Ethical Challenges in Nursing Homes in Bollig (2015)

Bollig reports that nursing home staff frequently experience ethical challenges in daily work, and many also experience these situations as a personal burden. The study emphasizes that ethics in nursing homes is not limited to rare dramatic cases. Instead, staff face both major decisions, especially around end-of-life care, and many recurring everyday ethical problems. According to Bollig, this pattern shows a strong need for more systematic ethics work in nursing homes.

1. End-of-life decisions

One of the most prominent findings in Bollig is that end-of-life care was among the ethical challenges most often described by staff. These situations included difficult decisions about:

• Whether to hospitalize a resident or continue care in the nursing home
• Do-not-resuscitate decisions
• Artificial nutrition and fluids
• The balance of benefit and burden in treatment
• Respecting refusal of treatment

Bollig shows that such cases often involved uncertainty about what would best serve the resident, especially when frailty, confusion, or serious illness made decision-making more complex. Staff had to weigh prolonging life against comfort, dignity, and suffering. The study also notes that relatives frequently represented the resident's views in ethics meetings, while residents themselves did not participate in the prospective meetings that were observed.

2. Resource constraints

Bollig also identifies lack of resources as a frequent ethical challenge. Earlier work cited in the article had already shown that lack of resources and end-of-life issues were commonly mentioned in Norwegian nursing homes, and the 2015 study reinforces the importance of these concerns.

Resource constraints create ethical tension because staff may know what good care should look like but feel unable to provide it fully. Limited time, staffing, and organizational support can restrict attention to residents' needs and reduce opportunities for thoughtful discussion of difficult cases. In this way, resource shortages are not only practical problems; they become ethical problems because they affect fairness, quality of care, and the ability to act in residents' best interests.

3. Everyday ethical issues

A key contribution of Bollig is the argument that everyday ethical issues are extremely important, even if they receive less attention than major end-of-life decisions. The study introduces the image of an “ethics iceberg.” In this model, visible ethical discussions often focus on dramatic issues such as end-of-life treatment, but beneath the surface lie many more common ethical concerns from ordinary daily care.

These everyday issues may include questions about respect, autonomy, communication, routines, privacy, participation, and how care is carried out in small daily interactions. Bollig suggests that these problems occur more frequently than the larger cases discussed in formal meetings, yet they are often hidden and insufficiently addressed.

This means ethical practice in nursing homes should not only react to exceptional dilemmas. It should also pay close attention to the ordinary situations in which residents' dignity, preferences, and quality of life are shaped every day.

4. Burden on staff

Bollig finds that most staff members experienced ethical challenges in their daily work and that many experienced these challenges as burdensome. Ethical difficulty was therefore not presented as an abstract issue but as something that affects workers psychologically and professionally.

The article suggests that having opportunities to discuss ethical challenges may help protect staff psychological health. When employees face morally difficult situations without enough support, the strain can increase. Regular ethics discussions can therefore serve an important supportive function by helping staff reflect together, share responsibility, and handle uncertainty more constructively.

5. Need for systematic ethics work

The clearest practical conclusion in Bollig is that nursing homes need more systematic ethics work. Most participants preferred informal discussions in everyday practice, but this did not mean formal ethics support was unnecessary. On the contrary, 90% of informants felt that more systematic ethics work was needed in nursing homes.

Staff especially wanted:

• Ethics education for the whole staff
• Time for ethics discussion
• Meeting places for ethical reflection
• Access to someone with special ethics knowledge

Bollig argues that nursing homes should build a stronger culture of care by including ethics in everyday meetings and discussions, not only in special or crisis situations. The study therefore supports a structured approach in which ethics is recognized as a regular part of care work.

Conclusion

In Bollig, nursing home staff describe ethical challenges as frequent, complex, and emotionally demanding. The main issues include end-of-life decisions, resource constraints, and many hidden everyday ethical problems. The study also highlights the burden these situations place on staff and argues that regular, organized ethics support is necessary. Overall, Bollig presents systematic ethics work as essential for improving decision-making, supporting staff, and strengthening ethical care in nursing homes.