Introduction
Ethics include principles and values that guide behaviours and actions [1]. Professional care staff are engaged in care in their daily routine, and their experience in care is dependent on their thoughts, feelings, and values [2]. These values are particularly more important in aged care. Today, older adults who are admitted to health care centers are much older, do not have good physical health, and are dependent on others [3,4]. These individuals have physical limitations, chronic conditions, and sometimes cognitive problems which affect their decision-making capacity. This condition is suggestive of higher vulnerability of older adults in care settings [3-5]. Also, presence of discriminatory opinions about older adults complicates their vulnerable condition. These conditions reveal the necessity of addressing ethical issues in aged care [3,6].
Four ethical principles of autonomy, beneficence, non-maleficence, and justice, generally and theoretically, have specified the do’s and don’ts, appropriateness, and inappropriateness of actions. These are the general principles of ethics in medical care, and they are not enough for aged care. Ethical aged care requires knowledge, appropriate attitude, and ethical values to guide professional caregivers [7,8]. Although ethical values such as respect and preserving dignity of older adults, preserving autonomy, and self-determination have been the subject of many articles [4,8], no comprehensive study was found on ethical values in aged care. Introducing ethical values is useful in developing ethical codes in the field of aged care. Introducing these values is useful for the quality of care provision and the development of empirical ethics in aged care. Therefore, qualitative content analysis was used to answer the research question “What is the content of ethical values?” in the aged care literature.
Literature Search and Analysis
This qualitative content analysis was conducted in 2018. First, based on the research question, the keywords and search strategies were identified. For this literature review, a systematic search was conducted [Table/Fig-1]. The key words included value, right, ethic, moral, autonomy, justice, beneficence, maleficence, dignity, elder, older, senior, geriatric, aged, aging, and care, which were combined using the words AND and OR, and were searched in the databases of PubMed, Scopus, Ovid, ProQuest, Web of Science, Psych Info, and Google Scholar.
Study screening and flow of the articles through the review process.
There were 2890 articles in the search. After excluding 301 articles due to duplication, the titles and abstracts were then studied for unrelated articles, and 2398 articles were excluded. Finally, 191 articles were selected based on the full text. From these, 43 articles were suitable for the study and were related to ethical values in aged care based on the inclusion criteria. The inclusion criteria of the study were as follows: expressing ethical values in aged care directly or indirectly; providing ethical codes of aged care based on ethical values; addressing ethical values in aged care; addressing the human rights of older adults in care; addressing inter-professional ethical values in aged care; and studying the population of older adults and their relatives, or professional caregivers.
The conventional content analysis method was used to analyse the results of the studies. The analyses were conducted manually by two of the authors using the method presented by Graneheim UH and Lundman B [9]. The results of the studies were reviewed word by word several times and the initial codes were extracted. The information units included related words, phrases, and sentences. To validate the results, the data was obtained through the results of similar analyses by two researchers. The two researchers first analysed the data independently, and then they discussed and agreed upon the differences. The main researcher was engaged in the issue and its dimensions in advance, and the articles and particularly their results were reviewed several times.
Results
Out of the 43 selected studies, 28 were qualitative studies, 10 were reviews, and 5 were descriptive studies. Most of the studies involved nurses and older adults. A review of these studies, points to the importance of ethics in care, particularly in long-term care centers. Nurses had paid more attention to ethical issues, and most of the studies had been carried out in European countries, and then the United States and Asian countries. The results of analysing the articles showed five main themes of preserving dignity, preserving integrity, establishing human relationships, justice, and providing professional care, along with 19 sub-themes.
Preserving Dignity
Based on the results of the studies, preserving dignity is an important ethical value in aged care. Preserving dignity requires preserving respect of older clients and giving an opportunity to make their decisions in everyday affairs and care [6,10-12]. It also needs preserving privacy and confidentiality [10,13,14]. Provision of care in many aged care facilities and hospitals is routine-based. However, preserving patients’ dignity is inconsistent with routine-based care. Therefore, an open atmosphere and flexibility, and paying attention to the cultural, social, religious, and spiritual backgrounds of patients are the requirements for dignity-based care [15,16].
