Lessons learnt from managing a case of dengue hemorrhagic fever complicated with acute liver failure and acute kidney injury: a case report

Chamara Dalugama
Indika Bandara Gawarammana
Lessons learnt from managing a case of dengue hemorrhagic fever complicated with acute liver failure and acute kidney injury: a case report
10.1186/s13256-018-1766-0C A S E R E P O R T Open Access
Background: Dengue is a common arboviral infection with a diverse spectrum of clinical manifestations. Dengue hemorrhagic fever is a more severe form of infection characterized by plasma leak and hemoconcentration. Although hepatic dysfunction is common in dengue illness, massive liver necrosis is rarely reported. Lactic acidosis is a poor prognostic marker in liver failure related to dengue. Management of acute renal injury in dengue hemorrhagic fever due to prolonged shock is challenging as the fluid reabsorption during the recovery phase expands the intravascular volume and precipitates heart failure and pulmonary edema. Case presentation: We report the case of a 43-year-old Sri Lankan Sinhalese woman with serologically confirmed dengue fever presenting with evidence of plasma leakage developing acute liver failure evidenced by deranged liver functions, coagulopathy, and altered sensorium and acute kidney injury with anuria. She had elevated serum lactate levels. In addition to the "standard care," she was managed with intravenously administered N-acetyl cysteine and blood transfusions, even in the absence of bleeding or dropping packed cell volume, targeting a higher packed cell volume anticipating a better oxygenation at tissue level. Continuous veno-venous hemodialysis was employed and continued for 138 hours removing the fluids reabsorbed during the recovery phase to prevent her from developing heart failure and pulmonary edema. She made full recovery with no sequelae. Conclusions: N-acetyl cysteine and packed cell transfusion aiming at a higher packed cell volume to maintain adequate tissue perfusion during shock may be beneficial in acute liver failure due to dengue virus. The use of a continuous form of renal replacement such as continuous veno-venous hemodialysis is of paramount importance in managing fluid states in the recovery phase of dengue hemorrhagic fever in those with renal impairment. Interesting observations made in the fluid dynamics during the reabsorption phase need further studies preferably with an animal model.

Background

Dengue fever (DF) is a common arboviral disease that is endemic in Southeast Asia; DF has four distinct serotypes [1]. Dengue illness has a diverse clinical spectrum ranging from asymptomatic subclinical infection to severe multiorgan involvement and death [2]. Dengue illness encompasses changeable unusual manifestations [3][4][5]. Hepatic dysfunction is well reported both in DF and dengue hemorrhagic fever (DHF). Liver involvement can be varied ranging from mild to moderate elevation of serum transaminases to fulminant liver failure [6][7][8][9][10][11][12][13]. Various mechanisms are postulated to explain the hepatic dysfunction seen in dengue illness including direct viral damage, immunological injury, and hypoxic injury due to reduced hepatic perfusion during shock [14][15][16][17][18][19][20][21]. The role of N-acetyl cysteine (NAC) in liver injury is debated [22][23][24]. Lactic acidosis is a poor prognostic marker in DHF [25][26][27][28][29][30][31][32]. Acute oliguric renal failure is known to occur in patients presenting with prolonged shock. Renal impairment with oliguria raises concerns because the reabsorption of fluid during the recovery phase of DHF can lead to fluid overload and pulmonary edema. We report a case of a late presentation of DHF complicated with liver necrosis, lactic acidosis, and acute renal failure managed successfully. The use of NAC, the use of serum lactate levels to monitor improvement, the role of pack cell transfusion to improve tissue level oxygenation, and prophylactic employment of continuous veno-venous hemodialysis (CVVHD) anticipating the fluid overload during recovery in the background of renal impairment are discussed as important management strategies. Interesting observations on fluid dynamics were made during the fluid reabsorption in the recovery phase.

Case presentation

We report a case of a 43-year-old Sri Lankan Sinhalese woman who presented to our Teaching Hospital, Peradeniya, in the morning with a history of fever, arthralgia, myalgia, and headache of 4 days' duration. She had been previously diagnosed as having type 2 diabetes mellitus and dyslipidemia for which she received treatment with satisfactory control of the medical conditions and she had normal renal functions.

