Moral injury emerged in the healthcare discussion quite recently because of the difficulties and challenges healthcare workers and healthcare systems face in the context of the COVID-19 pandemic. Moral injury involves a deep emotional wound and is unique to those who bear witness to intense human suffering and cruelty. This article aims to synthesise the very limited evidence from empirical studies on moral injury and to discuss a better understanding of the concept of moral injury, its importance in the healthcare context and its relation to the well-known concept of moral distress. A scoping literature review design was used to support the discussion. Systematic literature searches conducted in April 2020 in two electronic databases, PubMed/Medline and PsychInfo, produced 2044 hits but only a handful of empirical papers, from which seven well-focused articles were identified. The concept of moral injury was considered under other concepts as well such as stress of conscience, regrets for ethical situation, moral distress and ethical suffering, guilt without fault, and existential suffering with inflicting pain. Nurses had witnessed these difficult ethical situations when faced with unnecessary patient suffering and a feeling of not doing enough. Some cases of moral distress may turn into moral residue and end in moral injury with time, and in certain circumstances and contexts. The association between these concepts needs further investigation and confirmation through empirical studies; in particular, where to draw the line as to when moral distress turns into moral injury, leading to severe consequences. Given the very limited research on moral injury, discussion of moral injury in the context of the duty to care, for example, in this pandemic settings and similar situations warrants some consideration.

The aim was to synthesize the findings of empirical research about the unmet nursing care needs of older people, mainly from their point of view, from all settings, focusing on (1) methodological approaches, (2) relevant concepts and terminology and (3) type, nature and ethical issues raised in the investigations. A scoping review after Arksey and O’Malley. Two electronic databases, MEDLINE/PubMed and CINAHL (from earliest to December 2019) were used. Systematic search protocol was developed using several terms for unmet care needs and missed care. Using a three-step retrieval process, peer-reviewed, empirical studies concerning the unmet care needs of older people in care settings, published in English were included. An inductive content analysis was used to analyse the results of the included studies (n = 53). The most frequently used investigation method was the questionnaire survey seeking the opinions of older people, informal caregivers or healthcare professionals. The unmet care needs identified using the World Health Organization classification were categorized as physical, psychosocial and spiritual, and mostly described individuals’ experiences, though some discussed unmet care needs at an organizational level. The ethical issues raised related to the clinical prioritization of tasks associated with failing to carry out nursing care activities needed. The unmet care needs highlighted in this review are related to poor patient outcomes. The needs of institutionalized older patients remain under-diagnosed and thus, untreated. Negative care outcomes generate a range of serious practical issues for older people in care institutions, which, in turn, raises ethical issues that need to be addressed. Unmet care needs may lead to marginalization, discrimination and inequality in care and service delivery. Further studies are required about patients’ expectations when they are admitted to hospital settings, or training of nurses in terms of understanding the complex needs of older persons.

Missed care, defined as any aspect of patient care that is omitted or delayed, is receiving increasing attention. It is primarily caused by the imbalance between patients’ nursing care needs and the resources available, making it an ethical issue that challenges nurses’ professional and moral values. In this scoping review, conducted using the five-stage approach by Arksey and O’Malley, our aim is to analyze the patients’ perspective to missed care, as the topic has been mainly examined from nurses’ perspective. The search was conducted in April 2019 in PubMed, CINAHL, PsycINFO, Web of Science, ProQuest and Philosophers Index databases using the following terms: omitted care, unfinished nursing care, care undone, care unfinished, missed care, care left undone, task undone and implicit rationing with no time limitation. The English-language studies where missed care was examined in the nursing context and had patients as informants on patient-reported missed care or patients’ perceptions on nurse-reported missed care were selected for the review. Thirteen studies were included and analyzed with thematic content analysis. Twelve studies were quantitative in nature. Patients were able to report missed care, and mostly reported missed basic care, followed by missed communication with staff and problems with timeliness when they had to wait to get the help they needed. In statistical analysis, missed care was associated with patient-reported adverse events and patients’ perceptions of staffing adequacy, and in patients’ perception, it was mainly caused by lack of staff and insufficient experience. Furthermore, patients’ health status, as opposed to gender, predicted missed care. The results concerning patients’ age and education level were conflicting. Patients are able to identify missed care. However, further research is needed to examine patient-perceived missed care as well as to examine how patients identify missed care, and to get a clear definition of missed care.

Background: Identifying and safeguarding ethics in eHealth services from the service users’ perspective in social care and healthcare is important. The use of eHealth services should not prejudice the quality of services or the social interaction required in care. There is a lack of studies about the ethics of eHealth services from the service users’ perspective. Aim: The aim of this study is to identify and analyse ethical issues related to eHealth in social care and healthcare from the service users’ perspective. Research design: An integrative literature review. Ethical considerations: The review followed good scientific conduct. Research context and data sources: A systematic literature search was performed using CINAHL, Scopus, PubMed/MEDLINE, Web of Science, Cochrane Library and Academic Search Premier to find relevant empirical studies published in English from their earliest up to 30 November 2018. In addition, reference lists from the identified research papers were searched. A quality appraisal of each paper included in the review was conducted before thematic analysis. Results: In total, 26 studies were included in the review, and from these four ethical themes were identified: (1) privacy in eHealth, (2) beneficence and nonmaleficence in eHealth, (3) justice in eHealth and (4) trust in eHealth. The ethical issues within these themes were related to information sharing; ownership; access to information and data protection; informed consent; defence of rights; and equity, equality and proportionality of response. Conclusion: eHealth inequality occurs in social care and healthcare. eHealth service designers and social care and healthcare professionals need to act to maintain and improve user access and data accuracy and provide different levels of security in eHealth services, relative to the information stored. There is a need for further research about ethical issues of eHealth from the user’s perspective, including the customer-oriented availability and usability of eHealth services which avoid discrimination.