Preserving Integrity of the Elderly
Preserving integrity as an ethical value is one of the prerequisites of good care, and requires attention to the various physical, psychological and social dimensions of an older person as a human being. Respecting the physical integrity of older adults requires not limiting them and encouraging them to participate in their daily activities and physical activities [17-19]. Approving of older patients’ human experiences and values, and respecting them as persons with unique personalities, habits and needs, ensures psychological integrity [14,20]. Social integrity, another dimension of human being, covers the family, friends, and community. Elderly people need to interact with others as human beings. Social interactions play an important role in their feeling of worthiness [21]. Preserving integrity also requires paying attention to safety of care, and fulfilling the information needs of older clients. [Table/Fig-2] shows the selected articles [2-6,8,10-19,21-47].
The information related to the studied articles and identified values [2-6,8,10-19,21-47].
| Authors | Study type | Participants (Mean age)/Sample size | Identified values |
|---|
| Welford C et al., [11] | Content Analysis (CA) | - | Respect for autonomy, flexibility, empathy, respect for dignity, encourage participation |
| Hedman M et al., [10] | Phenomenology | Nurses/13 | Trusting relationships, autonomy, participation, respectful behaviour and privacy |
| Black K & Dobbs D, [25] | CA | Older adults (79.4)/267 | Preserving self-determination, living without pain, having control over everyday function, relationship with others, respectful treatment and positive attitude |
| Koskenniemi JH et al., [4] | CA | Elderly patients (84) and their relatives/20 (10, 10) | Polite behaviour, patience, providing information, assistance basic needs, pain relief, advocacy, positive attitude |
| Zhai X & Qiu RZ, [6] | CA | Elderly persons, relatives, assistant nurses, physicians and administrators /26 (6, 10, 4, 3, 3) | Respecting autonomy, encouraging participation |
| Teeri S et al., [8] | CA | Elderly patients (79), relatives, nurses/36 (10, 17, 9) | Preserving self-determination, giving information, physical integrity, individualised care, preserving psychological and social integrity |
| Anderberg P et al., [16] | Literature Review (LR) | - | Preserving dignity, considering patient preferences, autonomy and independence, individualised care, respect, sensitive listening |
| Sung KT & Dunkle RE., [26] | Descriptive | Social workers/50 | Respectful behaviour |
| Daher M [27] | LR | - | Preserving dignity, giving information, involving decision making, confidentiality and spiritual assistance |
| Tranvag O et al., [21] | Metasynthesis | - | Preserving autonomy and integrity, compassion, respectful communication, respect for values, positive attitude, encouraging social participation |
| Pleschberger S [28] | CA | Older adults (82) and nurses/73 (20, 53) | Relieving pain and suffering, encouraging relatives to be with the patient |
| Bollig G et al., [19] | CA | Older adults (83) and relatives/43 (25, 18) | Encouraging social interaction and participation, relationship with the patient, respect for privacy and autonomy |
| Woolhead G et al., [29] | CA | Older adults (72)/72 | Respect, observing privacy and autonomy |
| Jonasson LL et al., [30] | CA | Patient relatives/14 | Showing respect, friendly behaviour, facilitating participation, empathy and being amenable |
| Mezey MD & Mitty E, [23] | Qualitative | Older adults (83)/23 | Considering habits in care, giving information, honesty, relieving pain, being with the family, safe care and involving family in decision-making |
| Tracy MF et al., [31] | LR | - | Respect, knowledge, maintaining physical integrity, respect for autonomy, positive attitude, providing information, effective communication, promoting privacy and patience |
| Jonasson LL et al., [24] | CA | Nurses/20 | Corroborating, knowledge, experience, showing consideration, presence, kindness, spending time |
| Das MM [12] | LR | - | Considering patient preferences, respect, safe care, autonomy |
| Randers I et al., [14] | CA | Nurses/30 | Respect for integrity and privacy |
| Tadd W et al., [13] | CA | Older adults, adults, nurses, doctors, care workers, social workers, physiotherapist, managers, students and other professional /1320 (391, 505, 191, 42, 42, 25, 21, 25, 14, 64) | Respect, patient involvement in decision-making, privacy, pain relief, paying attention and encourage participation, positive attitude |
| Bolmsjo IA et al., 32] | CA | Older adults/12 | Autonomy, independence, professional knowledge |
| Tuominen L et al., [33] | Phenomenology | Older adults (81)/15 | Preserving autonomy, paying attention |
| Corvol A et al., [34] | CA | Nurses, psychologists, social workers, and occupational therapists/12 (3, 2, 5, 2) | Confidentiality, respect for privacy |
