particular, these findings show the serious challenges to the role of nurses, and especially in their care of the elderly. If nurses primarily see their role as accommodating to the needs for vital biomedical care, then the standards of basic care for patients are jeopardised. Some of the nurses voice worry and concern that nursing merely responds to the needs of medical treatment thus narrowing and limiting their professional role. Though there are some examples of a growing awareness among healthcare workers considering distributional justice in healthcare, professional measures taken by both the nursing and medical community to come to terms with this obvious challenge seem to be needed.12

Distributing healthcare services in a fair way are generally not described as integral to the clinicians’ role in clinical prioritisations. It seems fair to say that resource prioritisations and considerations of justice in general did not seem to be perceived by doctors and nurses as part of their professional responsibility. If clinicians continue to shy away from this task, it is possible that others will shape their roles and responsibilities in clinical prioritisations. We believe that a fair distribution of healthcare services to older patients and other patient groups is possible only if clinicians accept responsibility also in these difficult questions.