She had experienced postural dizziness since the afternoon of the previous day and she had had nausea, vomiting, and abdominal pain since the morning of the previous day. Soon after admission she collapsed in our emergency care unit. She was severely dehydrated with cold clammy peripheries. Her pulse rate was 130 beats per minute with an unrecordable blood pressure. She had reduced breath sounds in the base of her right lung and marked tenderness over the right hypochondrium with flank dullness with shifting. She was drowsy, but arousable.

Her complete blood count showed hemoglobin of 15.3 g/dL, platelet count of 74 × 10 3 /microL, and white cell count of 3.22 × 10 6 /microL. Her serum creatinine was 277 micromole/L with potassium of 5.8 mmol/L. Alanine transaminase (ALT) was 6542 U/L with aspartate transaminase (AST) of 30,617 U/L. Her serum albumin value was 24 g/L. A bedside ultrasound scan demonstrated bilateral pleural effusions (more in the right) with free fluid in her abdomen. A diagnosis of DHF with decompensated shock complicated with acute liver failure and acute kidney injury was made. DF was confirmed by positive non-structural protein 1 (NS1) antigen and serotype was identified as dengue virus type 2 (DEN-2). Both dengue immunoglobulin M (IgM) and immunoglobulin G (IgG) were positive suggesting a secondary infection with dengue virus (DENV). She was screened for alternative causes for liver necrosis including hepatitis A immunoglobulin A, hepatitis B surface antigen, hepatitis C IgM, leptospirosis serology, and rickettsial serology, which were negative. Her baseline transaminase levels and serum creatinine done 1 month earlier at a medical clinic were within the normal range. She denied taking supra-therapeutic dose of paracetamol or other native medical preparations for her fever. She had been treated with metformin and atorvastatin until the previous night.

She was assumed to be at the peak of the critical phase of DF (that is, 24 hours in the plasma leakage) on admission. On admission her packed cell volume (PCV) was 44%. (Her baseline PCV was 33% for hemoglobin of 10.5 g/dL in her clinic book.) She was given a 10 ml/kg crystalloid bolus (500 ml) over 15 minutes followed by 10 ml/kg bolus over 1 hour. She was given a 10 ml/kg dextran 40% bolus in the next hour. She had heavy per vaginal bleeding and one episode of melena. Her PCV dropped from 44 to 33% without clinical improvement and she had low urine output (< 0.5 ml/kg). She was administered packed cells to maintain the PCV around 40% to a total volume of 1200 ml.

During the latter 24 hours of the critical phase of DF, she had severe metabolic acidosis with lactic acidosis: PH of 7.2, bicarbonate 8 mmol/L, and partial pressure of carbon dioxide 16 mmHg with a lactate level of 12 mmol/L, which was corrected medically with 8.4% sodium bicarbonate 200 ml in divided boluses. Her ionized calcium was persistently low and corrected with multiple boluses of intravenously administered calcium gluconate. Her blood sugar was checked every 2 hours and corrected accordingly.

At the end of presumed critical phase, we gave her 5500 ml of fluid including normal saline, dextran, and packed cells. She was conscious, rational, but drowsy. She had a spiking high temperature. She was icteric but not pale. She was breathless at rest with oxygen saturation of 85% on room air, which increased to 95% with 60% oxygen via mask. Her pulse rate was 120 beats per minute with blood pressure of 140/100 mmHg. She had bilateral pleural effusions up to mid zone. Her liver was 5 cm below the costal margin with normal upper border and markedly tender. She had gross ascites in a horseshoe-shaped distribution. Her serum creatinine was raised to 345 micromol/L with serum potassium of 5.8 mmol/L and during the last 6 hours of the critical phase she was anuric. Her ALT was 8010 U/L and AST 41546 U/L. Her prothrombin time was 22.1 seconds (control 12 seconds) and activated partial thromboplastin time (APTT) was 42 seconds (control 26 seconds). C-reactive protein (CRP) was 240 U/L. Her blood sugars were elevated toward the end of presumed leaking phase of DHF.

At the end of the presumed leaking phase of DHF our patient had: massive liver necrosis; acute kidney injury with acidosis, hyperkalemia, and anuria; deranged clotting with bleeding; and symptomatic volume overload with large plural effusions and gross ascites. Many concerns rose at this point regarding management:

1. The fluid in the third space mainly in the pleural and peritoneal cavities would get reabsorbed and as she probably had an established acute kidney injury with anuria, the reabsorbed fluid would accumulate in her intravascular compartment leading to expansion of intravascular volume and massive volume overload with pulmonary edema and heart failure. 2. Massive liver necrosis with deranged synthetic function would worsen the lactic acidosis which in turn would have a negative effect on the inotropic effect of her heart, clotting derangements might aggravate the bleeding risk, and ongoing hypoxia of the liver might further damage her liver.

