Ethical Issues Encountered by Nurse Managers Working With Older Adults in Long-Term Care Settings: A Qualitative Interview Study.

Nurse managers (NM) face ongoing ethical issues when they work with older adults in long-term care settings (LTCS), including around end-of-life care. Legislation and healthcare ethics guide the provision of ethical care to older adults in a changing societal and global context. Our aim was to describe the ethical issues encountered by NMs. This qualitative study involved 23 NMs from seven randomly selected organisations who participated in semistructured focus group interviews in 2021. We analysed the data using inductive content analysis. The subject of this study was sensitive and reflected the participants' individual views. They provided informed consent and their anonymity was guaranteed. Ethical issues faced by NMs are related to residents' rights to self-determination, ethical decision-making about staff and procedures, providing ethical leadership despite having conflicting roles, and defending ethics in LTCS on a societal level. NMs struggled to spend sufficient time supporting their staff during everyday care. The ethical issues encountered by NMs are multidimensional and have both external and internal causes. NMs often deal with ethical issues on their own. Structuring their roles so that they can focus more on daily care could help NMs to provide more effective leadership and get more involved in their organisation's decision-making. Further research into the impact of NMs' backgrounds on their performance and responsibilities could provide new insight which would be useful in educating NMs and designing relevant organisational structures. Our research can be applied to practice, policy, education and research. NMs' daily work should be organised in a way that enables them to work closely with residents and staff. Reducing their secondary tasks could increase the time available to manage staff and provide individual coaching for those with different independent abilities. Being present during daily care would make it easier to deal with ethical issues in a timely manner, which could reduce staff's moral distress and increase their well-being at work. Understanding the importance of the role of NMs could help policy makers in planning LTCS care. Involving NMs in decision-making in organisations and society could increase awareness about the relevant ethical issues and improve the care that residents receive and the well-being of staff and new members. For example, how many employees a single NM can manage could be defined in the same way as the number of staff per resident has been determined. Implementing ethics committees in LTCS could provide a mechanism for considering the views of NMs. Ethical issues in the care of older adults should be included in the curriculum of those studying for the profession. Ethical issues change over time as the world around them changes. Addressing ethical issues should be a continuous theme in continuing education for relevant workers. This qualitative study gave a voice to LTCS NMs in a society with a rapidly ageing population and labour shortages. Ethical issues faced by NMs were related to implementation of nursing and healthcare values in the daily care of residents. In the future, generalisable knowledge is needed about what is the ethical climate in LTCS workplaces, and what is the role of NMs' and care workers' ethical competencies and attitudes towards ageing when performing daily care in the LTCS. In addition, it is noteworthy that the ethical issues' NMs faced were related to policy decisions made in the surrounding society, and NMs felt they had no power or ability to influence on them. In the future, more knowledge is needed to understand how NMs in LTCS, but also in other areas of nursing, identify and consider their role in ethical issues related to health policy.