| Mail E et al., [3] | LR | - | Considering patient preferences, justice, knowledge, respect to patient’s religious values |
| Jakobsen R & Sorlie V, [35] | Phenomenology | Physiotherapists, nurses, social workers and nursing students /23 (3, 16, 1, 3) | Preserving physical integrity, self-determination and respect |
| Tuckett AG [15] | LR | - | Fulfilling information needs, favourable interaction with the elderly, trusting relationship, respect for needs and values, autonomy |
| Nordam A et al., [36] | Phenomenology | Nurses/5 | Justice, positive attitude, knowledge, respect, good communication, promoting self-determination, providing information |
| Blass DM et al., [37] | Descriptive | - | Protecting confidentiality |
| Rehnsfeldt A et al., [38] | Phenomenology | Relatives/28 | Respect, kindness |
| Jonasson LL, [2] | CA | Older adults, their relatives, and nurses/58 (24, 14, 20) | Respect, compassion, inviting participation, appropriate attitude, showing consideration, respect for values, safe care, equality, preserving self-determination, professional competency, accountability, justice, dignity |
| Choe K et al., [39] | Descriptive | Nurses/17 | Respect for autonomy, safe care |
| Frilund M et al., [40] | Descriptive | Nurses/105 | Paying attention, flexibility, involving patients and relatives in care, protecting integrity, respect, presence, professional competency |
| Marchesoni MA et al., [22] | CA | Nurses/12 | Presence in caring encounter, empathy, knowledge, gaining patient confidence |
| Webster C & Bryan K, [41] | CA | Older adults (78)/12 | Preserving privacy, confidentiality, clean environment, control over situations |
| Gastmans C & Milisen K, [42] | LR | - | Respect, politeness, preserving autonomy, promoting wellbeing, preserving physical integrity, promoting self-reliance, active communication, encouraging participation and physical activity |
| Woolhead G et al., [43] | CA | Older adults and health and social workers/815 (391, 424) | Politeness, respect, observing privacy, kindness, effective communication, including older person in decision-making |
| Frilund M et al., [44] | Descriptive | Nurses/105 | Respect, empathy, preserving dignity |
| Arino-Blasco S et al., [45] | CA | Nurses and other professionals/424 (191, 233) | Promoting autonomy and independence, respect, encouraging participation, effective communication, preserving privacy |
| Lothian K & Philp I, [18] | LR | - | Preserving dignity and autonomy, giving information, positive attitude |
| Goethals S et al., [17] | CA | Nurses/21 | Protecting physical and psychological integrity, preserving dignity, justice |
| Rees J et al., [5] | LR | Nurses | Respect, giving information, autonomy, privacy, informed consent |
| Birrell J et al., [46] | LR | - | Greeting, clean environment, preserving privacy and confidentiality, relieving pain, experience, promoting positive attitude |
| Bayer T et al., [47] | CA | Older adults/391 | Preserving privacy, cleanness, relieving pain, politeness, kindness, providing information and having control over decisions |
Establishing human relationships
Providing good and effective care requires effective human relationship and the relationship which is based on trust, respect, and mutual understanding. Honesty in behavior and speech, empathy, compassion and kindness, and patience in providing aged care are among other ethical values in providing care based on the analysis conducted in this study.
Justice
Justice in care refers to valuing humans equally, not discriminating against them in care, and trying to gain their rights as human beings. Older people, similar to other age groups, have equal rights in receiving treatment and care facilities, and the staff must provide medical and care services to them regardless of their age, culture, religion, and medical conditions [13,18,22].
Providing Professional Care to The Elderly
Providing professional care require professional competence, team care, presence in the care situation, and positive attitude toward ageing. The basis of professional competence is the possession of basic clinical skills, scientific knowledge, and ethical development. Due to physiological, cognitive, functional, and social changes related to old age, providing care to this group requires sufficient expertise and knowledge in the field of geriatrics as well as experience of care and decision-making in complex situations [3,20,23,24]. Providing care for the elderly requires the involvement of a multi-professional team. It also require presence in the caring encounter and paying attention to older persons through verbal and non-verbal behaviors. Since the attitude of professional caregivers affects the quantity and quality of care provision, a positive attitude toward ageing is another ethical value in providing professional care and respecting older patients’ dignity. [Table/Fig-3] shows themes and subthemes of ethical values [3,4,8,10,11,13-26,28-32,36,40-42,45-48].
