ORIGINAL ARTICLE

Ethics and gender issues in palliative care in nursing homes: an Austrian participatory research project Elisabeth Reitinger

Dr. MMag.

Associate Professor, IFF Palliative Care and Organisational Ethics, University of Klagenfurt, Vienna, Austria

Katharina Heimerl

Dr. MPH

Associate Professor, IFF Palliative Care and Organisational Ethics, University of Klagenfurt, Vienna, Austria

Submitted for publication: 8 November 2013 Accepted for publication: 31 March 2014

Correspondence: Elisabeth Reitinger IFF Palliative Care and Organisational Ethics University of Klagenfurt Schottenfeldgasse 29/4, Vienna 1070 Austria Telephone: 004315224000 103 E-mail: [email protected]

REITINGER E. & HEIMERL K. (2014) Ethics and gender issues in palliative care in nursing homes: an Austrian participatory research project. International Journal of Older People Nursing 9, 131–139. doi:10.1111/opn.12049

Background. The development of palliative care in nursing homes in Germanspeaking countries has gained in importance within the past 15–20 years. Ethical and gender issues are core aspects of a palliative care culture and should therefore be better understood. Aims and objectives. The aim of this study was to highlight insights regarding ethical and gender issues, based on the experiences of professionals in nursing homes. Design. A 2-year participatory action research study was performed in collaboration with three nursing homes in Austria. Methods. The article focusses on 10 group discussions with interdisciplinary professional teams that were conducted to generate ethical narratives. Thematic and narrative analysis was undertaken both individually and within the interdisciplinary research team. Findings and interpretations were validated with practitioners and researchers. Findings. A total of 36 narratives were collected and summarised within eight themes concerning the theoretical journey of a nursing home resident with relatives from entry into the house until death. The most burdensome ethical dilemmas are not the ones around death and dying but rather those relating to small-scale everyday work/life issues. Sharing experiences and feelings in ethical discussions provides relief. Emotions are important facilitators of insight into ethical dilemmas. Gender issues can be observed in care situations as well as in the organisational structure of nursing homes. Conclusions. Opportunities to share experiences and perspectives around ethical questions in interdisciplinary group discussions help professionals to better understand difficult issues and find appropriate ways of managing them. Implications for practice. There is a need for communication structures such as facilitated ethical discussions that enable nursing home staff to reflect their everyday decisions. Expression of emotions should be encouraged in ethical decision-making processes in nursing homes. Gender-sensitive reflection supports the development of palliative care as organisational culture. Key words: ethics, gender, long-term care, palliative care, participatory research

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E. Reitinger and K. Heimerl

What does this research add to existing knowledge in gerontology?  The most burdensome ethical dilemmas in palliative care in nursing homes are not the ones around death and dying but concern rather more ‘trivial’ issues such as washing a person with dementia without employing physical coercion or preventing persons with dementia from running away.  Emotions are relevant facilitators for understanding ethical dilemmas.  Gender as social category influences ethical decisionmaking on individual, relational and structural level.

What are the implications of this new knowledge for nursing care given to older people?  Ethical dilemmas cannot be ‘solved’, but there is a need for clear orientation through communication structures and responsibilities that enable nursing home staff to discuss their everyday decisions.  Expression of emotions should be encouraged in the course of ethical decision-making processes in nursing homes.  Gender-sensitive ethical decision-making contributes to palliative care culture within nursing homes.

How could the findings be used to influence policy or practice or research or education?  Ethical group discussions help caregivers to deal with ethical dilemmas and therefore time and funding should be dedicated to support structured communication within nursing homes.  Raising the awareness for gender issues seems to be crucial in ethical decision-making therefore gendersensitive trainings within nursing homes should be fostered.

Introduction: ethical decisions in palliative care in nursing homes Institutionalised long-term care settings for older people, such as nursing homes or care homes,1 make an essential contri-

1 The terms ‘long-term care (LTC) settings for older people’ and ‘nursing homes’ are both used interchangeably in this article as general umbrella terms to include nursing homes, care homes, residential aged care and geriatric hospitals. We are aware that there are different meanings behind the different terms. For a discussion of terms at European level, see Froggatt and Reitinger (2013).