3. Sepsis with high fever and elevated inflammatory markers. What is the focus? 4. Management of uncontrolled blood sugar. Is it due to her existing type of diabetes or pancreatitis?

She was started on continuous renal replacement therapy (CRRT) with CVVHD. We decided to keep CVVHD running and titrate the ultrafiltrate according to the volume state. Observations on central venous pressure (CVP) and blood pressure were made hourly. Intermittent measurements of her inferior vena cava (IVC) diameter and internal jugular vein (IJV) diameter were noted. We assumed that reabsorption of the fluid in the third space would increase the CVP, distend the IJV and IVC, and would increase mainly the diastolic pressure. Depending on the above assumptions, observations were made and ultrafiltrate was gradually increased. Surprisingly, fluid reabsorption occurred in an exponential pattern over a period of 5-6 days and came to a halt abruptly (Figs. 1 and 2). Maximum ultrafiltrate was 280 ml/hour. Heparin was not used in CVVHD due to high risk of bleeding.

She was started on intravenous NAC 100 mg/hour infusion which was continued for 5 days. She was given orally administered metronidazole 400 mg 8 hourly and syrup lactulose to maintain bowel motion 2-3 times per day. She was started on an intravenous infusion of proton pump inhibitors, intravenously administered tranexamic acid, and orally administered norethisterone. She was given intravenously administered vitamin K 10 mg daily for 3 days. She was given 4 units of fresh frozen plasma and 10 units of cryoprecipitate, and 6 units of platelets to correct the coagulopathy. She was transfused with packed cells to maintain PCV around 40% in order to maintain adequate oxygenation of hepatocytes. CVVHD was continued and her lactate level was noted to decline gradually. She had spiking high fevers on day 3 of hospital stay with high CRP. Septic screening was done with blood culture and urine culture and intravenously administered ceftriaxone was changed over to renal-adjusted dose of intravenously administered meropenem and teicoplanin. Later cultures were negative after 72 hours of incubation. However, gradually her fever settled by lysis of fever over the days.

Although during the presumed critical phase her blood sugar was rather low, her blood sugar started to rise over the days. She was a type 2 diabetic with good control with metformin. Her blood sugar was checked hourly and insulin infusion was continued and titrated according to her blood sugar. Her amylase was 450 U/L (normal range 1-37 U/L).

Over a period of 6 days she was closely monitored. Gradually her transaminases declined, her lactate level normalized, and serum creatinine reduced and normalized (Table 1). Her urine output gradually increased. CVVHD was terminated after 138 hours of dialysis. She was discharged on ninth day of admission after restoring her full physiology. She was discharged on Mixtard insulin (biphasic isophane insulin injection) for diabetic control. She was reviewed in the ward after 3 days, 7 days, and at 1 month after discharge. Her renal functions and liver functions were within the normal range. She was started again on metformin and atorvastatin 1 week after discharge and insulin was discontinued.

Discussion

DF is a common mosquito-borne viral disease among humans seen mainly in the Asia-Pacific region [1]. It can present with a diverse clinical spectrum ranging from asymptomatic infection or simple undifferentiated fever to DHF with multiorgan failure. Four distinct dengue viral serotypes (DEN-1 to DEN-4) are known to cause illness. Infection with one serotype confers protection from reinfection with the same serotype, while reinfection with different serotypes confers no long-term protection and may even predispose plasma leak and worse clinical outcome [2]. No specific antiviral therapy is available for DF. Dengue infection can present with various unusual manifestations. Most of these manifestations of DF are under-reported, under-recognized, or not casually linked to DF including hepatitis and liver failure [3], myositis [4], and encephalitis and other neurological manifestations [5].

We report a case of a middle-age woman with diabetes and dyslipidemia who presented late to our hospital while peaking in the leaking phase of DHF. Her DHF was complicated with massive liver necrosis, acute renal failure with anuria and gross volume overload, and secondary sepsis. After an extensive literature search we believe that this case is the first who survived this sort of complicated DF. We would like to discuss the management principles that we employed in this success story.

