Ethical Model-A Synthesis between Caring Sciences and Nursing Administration

We want more than we have realistically possibilities to do. Caregivers are aware about how they have to act in the daily work in patient settings. Still we have to stat that we don ́t can guarantee ethically good care of patients. Aim: Aim of the study is to describe and explain the relationship between the ethos of caring and nursing intensity, based on a theory model developed by a hermeneutic approach. Method: The study is a theoretically study with a hermeneutic approach and a hypothetic-deductive design. Materials are results from four sub-studies published between 2009 and 2013. Findings: The model includes for corn stones and sex interoperations patters witch keep the corn stones together in a process of moving. Conclusion: The theoretical model explained in this paper has opportunities to guide the caregivers in their daily work for providing ethically good care to older people.


Background
Everyday work for nurses includes lot of ethical challenges and in the future ethical dilemmas and problem will increase because of the changes in the public healthcare. Today politicians and the financially responsible ask for efficiency, productivity and high quality standards of service from health care. They want the care providers to do the job cost-effectively and ethically [1][2][3]. In the public health-care, we have much more needs to meet then we have professional caregivers available. People over 65 years-old increase. They have more complex care needs and they know much more about their rights and benefits in case of illness and desire. Still the patient, now days, want to make their own decisions in relation to their own life's [4,5]. The nursing intensity will be higher, problems more complex and money less [6]. This is the reality and we have to find out how to manage these challenges and make the good ethical care possibly in the future.
This paper is based on thesis by Frilund in the field of Caring science and Nursing administration. The synthesis between ethos and nursing intensity evolves thought a hermeneutic moment between understanding and interpretation, in a dialectic tension between thesis and antithesis [7], i.e., the ethos of caring and nursing intensity [8].
The thesis had three main aims, the first aim was to deepen the understanding of caring ethos, the second aim was to deepen the understanding of the nursing intensity within the care of older people and the third aim was to create a theoretical model describing the synthesis between the caring ethos and nursing intensity. A theoretical model was developed by four sub-studies [9][10][11][12]. Propose of clinical caring-science is to form the ethical ideals and to implement the ideals into the reality [13,14]. These kinds of knowledge expansion and theoretical formation described in the study had a hypotheticdeductive design, [15] in accordance with a humanistic tradition [16].
The synthesis between the ethos of caring and nursing intensity highlight new knowledge formation in a theoretical model, and took place in a process of creativity [4]. Propose of the model was to start a discussion about ethic and ethical manners in praxis. Good care is in constant movement and tension between the ethical and the unethical.
The caregivers are aware about the ethics in the daily work but they lack realistic possibilities to act in an ethical manner in their daily work. Good Care is always at risk of changing into more or less unethical care, despite good intension of the caregivers [17,18].
Based on earlier research we can state that basic ethical values can be summered into four values: dignity [19,20], autonomy [21,22], safety [23] and caring community [24]. The caregivers most often accept these values, but they not necessary guide the nurses in their daily work. Researches stat that still the care of older people are stereotypic and based on routines. Patient's autonomy and integrity safeguarded in an unsatisfactory manner [18,19] Research shows that especially in care of older people the risk of being carried of tiered and stressed caregivers increase. Nursing today will be a job with lot of stress and impossibilities to provide a care in accordions with the ideals of the caregivers. The everyday work don´t take account the older persons individual needs and don't planning patient's care from this point of view [8].
Most of the nurses' will everyday meet ethical dilemmas and challenges. Ethical discussions and problem-solving are necessary, and it is the leader how have the responsibility to start the process and make good ethical care possible [8,9].
The caring ethos, ethical values or caritativ caring ethics are used as synonyms in the study, and they have to be understood from a caring science perspective. The concept "nursing intensity" will be an administrative concept witch refers to the patients 'needs and how well the nurses experience they have had possibilities to meet the needs [25]. For to guarantee the patient an ethical good care it will be important that the patients 'needs will be in balance with available resources [26]. It will be one of the nursing leaders' main task to make "good ethical care" possibly by relevant resource allocation, recruitment and the development of the staff to provide good care [1,11,27].
The propos of this paper is to describe the theoretical model called a synthesis between ethical values and nursing intensity. The model was developed thought a hermeneutic movement between understanding and interpretation, in a dialectic tension between thesis (ethos of caring) and antithesis (nursing intensity) [28].