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bution to caregiving in our modern societies. A high percentage of caregiving is performed by relatives in informal care settings, and older people tend to stay at home as long as possible. Nursing homes are therefore challenged by a significant change in their client structure. Dementia, a much higher risk of multimorbidity, chronic illness and fragility are part of everyday life. As a consequence, nursing homes are confronted with both more diversity of and an overall increase in the care needs of their residents (Heller et al., 2003; Froggatt et al., 2009; Kojer & Schmidl, 2011; Hov et al., 2013). Palliative care has been identified as the appropriate answer to these challenges (Abbey et al., 2006; Hockley & Clark, 2002; Brazil et al., 2011; Parker, 2011; Heimerl, 2008), with dementia care being of paramount importance (Small et al., 2007; Van der Steen et al., 2014). The understanding of palliative care used in this study encompasses more than end-of-life care and starts when frail older persons move into a nursing home or even earlier.2 The new challenges create new problems in nursing homes. More often than not, individual staff members are left alone to cope with situations that can be overwhelming and cause moral distress (e.g. Gr€ oning, 2005; Brazil et al., 2010 for professionals who provide home-based palliative care). Ethical dilemmas and ethical decision-making are core elements in the search to develop a palliative care culture within nursing homes. Nurses’ understanding of dignity has been shown to be crucial for the successful implementation of palliative care in nursing homes (Yalden & McCormack, 2010). Living and dying with dignity in nursing homes (Pleschberger, 2007) are highly dependent on the quality of ethical decision-making. Therefore, ethical issues need to be highlighted within palliative care culture in longterm care settings. Nursing homes are ‘female lifeworlds’ in the sense that most of the residents, professionals and relatives are women. Gender issues affect palliative care culture on different levels. On an individual level, gendered biographies influence ways in which residents express their needs, cope with loss of competencies or morbidity. In relation to care staff, ‘doing gender’ always influences care interactions. On a structural level, running an institution like a long-term care setting has a dominant ‘male’ focus. This has an impact on gendered interpretations of leadership roles and communication cultures (Backes et al., 2006; Beyer, 2008; Reitinger & Lehner, 2013). Based on these

2 In this sense, it corresponds with the meaning of ‘general palliative care’ (Froggatt and Reitinger (2013), p. 12) and the ‘palliative approach’ in residential aged care (Parker & Hughes, 2010; Australian Government Department of Health & Ageing, 2006, p.37f).

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Ethics and gender issues in palliative care in nursing homes

insights, it is necessary to study the relevance of gender issues within palliative care in long-term care settings.

Research questions Focusing on ethical dilemmas and related communication processes as well as questions around gender therefore provides a better understanding of palliative care in nursing homes. The overall aim of the research project reported in this study was to highlight insights regarding ethical issues and gender, based on the experiences of professionals in nursing homes. It was conducted in collaboration with three nursing homes in Vienna, Austria.3 The main research questions were as follows: 1 What are the relevant ethical issues in the case of Austrian nursing homes? 2 What are important insights into the processes that deal with ethical issues in these nursing homes? 3 How can the process of ethical decision-making be improved? 4 What relevance do gender issues have in ethical decisionmaking processes in nursing homes?

Methods Participatory action research To develop answers to the research questions, we chose a participatory research design. ‘Participatory action research (PAR) with older adults’ (Blair & Minkler, 2009) aims to create appreciative relationships between those involved. Following systemic thinking in action research (Burns, 2007), it seems vital to us that research is understood as ‘a means for getting things done, which is owned by many stakeholders who are affected by the problems, and have a part to play in their resolution’ (Burns, 2007, 4). Participatory research for palliative care in nursing homes – as was shown by Hockley and Froggatt (2006) – supports trusting relationships and makes a simultaneous contribution to social science and social change; (Hockley et al., 2013). These trusting relationships are of particular importance when intimate questions around ethical issues and gender are discussed.

Design and methods In the research project, we collaborated with three nursing homes in Vienna, Austria. We followed a theoretical

3

Project duration: April 2005–November 2007.