Liver dysfunction is a well-recognized feature in both DF and DHF. Liver involvement in dengue infection could be suspected in patients with DF complaining of abdominal pain, nausea, vomiting, and anorexia [6]. Hepatomegaly is present in both DF and DHF but more common in DF [7]. Clinical jaundice has been detected in 1.7-17% of cases in various series [7,8]. A mild to moderate increase in the transaminases is common in DF and DHF, and AST was higher than ALT [9][10][11]. The AST released from damaged striated muscle, cardiac muscle, and erythrocytes could explain the levels of AST that are higher than those of ALT in patients with DF at an earlier stage [12,13]. Therefore, a rise in AST might not be a true reflection of hepatic involvement. The pathogenesis of liver injury in dengue infection is yet to be fully elucidated. Possible hypotheses include direct Fig. 2 The ultrafiltration removed by continuous veno-venous hemodialysis per hour plotted against time effects of the virus or host immune response on liver cells, circulatory compromise, and metabolic acidosis and/or hypoxia caused by hypotension or localized vascular leakage inside the liver [14]. Studies have shown that DENV readily infects the liver cells in mouse models [15]. High levels of cytokines particularly interleukin-22 (IL-22) and interleukin-17 (IL-17) were found in mouse models which may be responsible for the cytokine-induced liver damage [16]. Sung et al. observed the infiltration of hepatocytes with natural killer cells followed by T cells and this was found to be associated with the apoptosis of hepatocytes [17].

Histopathological studies of postmortem specimens of patients who had a fatal outcome have shown that the liver is congested with liver cell necrosis and apoptosis, predominantly in midzonal and centrilobular areas, macrovascular steatosis, and Councilman bodies. Many postmortem reports show little or no inflammation [18,19]. It is interesting that similar centrilobular necrosis is a typical finding in hypoxic hepatitis [20]. Considering the fact that a severe form of liver necrosis is seen among the patients with DHF who present late with prolonged shock, we can postulate the fact that hypoxic injury due to reduced hepatic perfusion is probably an important contributor to the causation of liver damage. By contrast, few cases of fulminant liver failure have been reported in the absence of shock [3]. Khongphatthanayothin et al. reported an interesting case of liver failure from DENV infection with reversal of portal venous blood flow [21]. They postulated that hepatic sinusoidal obstruction coupled with shock might have been the underlying mechanism of liver failure in this disease [21].

Our patient presented at the peak of the leaking phase and collapsed on admission with cold and clammy peripheries. She had very high transaminases with deranged clotting and venous blood gas showing elevated lactate levels. Her liver involvement could be multifactorial including direct viral damage, immunological damage, hypoxia due to dehydration, and intravascular volume depletion due to leaking. It was further exacerbated by ongoing gastrointestinal and per vaginal bleeding. We aggressively resuscitated with crystalloids followed up by colloids. We considered transfusion of packed cells to maintain PCV around 40% to maintain adequate oxygenation to her liver.

She was started on intravenous NAC infusion at a rate of 100 mg/hour. NAC scavenges free radicals, improves antioxidant defense, and acts as a vasodilator to improve oxygen delivery and consumption [22]. However, limited data are available in the literature regarding the efficacy of NAC in DF-related liver dysfunction. A retrospective analysis on NAC in dengue-associated liver failure by Kumarasena et al. showed that five patients who survived out of eight were in early (coma grade 1, 11) liver failure stage at the time when NAC was started [23]. Habaragamuwa and Dissanayaka reported another case of hepatitis following dengue treated with NAC with success [24]. Large randomized trials should be carried out to establish its efficacy along with appropriate dosage, timing, and duration of treatment. We decided to continue NAC until our patient's liver enzymes were less than 500 U/L. Lactic acidosis resulting from excess accumulation of lactate and protons is associated with increased mortality and poor clinical outcome [25]. Hyperlactatemia occurs when lactate production exceeds lactate consumption. In tissue hypoxia lactate is overproduced as a result of decreased mitochondrial oxidation [26] that could be either due to generalized hypoxia or microcirculatory dysfunction [27,28]. Coexisting acidosis might further reduce the renal excretion of lactate. At the hyperdynamic stage of sepsis or shock, epinephrine-dependent stimulation of the β 2 -adrenoceptor augments the glycolytic flux both directly and through enhancement of the sarcolemmal Na + , K + -ATPase which lead to overproduction of lactate [29]. The liver accounts for up to 70% of whole-body lactate clearance [30]. Hyperlactatemia is common in acute fulminant liver disease, reflecting both reduced clearance and increased production of lactate by the liver [31]. Metformin interferes with oxidative phosphorylation and suppresses hepatic gluconeogenesis which can lead to hyperlactatemia in rare cases [32].

