Hotel-type nursing and ethical dilemmas due to business interests

Introduction: In the age of neoliberalism, there are differences in the implementation of nursing activities due to business interests being integrated into nurse-patient relationships. An example of this is hoteltype nursing, which involves fulfilling patients’ needs by charging for nursing services (or by charging an additional fee for extra services). Whether this constitutes a contemporary nursing development or a danger is an important question. This paper explores an approach to resolving ethical dilemmas, which often emerge when the interests of businesses, nurses, and patients are integrated, as contemporary nursing is implemented according to community care principles. Methods: In a case study of nurses’ activities conducted in June 2013 and 2014 in three different institutions, the methods of observation and interviews were used. The collected data were analyzed using Strengths, Weaknesses, Opportunities, and Threats (SWOT) methodology, and then verified and updated with a power diagram qualitative interpretation and the Decide, Establish, Consider, Identify, Develop, and Implement (DECIDE) decision-making model. Results: Based on my study of hotel-type nursing, an approach to resolving ethical dilemmas which arise with the integration of business interests into nurse-patient relationships is explained. Discussion: Hotel-type nursing involves an adaptation by nurses to a change in their relationship with the patient. This adaptation must ensure that the nurse’s professionalism is recognized as being significantly more beneficial to the patient than a reduction of the nurse’s role to one of simply fulfilling a patient’s


INTRODUCTION
Due to widespread globalization (1)(2)(3)(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 'winwin' 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 wellthought-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.

Data collection
I did a case study on the operation of nursing care providers in selected (reference) institutions.I observed the nurses' interactions with their patients and interviewed the nurses, using both a structured set of questions and a semi-structured method, which allowed new ideas to enter into the discussion.My focus was on getting quality, albeit subjective, data and not on numerical representations of care.The research was conducted in two phases.In the first phase (June 2013) data was collected, and in the second phase (June 2014) data was mainly validated.It was conducted in the form of agreed personal successive attendance at the institutions.

Sample
I observed the nurses' interactions with patients in health care organizations in the south-eastern region of Slovenia, to determine whether hotel-type nursing was being practiced.I based my assessment on randomly observed differences in the time devoted by nurses to each patient, the nurses' communication with them (knocking upon entry, greeting, using literary colloquial language), the equipment in the units/bedrooms and the services performed, as well as the available accessories and materials.
I identified three reference institutions where hoteltype nursing was being practiced: a 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.My observations included the work process and the relationships between nurses and patients staying at the facilities during the data collection period, as well as interviews about the decision-making processes and potential ethical dilemmas.(I did not give a detailed explanation beforehand, but I did obtain the consent of the parties involved).

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).

Data analysis
During the phase one, data were collected and recorded at the institution itself-usually on the same day-and at the health care organization during phase two.The collected data were analyzed qualitatively (18) and the codes and categories were defined.The findings of the phase-one qualitative analysis were evaluated by SWOT analysis and later verified and revised in phase two using a qualitative interpretation of power diagrams and the DECIDE decision-making model.

Ethical considerations
The necessary consent for carrying out the study was obtained.During phase one, the specific aim of the research was not revealed to the participants; it was, however, explained in phase two.Patients were directly informed about the researcher's presence and gave oral consent.The results are presented objectively and impartially without any additional non-scientific interests.

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.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).
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  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 main characteristics of hotel-type nursing-i.e., fulfilling patients' (guests') needs by charging for services (or an additional charge)-must also include the situational constant of patient-centrality, payment of services, and business responsibility.Three simultaneous processes must be considered: (1) patients' tendency to overcome partnership and dominate the relationship, which is conditional on their payment for services, (2) employers' tendency to reduce costs to ensure patient satisfaction, (3) nurses' tendency to provide high-quality and safe nursing, and increase patients' self-sufficiency.• Hotel-type nursing may benefit the development of contemporary nursing if nurses retain their high ethical standards in the transition to post-conventional ethical practices.There is imminent danger in a) the increasingly unequal access to health resources, b) allowing patient-centrism due to the delayed transition to post-conventional ethical practices and uncoordinated operation of stakeholdrs, c) absence of a teamwork model, and d) disregarding community care principles.
• Based on hotel-type nursing, the approach to resolving ethical dilemmas in the integration of business interests into nurse-patient relationships (while implementing contemporary nursing according to community care principles) can be explained.• The nurses' approach to resolving ethical dilemmas includes recognizing the need to tactfully redirect patients' initial tendencies to patient-centrism by personally providing expert information, while bearing in mind the emotional state of the patient.An autonomous agreement is achieved with patients concerning the boundaries to be set in order to achieve the best possible impact on their health and self-sufficiency.Ethical dilemmas (unequal treatment, disproportion between rights and obligations, and reduced quality of treatment) may only appear as such, due to the (inter)action of several factors upon which nurses have no direct influence, while the potential indirect influence is small.
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.

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 associationsC

TABLE 1 .
Theoretical variables and results of observation and interviews

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