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sampling process (Corbin & Strauss, 1990, 5) by identifying criteria for recruitment of nursing homes. Based on theoretical assumptions of systemic action research (Burns, 2007), we sought for the most dispersed types of nursing homes. Although all nursing homes were located in the city of Vienna, they varied considerably regarding four criteria: (i) size (number of staff and residents), (ii) location within the city, (iii) providers (diverse legal and structural bases; community and confessional providers), and (iv) organisational culture and structure (such as cooperation structure with physicians or admission procedures). Saturation was achieved for the three nursing homes included as the themes of the ethical narratives started to repeat and overlap. It is possible that for nursing homes in other regions or with different organisational structures, new narratives could be generated. The action research design comprised many components as is shown in Fig. 1. The component ‘management’ for instance consisted of several parts: regular meetings with the nursing home leaders where the next steps were agreed upon; coauthorship between researchers and management of two brochures; discussion and exchange of preliminary results between all managers involved in the research. This article focusses on a distinct section of the data (that belonged rather to the reflective aspects of the project than the action part), namely the ethical narratives that were generated in the following way. Interdisciplinary ethical group discussions were core elements of the inquiry (Bohnsack, 2002). The explicit aim of the group discussion was to generate and discuss ethical narratives about situations in the nursing homes, where residents play a central role. Altogether, 35 persons (27 women and eight men) participated in the group discussion (see Table 1). Management was asked to invite as many participants as possible on a certain day. To mirror the organisational complexity of nursing homes, we attempted to include different professional and hierarchical perspectives from different subunits of the nursing homes. Table 2 gives an overview of the represented professional perspectives in each group discussion in each nursing home. To collect more data, a qualitative questionnaire was sent out to all participants prior to the group discussions, through which they were invited to describe and discuss difficult situations from their daily working life. A narrative approach to ethics was chosen (Adams, 2008). Ethical narratives (Nicholas & Gillett, 1997) were generated both in the questionnaire and in the ethical group discussion through the initiating question: ‘Please tell us about a situation where a resident plays an important role that left you with an unpleasant feeling’. At the onset of each group 133

E. Reitinger and K. Heimerl

Figure 1 Research Design.

Ethical scrutiny

Table 1 Gender of participants of the group discussions

Nursing home 1 Nursing home 2 Nursing home 3 Total

Female

Male

Total

9 10 8 27

0 5 3 8

9 15 11 35

discussion, we chose two of the narratives that were described in the questionnaires together with the participants to be reflected upon in the group discussion. Agenda setting by the participating nursing home staff therefore took place. A total of 10 interdisciplinary ethical group discussions (‘GD 1–10’) between September 2005 and March 2006 were conducted, each facilitated by two researchers, and these were digitally recorded.

As human subjects were involved in the research, the process of considering ethical standards for research was based on the ‘Helsinki declaration (2008)’. Prior to undertaking the research, the research team thoroughly considered risks and burdens of the project. The strongest risk was seen in the fact that reflection about ethical decision-making processes could possibly increase moral distress (Brazil et al., 2010) among the participants, especially if framework conditions could not be negotiated or altered in the course of the project. We therefore decided to include management in the group discussion – being aware that this might hinder staff from talking frankly about their issues. A research protocol was put together to obtain the grant from the Austrian federal ministry of science and research. Furthermore, it is important to note that the persons involved in this research are

Table 2 Disciplinary background of participants of the group discussions Ancilliary nurse

Medical doctor

Occupational and physical therapy

Management

Psychologist, social worker, counselling

4

1

0

0

2

2

9

5

3

3

1

2

1

15

2

0

2

2

2

3

11

11

4

5

3

6

6

35

Nurse Nursing home 1 Nursing home 2 Nursing home 3 Total

134

Total

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Ethics and gender issues in palliative care in nursing homes

hospital or responsibility for fragile people with dementia leaving the nursing home were also prepared for presentation in validating group discussions with management.

Findings: ethics and gender issues and processes Overall, we were able to generate 36 narratives through questionnaires and group discussions. The full range of narratives can be summarised under eight thematic headings concerning the fictive journey of a nursing home resident accompanied by his or her relatives and professionals (see Fig. 2). Figure 2 Findings.

Relevant ethical issues in Austrian nursing homes professionals. Although confronted with overwhelming situations, they are not considered to be vulnerable according to the precise understanding of the term in the context of health research standards (Pleschberger et al., 2011). The study was undertaken with the informed consent of each participant according to the principles of voluntary participation, in each case with the option to withdraw consent even after the group discussion. To obtain informed consent, detailed information about the project was given to the participants. Privacy and confidentiality were assured, as all names of persons quoted in the narratives (see section ‘findings’) have been changed and are either anonymous or pseudonymous.