The lactic acidosis that developed in our patient could be multifactorial. She had poorly controlled diabetes and was on the maximum dose of metformin, she presented in severe shock due to plasma leakage and dehydration, and developed acute liver failure and renal failure. All these events could have contributed to her hyperlactatemia. High lactate levels will further suppress myocardial contractility and worsen the acidosis which will act as a vicious cycle deteriorating physiology.

The management strategies employed in this patient were:

1. Aggressive resuscitation with fluids during the initial shock including crystalloids and colloids. 2. Use of packed cells to maintain PCV around 40% to improve oxygen carrying capacity. 3. Supplementary oxygen to the patient during shock. 4. Use of CVVHD employed as a form of renal replacement therapy to remove lactate from the body and correct the acidosis.

Patients with DHF develop selective plasma leakage manifested as accumulation of fluid in pleural and abdominal cavities and hemoconcentration. The leakage is assumed to last approximately 48 hours and is followed by a spontaneous and rapid resolution but has wide individual variations [33]. Increased vascular permeability is mediated by an interplay between DENV, immune cells and endothelial cells with adhesion molecules, enzymes and cytokines according to the current evidence [33]. Very limited information is available in the literature regarding the rate and duration of plasma leak and about reabsorption of fluid in the pleura and peritoneal cavities during recovery. Understanding the trends in fluid leakage and reabsorption of dengue has been hampered by a lack of animal models.

During recovery from DHF, extravasated fluid will be reabsorbed and a functioning kidney would filter the extra volumes of fluid and the patient will be polyuric. Our patient's clinical course was complicated by acute renal failure, which was probably the result of acute tubular necrosis due to her late presentation with prolonged shock. She was anuric in the initial days of recovery. She was given 5500 ml of fluid during the presumed leaking phase of DHF and she had bilateral moderate to severe pleural effusions and gross ascites. We hypothesized that if she reabsorbed this excess fluid in the third space into the intravascular compartment with non-functioning renal tissue to filter it out, she would soon be intravascularly expanded which would lead to acute left ventricular failure and pulmonary edema. So we decided to have a renal replacement method prophylactically anticipating the reabsorption of fluid in the cavities. CVVHD was selected as the method of renal replacement therapy as it can be used continuously for a longer period, with less effect on the hemodynamics as opposed to intermittent hemodialysis.

What is the guide to assess the rate and volume of fluid reabsorption into the intravascular compartment?

We decided to make serial measurements of 1. CVP 2. IVC diameter and collapsibility 3. IJV diameter and collapsibility 4. Diastolic blood pressure (DBP)

CVP and DBP were considered as hard measurements, whereas IJV and ICV diameters and collapsibility had intra-operator and inter-operator variability. Ultrafiltration of the CVVHD was titrated according to the above measurements. Interesting observations were made during this period.

Our patient's CVP gradually increased reflecting reabsorption of fluid into the vascular compartment and we gradually increased the ultrafiltration starting from a figure of 60 ml/hour. CVP peaked in the 95th hour of CVVHD and ultrafiltration was increased in an exponential manner up to 280 ml/hour. CVP was maintained at the peak for 4 hours and a dramatic decline was noted in the central pressures indicating termination of fluid reabsorption. Over the next 24 hours CVP dropped from 24 cm H 2 O to 1 cm H 2 O and ultrafiltration was brought down to zero rapidly and CVVHD terminated. During the period of dialysis she was maintained on orally administered fluids at 50 ml per hour and she was anuric on initial 3 days of CVVHD and gradually improved over time. Total ultrafiltration removed 18.5 L over a period of 138 hours. She would not have survived the exponential rise in intravascular volume during reabsorption with poor renal function. The key for survival was the timely arrangement of renal replacement therapy.

