Hotel-type nursing and ethical dilemmas due to business interests

INTRODUCTION

Due to widespread globalization (1‒4), the development of nursing is at a turning point. The economic, political, and cultural dimensions of globalization affect the efforts to preserve the contemporary nursing model. This socially necessary model was developed based on a growing understanding of the complexities of an individual's identity (5). Neoliberalism, with its paradigm of competitive striving for profit and reduction of operating costs, indirectly leads the majority of people into conformity and dependence (6). Individualization processes extend an individual's life radius and increase the number of options, but also produce more risks for the individual and for society (7). In recent years, there is more of a tendency to transfer entrepreneurial, market, and consumer methods, tools, and activities into health care. There are limited resources on the one hand, and increasing needs and expectations on the other. The gap between the desired and the possible leads to ethical dilemmas in nurses’ decision-making, and decreases patients’ trust in the health care system. Establishing trust between nurses and their patients is required for them both to be satisfied, and for the successful implementation of nursing care activities (8).

According to Kaluz (9), the resolution of ethical dilemmas in nursing should be viewed from the perspective of an interactive nurse-patient relationship. Nurses must be aware that there is not just one moral theory, ethical model, or universal ethical principle for all situations, and that the uniqueness of people and situations must be considered and understood. This “uniqueness of the situation” has been identified in the integration of business interests into the relationships between nurses and patients who, a) pay for treatment with a combination of health insurance and additional self-payment or, b) pay for the entire service themselves. Based on the observed differences (without systematic measuring), there is a question of how the integration of business interests influences nurse-patient relationships. Additionally, there is the potential for ethical dilemmas in nurses’ decision-making, due to the addition of a financial factor. According to the ethical code, the ability to pay should not influence nurse-patient relationships, particularly in light of the potential consequences of unequal treatment.

Patients’ decisions can influence nurses and contemporary nursing in general, for instance by the cumulative impact of each patent's choice of services, depending on available resources (patient's resources and the communities’ available options) (8). According to Kamin (10), this demonstrates a consumer approach, as individuals voluntarily choose among offers on the health care market. This affects the way health care providers and other stakeholders operate, which can significantly influence health care services. Cameron (11) emphasizes that entrepreneurial culture in health care encourages a ‘win-win’ situation for all stakeholders: the state gets more taxes; the health care organization gets more profit, develops a good reputation, and grows; the health care providers get more work at higher wages; and patients are empowered, improve their health, and are rehabilitated and accommodated, while increasing their well-being, happiness, and pleasure. The inexorability of the modern business environment thus forces organizations into constant efforts for the highest possible level of business excellence.

The current state of the economy can inspire a period of innovations in the provision of services, dynamic role changes, and the improvement of nurses’ abilities. It is the starting point for developing a quality principle and new treatment models (12).

Merging the concept of the hotel business with health care empowers patients, who are now treated as guests who have a reduced self-sufficiency capability. This innovation does not only take place in hotels, but also in health care and social assistance institutions, or at patients’ homes. In the sociological sense, the hotel industry involves qualified people (employees) fulfilling existential and other needs, wishes, and expectations of others (guests) (13). From the perspective of the service user, business success involves luxury, prestige, comfort, accessibility, and ensuring high-quality fulfilment of the guests’ wishes. From the perspective of the employee, it is a stimulating and challenging work environment, demanding high levels of personal engagement. It is, therefore, a well-thought-out move by the hotel-business owners to offer the service of nurses with the knowledge and ability to fulfil patients’ needs. (Who else can best fulfil the health care needs of people with reduced self-sufficiency?) Alongside this, the owner of the health care organization also imposes requirements on nurses, i.e., treating patients as guests and unconditional adherence to the business-responsibility concept—thus achieving patient satisfaction at the lowest possible cost.