Analysis, interpretation and validation of data The participants filled most questionnaires by hand, and the data then were typed into the computer. Group discussions were voice-recorded and transcribed. Narratives were analysed in a threefold way: A thematic analysis of the data was conducted both by the individual researchers through coding and categorising and within the interdisciplinary research team (Kohler Riessman, 1993). This step yielded the thematic headings as shown in Fig. 2. In the second step of analysis, we followed the narratives in a chronological way, retracing step by step what happened in the described situation, attempting at preserving the narratives (Kohler Riessman, 1993). In the third step, a ‘gender analysis’ was performed for selected narratives, and the method is described elsewhere (Reitinger & Lehner, 2009). Findings and interpretations were then validated with practitioners and researchers in different settings that we summarised under the notion of ‘expert discussions’ (‘ED 1– 4’, see Fig. 1). Central areas for improvement such as decision-making about transferring palliative patients to © 2014 John Wiley & Sons Ltd

The thematic headings of the ethical issues identified are as follows: (i) ‘Moving into the nursing home’, (ii) ‘Running away’, (iii) ‘Washing’, (iv) ‘Conflicts with relatives’, (v) ‘Transfer to hospital’, (vi) ‘Starving or die of thirst’, (vii) ‘Dying with dementia’, (viii) ‘Bereavement’. Four narratives belonging to one of these thematic headings will be described in more detail to show the diversity of ethical issues. Validation of the preliminary results throughout the research process (ED 1–4) identified these four thematic headings as the most important in terms of ethical decision-making processes in palliative care in nursing homes. The first issue belongs to the thematic heading ‘Moving into the nursing home’. It is the narrative of Mrs. Frown, a woman who was always a very independent and self-reliant individual: Mrs. Frown was transferred to the nursing home after a hip fracture. Her daughter did not tell her that she couldn0 t go home again. After Mrs. Frown realised that she was ‘locked up’, she first became very aggressive and then subsequently depressive and didn0 t eat or take her medication. ‘She refuses to take her medicine, sometimes she simulates swallowing them and we find them later under her bed or elsewhere’ (GD_4, 70–74).

This illustrates the ethical dilemma regarding telling the truth straight away followed by the conflicts inherent in recognising the situation and coping in different ways. The narrative also shows the difficulty involved in supporting residents moving into the nursing home in a way that enables them to cope with this dramatic change to their way of life. The second typical narrative concerns a resident with dementia who is still mobile and regularly leaves the nursing home and belongs to the thematic heading ‘Running away’: 135

E. Reitinger and K. Heimerl Well . . . Jo came in and told me that Mr. Pauls left the house again. (. . .) It was shortly after my shift had ended but I went out and stayed with Mr. Pauls. He refused vehemently to come back into the house. It was quite cold and he wasn0 t wearing much, just slippers and a short-sleeved shirt. He was rather shaky on his feet and very aggressive in his language towards me. Not that he pushed me away, but his defensive attitude was quite obvious (GD_1, 16–26).

This situation also shows that diverse ethical dilemmas make the situation complex: autonomy vs. self-endangering behaviour, care-taking vs. violence or aggressive behaviour. The third narrative describes an issue that often occurs in daily routines and belongs to the thematic heading ‘Washing’. As can be seen in the example described here, the intimacy of the care act as well as diverse professional expectations and boundaries leads to ethical considerations. The problem starts when the time for washing comes, especially when it comes to the genital area. (. . .) Well, she then becomes angry and doesn0 t want to be touched at all. And then the ethical problem starts. Firstly, after a while the area doesn0 t smell good and I know from my professional experience that the skin will be irritated soon. So what am I allowed to do? How far may I go in my attempts to wash her? (. . .) It is difficult, really difficult to do so, to articulate it, to act in a gentle yet forceful way (GD_2, 12–20, 192–194).

Similarly to the narrative of ‘running away’, caregiving here is strongly connected with the option of using force and at the same time demonstrates the contradiction embodied in behaviour that represents both hurting oneself and exercising autonomous decision-making. In addition, the problem associated with ‘smell’ indicates underlying social conflicts and the expectations of other people – including not only professionals but also relatives and other residents. The fourth narrative concerns the issue of how to find out about the needs and wishes of a person who can no longer communicate verbally and belongs to the thematic heading ‘Starving or die of thirst’. The narrative of Mrs. Mull illustrates this difficulty: She was born in 1919, lost her husband when she was 33 and raised her daughter alone. Therefore the relationship between mother and daughter is very close and strong. Now the mother is suffering from dementia. The daughter visits her every day and gives her food to eat. Mrs. Mull is very reduced in her capabilities and no longer has any will to live. The daughter cannot accept this (GD_4, 3–39).

