Barriers to and facilitators of ethical encounters at the end of life in a nursing home : an ethnographic study

Background: Among a growing population of older persons, many afected by multiple diseases and complexneeds, are cared for in nursing homes. Previous studies of nursing homes have highlighted the importance of personalised palliative care. Nevertheless, we know little about whether everyday care practice involving assistant nurses andfrail older persons accomplishes ethical encounters, especially in assisted bodily care. Therefore, the aim of this studywas to understand and conceptualize the encounter between residents and assistant nurses in bodily care-situationsat the end of life in a nursing home. Methods: Focused ethnographic design was used. Residents and assistant nurses from one nursing home in anurban Swedish area participated in this study. Data were collected for 6 months and consisted of 170 h of feldwork,including participant observation and interviews. Observations and digitally recorded interviews were analysedthematically. Five public community stakeholders contributed to the analysis by discussing preliminary results andclinical implications in a focus group. Results: Four themes, each encompassing both barriers to and facilitators of ethical encounters in assisted bodilycare, were identifed: Coping with the impact of workplace demands; Interacting in dialogue and communication;Experiencing involvement in the provision of assisted bodily care; and Adapting to good care and comfort. Conclusions: The fndings suggest that accomplishing ethical encounters in assisted bodily care practice in a nursing home context has many barriers that are related to communication, relationships, and quality of care. Barriersincluded lack of resources, inefective communication, and work values, which hinder ethical encounters. Nevertheless, moral sensitivity, genuine interest in resident engagement, and collaborative practices facilitated ethical encounters and are thus central to person-centred care. Uniquely, assistant nurses must be aware of their responsibility forperforming their tasks in response to residents’ vulnerability. We therefore suggest that moral deliberation over issuesof communication, compassion, decision-making, and behavior, with particular consideration for the care relationship.To further improve the quality of care, organisations must provide resources for the building of relationships, as wellas time for assistant nurses to recover after long shifts. Additional research is warranted, including implementation ofethically grounded palliative car