Aim
Aim of the study is to describe and explain the relationship between the ethos of caring and nursing intensity, based on a theory model developed by a hermeneutic approach.

Research Questions
What central entities does a theoretical model consist of when the aim is to support the ethos of caring as well as ethical manners?
How can we describe the relationship between ethos and nursing intensity?

Methods
The sub-studies had a hypothetical-deductive design. Previous research, theoretical standpoints of relevance for the study has provided the interpretive framework. Data for building the model was four sub-studies, Frilund et al. [9][10][11][12]. The authors interpreted and analyzed findings from the studies and by a hermeneutic process the model was formed. The model that describes the synthesis between caring ethos and nursing intensity consist of four cornerstones and sex interpretation patterns The concept used in the model has been chosen in line with the theory of caritative. The model has to be understood from a caring and nursing management perspective. That constituted for the researcher new pre-understanding for further interpretation.
The model for to describe ethical values and nursing intensity was formed by a logical deductive process and with a hermeneutic approach [29] based on Ghadames's philosophy. The synthesis between ethos of caring and nursing intensity took place in a process of creativity and logical deduction. The analyze process, was done in three steps.
The first step of the analyze process was based on result from the four sub studies mined above. The sub studies was early published and thereby been reviewed. Conclusion from the analyze process was explained as theoretical patterns of interpretation. In the second step a new logical deductive process was done and the results of this process results in four corn stones for the model. The meaning for the model was given by using concepts that liked together the cornerstones as well as the interpretation patterns. The final model formation was the third phases in the inquiry of the process. Corn-stones and patters of interpretation form the model and the model will be understood by the concepts and relations between the concepts from clinical nursing science and nursing administration point of wave. The model has been reviewed by researches from different countries and the model has been found logical and reliable. The process of review was taken place before my dissertation.

Findings
A theoretical model showing the synthesis between ethos of caring and nursing intensity grew up and started with six patterns of interpretation, i.e. new horizon of interpretation in accidence with a hermeneutic approach. The "patterns of interpretation" was named: the ethical ideals, ethical wishes and expectations, ethical manners, the older persons caring needs and optimal level of nursing intensity, ethical dilemmas and challengers and finally ethical leadership [8][9][10][11]13]. The corner stones was named; ethical values as ideals, ethical wishes' and expectations in relation to nursing intensity, ethically possibilities, and ethically leadership [3].
First, we want to explain the six interpretative patterns that step forward in the analysis and interpretation of results.
The ethical ideals Good ethical care starts with ethical values. The sub study two [10] show four ethical values of relevancy to provide good ethical care for older people; autonomy (integrity), safety, dignity and caring community. This values where accepted by the participants based on the findings in the study two [10] at a high level of agreement, but not good enough for guarantee patient good quality care, regardless of caregivers [8][9][10].
Ethical wishes and exceptions: Interpretation process indicate that ethical awareness and consensus needs to be done in the team of caregivers. Good ethical care also indicates that the patients' needs, wishes and expectations have to been met. Without ethical awareness you cannot be award ethical expectations and wishes of the patient.
For to meet the needs, expectations and wishes of the patient the nursing intensity at the unit has to be in balance. That means a balance between needs and available resources [26,28]. For to state the level of optimal nursing intensity the caregivers needs methods for assess the nursing intensity level, and well defined criteria's what good ethical care means at the unit in case. Caregivers have opportunities to assess this by using tools for nursing intensity measurement in relation to the criteria's of good care made by the staff at the unit. Based on study four we can state that RAFAELA system is a valid and reliable system to measure Nursing Intensity [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31]. The optimal nursing intensity level describe a level there resources and the patients' needs will be in balance, a level for the unit in case [11]. The study three shows that RAFAELA-system has the opportunities to determine the optimal nursing intensity in care of older people.
Optimal Nursing Intensity level is a determining factor for the patient's possibilities to got good ethical care. The sub study two show a remarkable result. Opportunities to provide ethical good care varies significantly. Based on early research one reason might be the unbalance between patients' needs and resources [30]. Good ethical care will thereby be in in a constant tension between the ethical and the unethical. Despite of good intensions good ethical care is always at risk of changing into more or less unethical care [9,10]. In order to guarantee the older person an ethical care based on dignity, a caring community, safety and integrity in caring, in the future, the caregivers need for an awareness of and responsibility for those entities from witch good care are grooving up (ethical values and ethos), otherwise ethical problems and dilemmas hidden the good intention of ethical care [8,9]. The caregivers have to be awereness of ethical dilemma and together make ethical consensus about how to act in the daily work. The point is, everybody has to take responsibility for good ethical care.
Caring with dignity as ideal longs for a care where compassion and mercy prevails. Other ideals as autonomy take account the older person´s free will to act (autonomy) and decide in cases that belongs to her care. To assert that the patient has received good care according to the department has established criteria for good care, both needs and wishes has to be met [8,11,13].
From the "patters of interpretation" four cornerstones was drawing out; such as ethics as ideals, wishes ethical manners and ethical leadership. Good care based on the values dignity, a caring community, safety and integrity, receive their legitimacy thought ethical awareness and consent among caregivers. The ethical awareness deepens the understanding of wishes and expectations that may arise as a result of ethical openness (Figure 1).