This narrative shows the dilemma that occurs when the person with dementia has accepted their approaching death, whereas the caregiving relative is still hoping to prolong life.

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Insights into the processes that deal with ethical issues in nursing homes: areas of improvement in a palliative care culture The most important insight made through talking about ethical issues within an interdisciplinary care team was the following: problems cannot be ‘solved’, although practitioners need a clear orientation to ensure their everyday decisions are appropriate: Our observations showed that practitioners do have an urgent need to solve problems. (. . .) the question here is what possible contribution to potential problem solving can be made through careful analysis (ED_2, 189–193).

Expression of emotions accompanying ethical dilemmas was encouraged throughout the group discussions. They play a core role in understanding ethical dilemmas. As a direct source of intuitive appraisal and personal values, they can be interpreted as indicators for ethical dilemmas. Underlying ethical dilemmas can be identified and discussed in a ‘dialectic process’: In this sense, I would say that the issue lies with enduring the contradictions that exist. And if the contradictions can be formulated, participants see clearly what they have to deal with. (. . .) The situations transcend individual persons (ED_3, 232–236).

‘Talking about it provides relief’ is the sentence that has frequently been articulated during feedback after the group discussions about ethical issues. It shows there is a need within the interdisciplinary team to take time for ethical reflection and dialogue. Understanding the perspective of colleagues from other disciplines increases the capacity for dealing with ethical dilemmas.

Relevance of gender issues in ethical decision-making in nursing homes Gender issues relating to ethical decisions in nursing homes become evident based on the themes and situations that were discussed. One of the most significant narratives concerned a female resident who did not want to be washed by a male care person. However, male caregivers are sometimes very welcome in communicative routines. This may be interpreted as ‘doing gender while doing care’. Another effect of doing gender can be seen in traditional family stereotypes that shape expectations towards relatives. As described in the situation of Mrs. Mull with dementia, it seems to be ‘natural’ for the daughter to visit her mother every day. On a structural level, the number of female and male participants gives information about gender status. As can be © 2014 John Wiley & Sons Ltd

Ethics and gender issues in palliative care in nursing homes

seen in Table 1, 27 female and eight male professionals attended the group discussions. This accords with the expectation that a higher proportion of women would attend the discussion groups due to the higher percentage of female care workers and other professionals working in nursing homes in Austria. Turning attention to the project’s collaboration partners at management level, it is interesting to notice that five female and four male persons were in leading positions. This also matches the expectation that the higher within a hierarchy one progresses, the higher the percentage of male employees. This finding has important implications for ethical decision-making. It becomes evident that residents are more closely accompanied by female care persons. So they are the ones dealing with the daily ethical challenges and are in need of structured communication processes. The responsibility for organising these processes and listening to those ethical issues lies in the hands of management. The power relations underlying these organisational structures that are reflected in personal relationships therefore also mirror the social constructed male–female hierarchy within society.

Discussion The key findings of the study can be summarised in the light of the research questions and study aims as followed: (i) core ethical issues in Austrian nursing homes can be identified along a fictive journey of a nursing home resident accompanied by his or her relatives and professionals. (ii) Insights into processes of ethical decision-making show the relevance of emotions and that ethical dilemmas cannot be ‘solved’. (iii) Areas of improvement encompass the importance of trustful relationships and adequate communication structures within a palliative care culture of nursing homes. (iv) The relevance of gender can be observed on individual, relational and structural level.

Ethical dilemmas as small-scale everyday work-life issues The systematic analysis of the narrative that was generated through the ethical group discussion showed that from the perspective of nursing home staff, the most burdensome ethical dilemmas are not the ones around death and dying but consist rather of ‘trivial’ issues such as washing a person with dementia without the use of force or preventing persons with dementia from running away. This finding is in accordance with arguments within ‘palliative geriatrics’ (Kojer & Schmidl, 2011) on the one hand. On the other, it is interesting that the ‘big issues’ concerning, for © 2014 John Wiley & Sons Ltd

example, euthanasia is not mentioned at all. One hypothesis for understanding this lack of evidence is that these themes are simply too overwhelming and have a taboo status.