On the other hand, nurses are ethically bound to respect the principles defined in the code of ethics (14): striving to reduce health inequalities (15) and developing community health care. According to Holm et al. (16), ethical dilemmas in decision-making only arise when employees are unable to act in accordance with their professional ethical stance and ensure an adequate level of care. The main obstacle to nurses’ decision-making when facing ethical dilemmas is conforming practices to the organization's management guidelines regardless of the patients’ needs. These researchers highlight the need for new ways of encouraging nurses to adopt post-conventional ethical practices. It is estimated that decision-making using Decide, Establish, Consider, Identify, Develop, and Implement (DECIDE) steps—even in reoccurring ethical dilemmas regarding the integration of business interests—encourages nurses to use self-reflection and make autonomous decisions which benefit their patients.

The questions regarding the hotel-type nursing concept that arose were “What are the fundamental characteristics of hotel-type nursing regarding the nurse-patient relationships and contemporary nursing? How to approach resolving of the ethical dilemmas inherent from the integration of business interests into nurse-patient relationship?”

The aim of this paper is to investigate and explain a potential approach to resolving ethical dilemmas in nurses’ decision-making regarding the integration of business interests into their relationship with patients. This approach integrates business interests into nurse-patient relationships while implementing contemporary nursing according to community care principles.

METHODS

Instruments

In order to take measurements for research purposes, a template for observation was created detailing various categories: the role of the patient, the purpose for the treatment at the institution, the role of nursing, interdisciplinary cooperation, the funding of the treatment, and the role of the health care organization. Health care organizations included department of a public social welfare institution for the elderly (O1), a private boarding house for the elderly with a concession (O2), and a nursing department in a private health establishment (O3), with approximately 30 beds, respectively. During phase one, additional interviewing clarified the observations and added various viewpoints; therefore, there was no instrument for interviewing prepared in advance. During phase two, a template for a semi-structured interview was prepared according to the DECIDE decision-making model, which calls for defining the problem, establishing the criteria, considering all the alternatives, identifying the best alternative, developing and implementing a plan of action, evaluating and monitoring the solution. Sub-questions were also prepared, along with cards picturing three power diagrams (17) for qualitative interpretation developed specifically for this purpose (Figure 1).

FIGURE 1. (A) Power diagram with ethical dilemma present; (B) Power diagram at status quo; (C) Power diagram of desired state. P – patient, N – nurse, O – organization, R – relatives and people close to the patient, DA – other providers, S – state, E – educational institutions, PA – professional associations

RESULTS

The results of the observation and interviews are presented in Table 1. The basic principle for creating a map characteristics of hotel-type nursing was identifying the main thematic areas (categories and subcategories) that help shape the efforts for quality treatment of patients, and evaluating them through defined codes.

TABLE 1. Theoretical variables and results of observation and interviews

Collected data was subsequently evaluated by SWOT analysis, and the key weaknesses, strengths, threats, and opportunities for nurses, patients, nursing, and society were highlighted according to the characteristics of hotel-type nursing (Table 2).

TABLE 2. SWOT analysis according to identified characteristics of hotel-type nursing

Based on data collected during phase one, three power diagrams were developed to provide a visual representation of activities in the relationship between nurses, patients, and other parties (Figure 1).

Figure 1A depicts a situation in which nurses encounter an ethical dilemma in decision-making. The nurse-patient relationship is based on a routine determined by the employer and agreed to by the patient. Nurses commented that “something similar existed in the past, but [they] now know what everyone is doing. Sometimes, though, the role of chambermaids, for example, involves actions performed only by professional staff elsewhere.” They also mentioned the demands of relatives (O1, O2), “who have a great deal of influence, but are not mentioned in the model.” Nurses stated (O1, O2) that they do not have the necessary influence to motivate patients to do activities that the patients do not want to do. On the other hand, some patients (O1, O3) stated, “I require a stricter nurse; if she is not urging me, I do not do anything. I would just remain lying down.” Figure 1B depicts a common interdependent nurse-patient relationship based on mutual agreement. Nurses (O1) state that they “sometimes encourage patients more, because they will be happier to be more independent and active when they return home” (O3). The administration (O2, O3) explained that they “are market-oriented, but [they] consider it important that every guest is happy, so employees cooperate with each other a great deal.”

