Ethical caregiving isn’t just about rules, values and patient charters. It’s also a group process where everyone is constantly adapting to the medical condition and behaviour of patients and the available resources – that’s the conclusion reached by two researchers, Jean-Baptiste Suquet (NEOMA Business School) and Damien Collard (Franche-Comté University), following observation of a geriatric department in a hospital over a four-month period.

When the subject of the ethics of care is raised, we immediately think of the way caregivers pay attention to patients in their interactions with them. But if we don’t go any further, then we’ll miss the bigger picture.

A never-ending stream of tricky situations

Care procedures in hospital departments are fine-tuned on a regular basis as staff try to find the right balance between ethics and the well-being of their patients. The context might be formal – during departmental meetings, for example, or hand-overs – or form part of an informal, group or individual process.

The day-to-day activities of a hospital department trigger a seamless stream of tricky situations: how should staff treat pain in an elderly, end-of-life patient? Whose responsibility is it to feed a patient if they can’t feed themselves? How do you solicit the view of someone who has lost the ability to speak? Should hospital staff agree to make exceptions to visiting hours in extreme cases?

The ethics of care comes face-to-face with reality around the clock. To understand how ethical practice is tailored to fit the context, we need to take a look at what goes on behind the scenes – and the authors did just this: Damien Collard observed the activities of a 36-bed geriatrics department for four months. He followed the staff’s formal meetings together with informal conversations between caregivers in the hospital corridors and staff room, around the coffee machine, and so forth.

A closer look at the day-to-day “crafting” of ethical practices

The researchers then  focused on the day-to-day “crafting” of ethical practices, before and after medical procedures, to point out what goes on outside patient interactions.

The first observation centred on the large cast of actors involved in the care process, with the hospital staff including doctors, nurses, nursing assistants, a speech therapist, dietician and palliative care expert. In addition, patients are surrounded by their family – whose members don’t necessarily all agree with each other – or a room-mate who may be so difficult that one of the patients has to be moved elsewhere.

These stakeholders  interact at different times and in different places. As a result, it is difficult to obtain an overview of each and every situation when the time comes to make choices that balance ethical practice and a patient’s well-being.

Executing simple rules: an impossible task

Nonetheless, the geriatrics department looks to its weekly meetings to achieve this goal, and it is here that staff describe and debate the most problematic cases as a group. These discussions focus on care protocols, patient well-being and ethical issues. It isn’t possible to apply simple rules, and decisions that were taken a week earlier are often thrown into question by subsequent events.

The authors cite the case of a female patient who refused to be fed by gastric tube. Questions about her treatment shifted from one meeting to the next: could they try out a liquid diet even though there was a high risk that it would “go down the wrong pipe”? Should the patient be forced to accept the tube? What should the staff do when the patient keeps on getting up from her chair while she’s being fed? The family were keen to jettison the tube, but the doctor took exception… what is the right decision?

A process that isn’t limited to meetings

The process goes on elsewhere beyond these official meetings, including in the treatment room. Here one of the authors learned one day that the decision to stop the tube had been ratified in a meeting… but hadn’t been acted on because a doctor had not approved it.

The stalemate was broken later on when two other nurses took things in hand: they held a conversation with the patient, who re-stated her refusal to be fed. In other words, the formal meeting was not enough in itself to rework the care model.

The authors also report on two implicit re-adjustment processes with a narrower impact: they do not re-organise the protocols that are already in place.

The first consisted of the humorous conversations caregivers have with one another. In the face of certain hopeless cases, they feel the need to distance themselves from the patients; this is their way of defusing and dialling down their emotional pain. Furthermore, laughter helps the caregivers grapple with the ethical difficulties when adjusting the care protocol proves to be futile.

Unofficial substitution between colleagues

The second re-adjustment: from time to time staff compensate for a colleague’s apathy in relation to specific tasks. To take one example: when a nurse spotted that an assistant was not helping a dependent patient with their meal, she took charge of the situation of her own accord. The relevant parties don’t discuss these “substitutions” among themselves, but they are designed to uphold the care protocol and ethical practice.

The three re-adjustment methods (formal meetings, humour and substitution) are not mutually exclusive: they combine or succeed each other according to the situation. They also reflect the hard work the caregivers put into maintaining ethical care principles regardless of the circumstances. It is worth stressing, however, that recourse to humour in these contexts comes with a certain degree of ambivalence.

In conclusion, the authors highlight the synergy between these ongoing efforts to adapt and “ethics of rules” grounded in universal values and principles: all are vital for the collective provision of “good” care. The researchers recommend that managers in care units schedule timeslots dedicated specifically to these issues so that caregivers can discuss them without being disturbed.

Find out more

J.‑B. Suquet, D. Collard, Maintaining “Good” Care: An Articulation Work Perspective on Organizational Ethics in the Healthcare Sector, Journal of Business Ethics, 02/2024. Doi :10.1007/s10551-024-05616-z