Fluid dynamics during reabsorption has never been described before in DHF. In the index patient reabsorption took a longer period than is described in a timeframe of 48 hours in the literature and it occurred in an exponential pattern, plateaued, and abruptly ceased.

Conclusions

Management of a patient with DHF complicated with acute liver failure, lactic acidosis, and acute kidney injury is challenging. Although conclusions cannot be drawn from a single case report we emphasize importance of the following management strategies.

1. Use of NAC in hepatic dysfunction in dengue illness. 2. Increasing PCV by transfusing blood to increase the oxygen-carrying capacity even in the absence of a compelling indication for a transfusion in the "standard care. " 3. Lactate level to be used as a prognostic marker and as a tool to guide treatment. 4. Use of CVVHD in those with acute renal impairment and DHF during the recovery phase to maintain intravascular volume without leading to heart failure and pulmonary edema.

Large randomized trials should be carried out to establish the efficacy of these treatment strategies to support the above observations and change current practice.

We believe that the fluid dynamics we have observed in the index case need to be tested in a proposed animal model and it will open up new research areas and will generate new knowledge in the management of DF.

Fig. 1
1Change in the central venous pressure of the patient over time. CVP central venous pressure

Table 1
1Summary of the basic blood investigations of the patient during hospital stayDay
1
2
3
4
5
6
7
8
9
10

Hemoglobin (g/dL)
15.3
14.2
11
11.3
12.8
12
11.5
11.8
12
12.5

White cell count (10 6 /microL)
3.22
5.5
7.5
7
6.6
4.6
5
5.4
7
7.5

Platelets (10 3 /microL)
74
21
27
46
79
80
126
146
189
224

Sodium (mmol/L)
146
150
141
136
139
136
135
132
135
135

Potassium (mmol/L)
5.8
4.9
4.2
4.4
4
4.5
3.9
3.2
3.4
4.2

Creatinine (micromole/L)
277
345
432
241
172
160
280
308
150
97

Calcium (ionized)
1.95
1.7

PT/INR
1.43
1.93
1.98
1.65
1.08
1.1

ALT (U/L)
6542
8010
4678
3103
1607
932
260
104
100
88

AST (U/L)
30617
41546
24331
5612
1472
302
250
250
110
74

ALP (U/L)
245
156
140

Bilirubin (micromole/L)
48
75.5
68.2
21

GGT (U/L)
N/A

Albumin (g/L)
25
24
27
29
32
35

CRP (mg/L)
138
145
150
134
254
208
160
84
46

ALP alkaline phosphatase, ALT alanine transaminase, AST aspartate transaminase, CRP C-reactive protein, GGT gamma-glutamyltransferase, N/A not available, PT/INR
prothrombin time-international normalized ratio

AcknowledgementsWe acknowledge Prof. Vasanthi Pinto and the medical staff of Teaching Hospital, Peradeniya for the support given to us during the management of the patient.Availability of data and materialsData sharing not applicable to this article as no datasets were generated or analyzed during the current study.Authors' contributions CD and IBG examined, assessed, and were involved in the management of the patient. Both authors collected data and analyzed. Both authors read and approved the final manuscript.Ethics approval and consent to participate Ethical approval was not obtained for the publication of this case report as this does not involve sharing of the personal details of the patient.Consent for publicationWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.Competing interestsThe authors declare that they have no competing interests.Publisher's NoteSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
. S B Halstead, Dengue, Curr Opin Infect Dis. 155Halstead SB. Dengue. Curr Opin Infect Dis. 2002;15(5):471-6.

Dengue in travelers. A Wilder-Smith, E Schwartz, N Engl J Med. 353Wilder-Smith A, Schwartz E. Dengue in travelers. N Engl J Med. 2005;353: 924-32.

Liver involvement associated with dengue infection in adults in Vietnam. D T Trung, Ltt Thao, T T Hien, 10.4269/ajtmh.2010.10-0090Am J Tropical Med Hyg. 834Trung DT, Thao LTT, Hien TT, et al. Liver involvement associated with dengue infection in adults in Vietnam. Am J Tropical Med Hyg. 2010;83(4): 774-80. https://doi.org/10.4269/ajtmh.2010.10-0090.

Dengue myositis and review of literature. C Dalugama, U Ralapanawa, T Jayalath, Clin Cas Repo Rese Trials. 2Dalugama C, Ralapanawa U, Jayalath T. Dengue myositis and review of literature. Clin Cas Repo Rese Trials. 2017;2:16-8.