Nurses found Figure 1C very difficult to understand but realistic. They stated (O3) that they “would be able to be more professional and the institution would not incur additional costs.” Social welfare institutions (O1, O2) found the model a good solution, “as health insurance companies allocate very small daily allowances for resident patient care at social welfare institutions,” and the patients are not entirely ready for the community care concept. Patients, for example, state that they feel as though they were “at a hotel, and [they] also have a nurse [they] can trust, who understands [their] needs.” Regarding community care principles, nurses (O1) stated that “clinical paths end at the organization's limits.” Most agreed (O1, O3) that improved working methods would remove ethical dilemmas, as “a satisfied guest means more guests.” It would, however, be reasonable, according to employers (O1, O3), to “make a thorough cost-benefit analysis.”

Nurses are familiar with the DECIDE model, but do not use it sufficiently, as they either make decisions intuitively or conform to the institute's rules. They are aware of ethical dilemmas in their relationships with their patients, i.e., “patient's wishes above professionalism”, “money is more important that quality of treatment”, “early release due to shortage of funding”, “unequal treatment options”, “cooperation with relatives”, etc. (O1, O3). The nurses’ personal opinions include “retaining one's job, all beds occupied”. Various possibilities and consequences to each dilemma can be resolved as a team, but nurses are “sometimes too passive in nurse-patient relationships” (O2, O3). They believe that the best alternative is “establishing a professional relationship with the patient by explaining professional guidelines and achieving agreement, while retaining a high level of empathy and clear responsibility”, and “an honest and sincere relationship with a thorough explanation and the patient's informed consent, and diligent documentation of all activities” (O1). Hotel-type nursing provides the possibility for reoccurring ethical dilemmas to be “overcome with small corrections in one's professional activities: retaining professional autonomy, confident and evidence-based defending of one's positions and listening to others’ opinions, and matching the expectations of and among different parties (interprofessional cooperation), and acting according to community care principles”; “in some cases, the DECIDE model could be employed to determine if an ethical dilemma is felt when there is no real basis for one” (O1, O2, O3).

DISCUSSION

Hotel-type nursing involves institutions enabling temporary or permanent voluntary accommodation of people for medical treatment, rehabilitation, active leisure or professional assistance in their daily activities. My research has established that it involves the implementation of contemporary nursing. Even if the starting point is nursing care philosophy, from the patient's perspective (respect, security, integrity, and wellbeing) differences cannot be confirmed. It is the contemporary nursing. The following should, however, be emphasized:

Contemporary nursing (CN) + business responsibility (BR) = hotel-type nursing (HTN)

Business success is the result of the comprehensive quality of an organization's business responsibility. It is defined as a set of logically connected implementing and monitoring procedures and activities, the consequence of which is the planned product or service (19). There appears to be an increased focus on the consumer/patient as a potential guest. As I observed the peculiarities in the nurses’ relationships to their patients (separate from the nurses’ usual business responsibility), I focused on the role of the patient, which is central in the relationship with nursing care providers. I highlight the following:

Central role of the patient (CRP) + CN {nursing care providers} > BR = HTN

At first glance, the relationship between nursing care providers and patients in hotel-type nursing is based on a utilitarian/hedonistic relationship, which includes striving for feelings of pleasantness, satisfaction, well-being, and thus comfort and luxury. However, in order to achieve these emotions, financial resources are required. Excessive emphasis on autonomy is referred to as patient-centrism. In nursing, the patient-centrism phenomenon is defined as a state where the rights of patients diverge markedly from their obligations (the patient's active participation in rehabilitation), and depend on their ability to pay or the expectation of other potential business benefits for the institution. However, the responsibility for self-sufficiency lies with the patient despite patient-centrism and commercial orientation. Generally, patients cannot perform the entire scope of their own required activities, and are thus satisfied with their patient identity (20). Gallan et al. (21) demonstrate the importance of patients/guests as active participants in the co-production of a service as a means of co-creating value. This is essential to the service these researchers describe as a process of “doing things in interaction with clients”. They define clients’ (patients’) satisfaction as a state which occurs when patients’ experiences fulfil or exceed their needs or desires.