Figure 1: Syntheses between ethical values and nursing intensity.
Good care requires an awareness of balance between the patient´s care needs and optimal level of nursing intensity. An ethical leader considers a work situation where optimal nursing intensity and optimal resource allocation makes good care possible, i.e., the caregiver have the opportunity to meet the patients 'needs, wishes and expectation in an optimal level. When ethical wishes and expectations can be met, we have an optimal nursing intensity with possibilities for ethical manners. The nursing process has to be supported by good leadership. An ethical aware leader proposes ethical discussions and ethical decision-making in the daily work. The ethical freedom is a task for the leader. He or she has to form a culture were goodness has a possibility to grow and caregivers has courage and willingness to do good for the patients.
The theoretical model presented is an ideal typical reasoning. The model can be used as a thought structure to develop an ethical transparency and in creating ethical consensus decision between caregivers. Ethical values creates ethical desires and expectations, and only when ethical aspirations, expectations and needs can be met, the patient can guarantee good care, the department is at an optimal nursing intensity level. An optimal Nursing Intensity level makes good ethical manners possibly. Based on early research can we state that caregivers know and want to act ethically, but they do not always have possibilities to act in accordance with their wishes.

Discussion
Ethical good care requires affirmed ethical values among caregivers and consent when the team of caregivers make a common decision about ethical values for to guide them I their daily care of patients. The caregivers need courage to see wishes and expectations of the patients, but they also need support of their nursing manager [1]. They need to know that their attitudes and manners make difference for the organization. Whiteout support and supervising the caregivers' don´t see their own responsibility for good ethical care in the caring team. To do well the caregivers have to feel there will be balance between expectations and the realistic possibilities to provide "good ethical care". Based on my study we can state that a prerequisite for meeting this needs are balance between available resources and caring needs [8,26]. The theoretical model show above have opportunities to guide the manager in here task to promote good care for older people. He or she can step by step, lead and supervise the caregivers in their professional development. Ethical values, nursing intensity, ethical manners would continuously be discussed. By interpretation of the entities in the model, the understanding of the possibilities of ethics in daily work deepens. Previous research shows that caregivers almost daily, face ethical problems and challenges. The caregivers are aware about the ethics in the daily work with older people, but they feel they lack realistic possibilities to act in ethical manners they would like to [1,9].
The care of older people faces great challengers due to the increase of number of older people and the decrease in available personnel. Society glorifies economically principles, efficiency and productivity, values that are hard to combine with "good ethical care", still it will be a very important area to find out a way for common communication [31]. Economic and ethics needs a common dialog. The field of work with older people is commonly considered unattractive, knowledge is lacking and recruiting staff is becoming more and more difficult to find. Care of older people needs highly professional caregivers and status of an attractive work area. Every caregiver have her his ideal about the good care, and they want to act in accordance with this ideals. Research has found that caregivers don\t stay in the caring area if they every day have to compromises with their conscience. The caregivers have to protect themselves and they have different ways to handle, they either live the caring area or they would get burnout.

Conclusion
Good care occurs when different professions work together develops ethical processes with ethical reflections in the daily work; the theoretically model would give the structure for this development process. Caregivers and leaders have to communicate with each other, take each caregivers experience in account and in an effective way eliminate inhibited factors for ethical good care. The entities in the model have been found reliable and logical. The model would need further research for to develop the entities and concepts. Further research is also needed for to find out how the model can support clinical praxis and ethical development. I look forward to start the