| Themes | Sub-themes | Codes |
|---|
| Preserving dignity | Respectful behaviour | Showing respect through greetings, saying hello, being careful in choosing words, having appropriate way of expression, having appropriate voice tone while interacting and communicating with older adults, respectful touching and gentleness at the time of patient examination and handling [8,26,28]. |
| Preserving autonomy | Respect for intelligence or competence [23], giving an opportunity to make decisions in care, supporting and promoting independence and autonomy [10,11], paying attention to older people’s preferences, sharing older people’s preferences with other staff, giving the right to choose their care [8,31], promoting control over the personal aspects of daily life and possessions [11]. |
| Preserving privacy and confidentiality | Allocation of separate space [24], preparation of care setting, providing care by the same gender, preserving privacy through controlling access to the older person’s room, getting permission to enter, preserving bodily privacy, preserving the boundaries during the care procedures and cleaning [10,13,23,29], discussing patient information in a private space, confidentiality of patient information [26,45] |
| Flexibility in care | Making the caring acts and environment adaptive to the older person’s needs [11,16, 41], not adhering too much to routines [8], trying to solve their problems [8, 21], becoming aware of the person’s needs, wishes and habits on a physical, mental, spiritual and social level [16], providing care based on individual habits [23]. |
| Respect for values | Honoring the client’s ideas, beliefs, and values [26], respecting individuals’ values and culture [15], nonpaternalistic and person-centered values and beliefs of staff [11], attention to one’s values in decisions [16], confirming cultural and social norms [11], respect for religious beliefs and values, providing culturally appropriate care, respecting spiritual values, providing the conditions for meeting a clergyman [3,11,26,48]. |
| Preserving integrity | Preserving physical integrity | Upholding physical integrity [17,48], not using physical restraint [23], providing conditions for physical activity, encouraging participation in physical activity [42], encouraging participation in daily life [19], quickly meeting basic physical needs [32], not limiting freedom of movement, engaging and encouraging older adults to perform everyday activities [17]. |
| Preserving psychological integrity | Affirming the patient as a unique person, helping the older person to accept his or her capacity to promote self-confidence [14,20], allowing to have control over everyday affairs [13], avoiding rude or angry behavior [8], providing comfort and tranquility [17], confirming patient through behaviour and speech [24], timely response to patient needs, response to needs without elder request [4,25]. |
| Promoting social interaction | Providing resources for social interaction [48], encouraging the family and relatives to meet and interact with the elderly [42], awareness of elderly social needs [16], social interaction and feeling valued [21], regular visits and interactions with older people [10]. |
| Safe care | Awareness of the vulnerability of older people [10], protecting patients/residents from harmful consequences [48], injury prevention, protecting the older person against mistreatment [40], sufficient skill to perform safe care [40], providing a safe environment [23]. |
| Fulfilling information needs | Explain about caring interventions [42], sufficient response to information needs [4], simple explanation about the disease to the elderly and the family [30], providing information to the elderly clearly and understandably in a timely manner [30], providing necessary education about the disease, providing the information needed for treatment [15], Providing adequate information for decision making about care [19]. |
| Establishing human relationships | Gaining trust and confidence | Openness in dealing with the elderly and the family [10], behaviour that leads to a sense of trust and confidence [40], communication with older companions beyond the need for care, good communication and accountability to patient companions [22], trust-based communication with the patient’s family [10], regular communication with the elder and his companions, allocating time to the elderly [4], showing respect and consideration [24,30]. |
| Honesty | Honesty in behaviour and speech [4,23], saying positive and negative consequences of treatment [23]. |
| Empathy | Empathy [22], empathetic presence with the elderly [11], putting yourself in patient’s place [21], empathetic attitude [21]. |
| Compassion and kindness | Being compassionate [48], compassion is the qualification needed to be a professional, compassion and easiness to endure suffering, kindness, warm behaviour [4,48], behaviour with kindness [41], showing friendship [30], openness, relieving the suffering of the elderly patient [23,46,47], kind words [4], kneeling in front of the elderly while talking, embracing the elderly [10], warm and cheerful behaviour, good sense of humour [4]. |
| Patience | Being patient in listening to the patient’s words, not rushing to perform tasks [4], giving the elderly enough time to comment, giving the elderly the opportunity to discuss about daily life, needs and limitations [16], taking the time to talk about the patient’s condition [31]. |