Dengue encephalitis. T K Koley, S Jain, H Sharma, J Assoc Physicians India. 51Koley TK, Jain S, Sharma H, et al. Dengue encephalitis. J Assoc Physicians India. 2003;51:422-3.

Clinical profile of dengue infection at a teaching hospital in North India. R Karoli, J Fatima, Z Siddiqi, K I Kazmi, A R Sultania, J Infect Dev Ctries. 6Karoli R, Fatima J, Siddiqi Z, Kazmi KI, Sultania AR. Clinical profile of dengue infection at a teaching hospital in North India. J Infect Dev Ctries. 2012;6:551-4.

Spectrum of hepatic dysfunction in 2012 dengue epidemic in Kolkata, West Bengal. A K Saha, S Maitra, S C Hazra, Indian J Gastroenterol. 32Saha AK, Maitra S, Hazra SC. Spectrum of hepatic dysfunction in 2012 dengue epidemic in Kolkata, West Bengal. Indian J Gastroenterol. 2013;32:400-3.

Liver involvement associated with dengue infection in adults in Vietnam. D T Trung, T T Thao Le, T T Hien, N T Hung, N N Vinh, P T Hien, N T Chinh, C Simmons, B Wills, Am J Trop Med Hyg. 83Trung DT, Thao le TT, Hien TT, Hung NT, Vinh NN, Hien PT, Chinh NT, Simmons C, Wills B. Liver involvement associated with dengue infection in adults in Vietnam. Am J Trop Med Hyg. 2010;83:774-80.

Aminotransferase changes and acute hepatitis in patients with dengue fever: analysis of 1,585 cases. L J Souza, J G Alves, R M Nogueira, Gicovate Neto, C Bastos, D A Siqueira, E W , Souto Filho, J T , Cezario Tde, A Soares, C E , Carneiro Rda, C , Braz J Infect Dis. 8Souza LJ, Alves JG, Nogueira RM, Gicovate Neto C, Bastos DA, Siqueira EW, Souto Filho JT, Cezario Tde A, Soares CE, Carneiro Rda C. Aminotransferase changes and acute hepatitis in patients with dengue fever: analysis of 1,585 cases. Braz J Infect Dis. 2004;8:156-63.

Liver biochemical tests and dengue fever. C H Kuo, D I Tai, C S Chang-Chien, C K Lan, S S Chiou, Y F Liaw, Am J Trop Med Hyg. 47PubMedKuo CH, Tai DI, Chang-Chien CS, Lan CK, Chiou SS, Liaw YF. Liver biochemical tests and dengue fever. Am J Trop Med Hyg. 1992;47:265-70. [PubMed]

The impact of dengue haemorrhagic fever on liver function. T L Nguyen, T H Nguyen, N T Tieu, Res Virol. 148Nguyen TL, Nguyen TH, Tieu NT. The impact of dengue haemorrhagic fever on liver function. Res Virol. 1997;148:273-7.

Ultrastructural changes in skeletal muscles in dengue virus-infected mice. P Nath, D K Agrawal, R M Mehrotra, J Pathol. 136Nath P, Agrawal DK, Mehrotra RM. Ultrastructural changes in skeletal muscles in dengue virus-infected mice. J Pathol. 1982;136:301-5.

Clinical relevance and discriminatory value of elevated liver aminotransferase levels for dengue severity. L K Lee, V C Gan, V J Lee, A S Tan, Y S Leo, D C Lye, PLoS Negl Trop Dis. 61676Lee LK, Gan VC, Lee VJ, Tan AS, Leo YS, Lye DC. Clinical relevance and discriminatory value of elevated liver aminotransferase levels for dengue severity. PLoS Negl Trop Dis. 2012;6:e1676.

Profile of liver involvement in dengue virus infection. S Itha, R Kashyap, N Krishnani, V A Saraswat, G Choudhuri, R Aggarwal, Natl Med J India. 18Itha S, Kashyap R, Krishnani N, Saraswat VA, Choudhuri G, Aggarwal R. Profile of liver involvement in dengue virus infection. Natl Med J India. 2005;18:127-30.