Feelings and emotions as facilitators in ethical decisionmaking As the findings show, emotions are an important source of insight within ethical decision-making. To better understand their meaning, it is useful to avoid the binary opposition of rationality and emotionality (Nussbaum, 2003). As MeierSeethaler (2007) shows, feelings and emotions have a long tradition as a source of knowledge within philosophical and psychological discourses. She argues that the important difference between ‘rationality’ and ‘irrationality’ traditionally connected with ‘cognition’ and ‘emotion’ should be reformulated. She differentiates between more or less conscious aspects of the interwoven processes of thinking, feeling and action. Accordingly, unconscious motivations as well as merely borrowed opinions or assumed habits are seen as ‘irrational’. ‘Rational’ arguments on the other hand emerge throughout considered processes of thinking, affective reflection and communication. Heller (2009) also argues within her theory of feelings that moral sense needs the reintegration of human competences in contrast to the dissociation of rational and emotional acting. Within ethical decisionmaking processes in nursing homes, this perspective emphasises that emotions, cognition and acting have an impact on the understanding of ethical dilemmas and should therefore be acknowledged as facilitators within ethical discussion groups (Sturdy, 2003; K€ upers & Weibler, 2008; Reitinger, 2011).

Areas of improvement: methodological considerations The interactive group discussions served a twofold purpose: The answers to the research questions were primarily generated through the group discussions. On the other hand, these discussions played an important role in the intended process of change within the nursing homes. By this means, the ethical group discussions themselves yielded insights into ways to deal with ethical dilemmas in the participating nursing homes, and the narrative approach played an important role regarding this insights, as explained by Adams: ‘If we learn how to think, feel, and interact with society via narratives, we also learn ethical ways of being with others, ‘correct’ and ‘appropriate’ ways that serve as foundations for many of our interactions’ (Adams, 2008, 175). 137

E. Reitinger and K. Heimerl

Gender as a relevant social category

Acknowledgements

‘Doing gender’ (West & Zimmerman, 1987) and gendersensitive approaches play an important role in ethical issues in nursing homes. Gendered biographies have a significant impact on care situations. On the other hand, care work is still labelled as ‘female work’ within our societies. As the male/female ratio of participants show, gender segregation in nursing homes mirrors gender status within society. It is connected with a devaluation of female competencies and traditional power relations in paternalistic societies (Twigg, 2006; De Prins, 2007; James, 2009). With Hochschild (1983), it can be argued that particularly emotional labour – which was shown to be a vital indicator for ethical dilemmas – requires the capability to coordinate intellect and feeling in such a way that the emotions of an individual carer can be held in check for the sake of being able to care for the needs and feelings of the client/s.

We want to thank our colleagues in the research team – Stefan Dinges, Andreas Heller, Larissa Krainer, Erich Lehner, Christian Metz, Sabine Pleschberger, Klaus Wegleitner and Georg Zepke – for the inspiring collaboration during this project. Special thanks are due to all participants in the ethical group discussions and the management of the nursing homes for their support, time and trust. We also wish to express our gratitude to the Austrian Ministry of Science and Research for funding support.

Contributions Study design: KH, ER and members of the research team; data collection and analyses: KH, ER and members of the research team and manuscript preparation: KH, ER.

Conflict of interest Conclusion The overall evidence of the study shows that palliative care in nursing homes raises central ethical questions: The most burdensome ethical dilemmas are not the ones around death and dying but rather concern ‘trivial’ issues, such as washing a person with dementia without the use of force or preventing persons with dementia from running away. Implications of the study are that ethical group discussions provide relief, help caregivers to deal with ethical dilemmas and foster a palliative care culture in nursing homes. Gender-sensitive narratives that include emotions as an important source of insight constitute powerful instruments for tackling everyday ethical decisions.

Implications for practice  To deal with everyday ethical dilemmas is an important issue in the work of nursing home staff. Therefore there is a need to acknowledge this challenge and offer adequate communication structures for reflection.  Emotions are indicators for ethical dilemmas and have to be taken serious in the course of ethical decisionmaking processes in nursing homes.  Gender aspects play a vital role in ethical decision making. Raising awareness and encourage gendersensitive communication in ethical decision making support a palliative care culture that is oriented on the needs of residents.

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No conflict of interest has been declared by the authors.

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Ethics and gender issues in palliative care in nursing homes: an Austrian participatory research project.

The development of palliative care in nursing homes in German-speaking countries has gained in importance within the past 15-20 years. Ethical and gen...
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