| Providing professional care to the elderly | Presence | Engaging the elderly in communication [13], listening carefully [16], sensitivity to nonverbal language during interactions [22], being in a caring situation [24], paying attention to the patient during examination and treatment, being here and now, showing attention verbally and nonverbally [24], paying attention to the elderly when their relatives are present, talking to the elderly and not just the companion [13]. |
| Effective cooperation with the care team members | Consultation with other colleagues, trusting relationship with the care team [10], efforts to improve communication with colleagues, involving all team members in the care plan, communicating with other professional members, collaboration and cooperation of other team members [36], viewing colleagues as individuals with the ability to participate [22]. |
| Professional competence | Having expertise [23], knowledge in the field of aged care [24,31], sufficient knowledge about disease and treatment, elderly care experience [3], experience – complex decision making [3], professional skill and competence, maintaining competence [20], training complex decision making [3]. |
| Promoting positive attitude | Awareness of own attitude towards the elderly [31,36], respect for dignity under the influence of positive attitude toward ageing [25], considering the elderly as an experienced and wise person [11], positive attitude in experienced professional caregivers [18]. |
| Justice | | Equal access to medical care [13], providing equal care [20,33], non-discrimination based on age, culture, religion and medical conditions [3,15], persistence of staff to admit elderly patients in ward [36], equal priority in allocating resources to the elderly compared to other age groups, equal care and treatment [20]. |
Discussion
This study aimed to investigate the content of aged care ethical values in the literature. Based on the results, preserving human dignity was one of the most common ethical values in the reviewed articles. Attention to human dignity is one of the needs of Maslow’s Pyramid, and a component of human rights [49]. The feeling of dignity leads to the promotion of self-confidence, worthiness, and well-being in older adults [47]. In line with the present study, different studies have introduced the aspects of dignity as autonomy, involvement in decision-making, and preserving privacy [47]. Preserving respect, privacy, and confidentiality are among the ethical values introduced in the nursing ethical codes in Iran [50]. For many older people, preserving privacy is an integral component of preserving dignity, and ignoring it leads to their feelings of shame and humiliation [41,47]. Another value presented in this study was flexibility. According to Edard’s flexibility model, flexibility leads to a sense of control, comfort, satisfaction of desires and needs, and thus a sense of well-being, and satisfaction of older adults and their families [51].
Human communication is the most important source of meaning for the elderly [52]. Establishment of human relationships as an ethical value was also the result of a study by Shahriari M et al., [50]. They describe human relationship as a relationship based on affectionate understanding, creating trust, professional behaviour, kindness, and confidentiality.
Preserving integrity was one of the findings of this study. According to Goethals S et al., good care requires attention to all human aspects of the patient, including physical, social, psychological, and ethical aspects [17]. Preserving integrity is one of pre-requisites of high quality care, especially in long-term care centers [53]. Providing safe care for the elderly is important because they are more vulnerable than other age groups in care settings. Non-maleficence and avoiding harming others is one of the first priorities in developing the principles of professional ethics [54]. Preserving safety was among the nursing ethical values in the ethical codes of the Canadian Nursing Association and other studies [55]. Presenting timely information about the disease and treatment options was one of the prerequisites of decision-making in care. Failure to present sufficient information threatens autonomy and care choice, and leads to the disempowering of the older person [18].
In this study, having sufficient knowledge and experience in providing care to older adults was found very important. Many studies have introduced professional competence as an ethical value [50,56]. In fact, establishing effective relationships, providing safe care, and beneficence require sufficient knowledge and experience. Without knowledge of the different needs of older adults, clients’ rights, including integrity and autonomy, cannot be respected [3,7,48]. Because of the prevalence of discriminatory views against older people, the ethical values of justice and positive attitude toward old age play a more important role in aged care [20]. Staff’s positive attitude to old age has an important impact on older adults’ autonomy, and guarantees respect and good equal care. The outcome of positive attitude is the feeling of safety and confidence in the care provider and the care receiver [18,20].
Conclusion
In addition to the ethical principles of medical care, ethical values in aged care should focus on providing professional care and paying more attention to human aspects of care including preserving integrity, establishing human relationships, and preserving dignity of older people. Providing ethical care requires better understanding of older adults, awareness of their needs, and efforts to solve their problems.
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