Nurses concurrently perform the role of employees committed to the health care organization by contract, experts committed to their profession, and human beings (kind, tolerant, understanding, good-willed, treat all equally, and positive). The subject of nurses’ activity is the patient with varying levels of functional (being well informed), interactive (developed skills) and critical (empowerment of individual and community) literacy (10). The key to their actions (within hotel-type nursing) is in tactfully redirecting patients’ initial tendencies to patient-centrism, which breaks down the partnership in the patient-nursing care provider relationship. Nurses have to provide expert information to patients, based on personal contact and consideration for the patient's emotional state, by reaching an autonomous agreement with patients on the limitations imposed on them in order to achieve the best possible effect on patient health and self-sufficiency.

The following power diagrams were used in the interviews with the nurses, for their use in decision-making when faced with ethical dilemmas. In this way, the possibility to approaching reoccurring ethical dilemmas caused by the integration of business interests was more easily explained. It appears that fewer ethical dilemmas would occur if activities complied with the third model presented (Figure 1C). However, this concerns organizational culture and cooperation between providers themselves. The effect of the patients’ relatives on the nurse-patient relationships is also emphasized. The attempt to find a balance between the inclusion of relatives and the patients’ needs is a very demanding task in terms of ethics (22). There is also a need for econometric research. With regard to the integration of business interests, there is targeted control over revenues and expenses. In the era of neoliberalism, it is certainly more effective to demonstrate required changes in this manner.

The DECIDE model was not only used to communicate with nurses about approaches to resolving ethical dilemmas, but to also lead them to the realization that “in some cases, the DECIDE model could be employed to determine that an ethical dilemma is felt when there is no real basis for one”. Nurses’ perceptions indicate that nurse-patient relationships may alternate between a wide range of favorable and unfavorable conditions, but it depends on the patients’ achieved goals and satisfaction. Nurses have only a limited influence on their satisfaction (23).

The findings of this analysis have all the limitations characteristic of qualitative studies. It can be defined as a pilot study of hotel-type nursing and the integration of business interests into nurse-patient relationships. It explains the situation with respect to the nurses’ daily practice in three different facilities, with a view to providing a comprehensive insight. This presents new questions and advances new theses. I have provided a set of relatively reliable information directly from observations and interviews, which requires validation through further research in different circumstances and using a different methodology. It is, however, a scientifically useful basis. There is certainly a lack of empirical evidence on the developments within the integration of business interests into nurse-patient relationships.

The problem of ensuring business success in the era of globalization has been identified previously. Ethical dilemmas are present in decision-making, which is common in the daily work of nurses, particularly those in leadership positions, and there is a need for nurses to move to post-conventional ethical practices.

The findings of this study may be summarized in four points:

The findings of this research may, through further scientific examination, be of practical value in daily nursing practice. It may help to develop theories concerning nurses’ post-conventional ethical practices. These findings may also be used in education, as they highlight gaps in knowledge (for example: community care principles, decision-making models, and the role in identifying the presence of ethical dilemmas and their resolution). Due to the limitations of the study and its findings, several ethical questions are raised that require a comprehensive systematic study. Despite its limited value, the present study provides a reliable basis for further research from various aspects.

CONCLUSION

The integration of business interests into nurse-patient relationships is inevitable in contemporary nursing. Hotel-type nursing represents an adaptation by nurses to this reality. Nurses’ professionalism benefits patients significantly more than a reduction of the nurse's role to simply fulfilling patients’ wishes. Hotel-type nursing certainly heralds a new development in nursing, as its future depends on nurses’ devotion to work, flexibility, versatility, and above-average moral and ethical potential and self-control.

CONFLICT OF INTEREST

There is no financial, personal, or academic conflict of interest.