Dengue virus entry into liver (HepG2) cells is independent of hsp90 and hsp70. A Cabrera-Hernandez, C Thepparit, L Suksanpaisan, D R Smith, J Med Virol. 794Cabrera-Hernandez A, Thepparit C, Suksanpaisan L, Smith DR. Dengue virus entry into liver (HepG2) cells is independent of hsp90 and hsp70. J Med Virol. 2007;79(4):386-92.

IL-22 modulates IL-17A production and controls inflammation and tissue damage in experimental dengue infection. R Guabiraba, A G Besnard, R E Marques, I Maillet, C T Fagundes, T M Conceicao, N M Rust, S Charreau, I Paris, J C Lecron, Eur J Immunol. 436Guabiraba R, Besnard AG, Marques RE, Maillet I, Fagundes CT, Conceicao TM, Rust NM, Charreau S, Paris I, Lecron JC. IL-22 modulates IL-17A production and controls inflammation and tissue damage in experimental dengue infection. Eur J Immunol. 2013;43(6):1529-44.

Intrahepatic infiltrating NK and CD8 T cells cause liver cell death in different phases of dengue virus infection. J M Sung, C K Lee, B A Wu-Hsieh, PLoS One. 7946292Sung JM, Lee CK, Wu-Hsieh BA. Intrahepatic infiltrating NK and CD8 T cells cause liver cell death in different phases of dengue virus infection. PLoS One. 2012;7(9):e46292.

Dengue virus pathogenesis: an integrated view. B E Martina, P Koraka, A D Osterhaus, Clin Microbiol Rev. 224Martina BE, Koraka P, Osterhaus AD. Dengue virus pathogenesis: an integrated view. Clin Microbiol Rev. 2009;22(4):564-81.

Pathologic highlights of dengue hemorrhagic fever in 13 autopsy cases from Myanmar. K S Aye, K Charngkaew, N Win, K Z Wai, K Moe, N Punyadee, S Thiemmeca, A Suttitheptumrong, S Sukpanichnant, M Prida, Hum Pathol. 456Aye KS, Charngkaew K, Win N, Wai KZ, Moe K, Punyadee N, Thiemmeca S, Suttitheptumrong A, Sukpanichnant S, Prida M. Pathologic highlights of dengue hemorrhagic fever in 13 autopsy cases from Myanmar. Hum Pathol. 2014;45(6):1221-33.

Hypoxic hepatitis. J Henrion, Liver Int. 327Henrion J. Hypoxic hepatitis. Liver Int. 2012;32(7):1039-52.

Possible cause of liver failure in patient with dengue shock syndrome. A Khongphatthanayothin, A Mahayosnond, Y Poovorawan, 10.3201/eid1907.121820Emerg Infect Dis. 197Khongphatthanayothin A, Mahayosnond A, Poovorawan Y. Possible cause of liver failure in patient with dengue shock syndrome. Emerg Infect Dis. 2013; 19(7):1161-3. https://doi.org/10.3201/eid1907.121820.

Acetylcysteine treatment for non-acetaminopheninduced acute liver failure. G E Sklar, M Subramaniam, Ann Pharmacother. 38Sklar GE, Subramaniam M. Acetylcysteine treatment for non-acetaminophen- induced acute liver failure. Ann Pharmacother. 2004;38:498-500.

Intravenous N-acetylcysteine in dengue-associated acute liver failure. R S Kumarasena, Mananjala Senanayake, S Sivaraman, K De Silva, A P Dassanayake, A S Premaratna, R , Hepatol Int. 4Kumarasena RS, Mananjala Senanayake S, Sivaraman K, de Silva AP, Dassanayake AS, Premaratna R, et al. Intravenous N-acetylcysteine in dengue-associated acute liver failure. Hepatol Int. 2010;4:533-4.

N-acetylcystein in dengue associated severe hepatitis. Bwp Habaragamuwa, P Dissanayaka, 10.4103/0972-5229.128712.Indian J Crit Care Med. 183Habaragamuwa BWP, Dissanayaka P. N-acetylcystein in dengue associated severe hepatitis. Indian J Crit Care Med. 2014;18(3):181-2. https://doi.org/10. 4103/0972-5229.128712.

Relative hyperlactatemia and hospital mortality in critically ill patients: a retrospective multi-Centre study. A D Nichol, M Egi, V Pettila, Crit Care. 1425Nichol AD, Egi M, Pettila V, et al. Relative hyperlactatemia and hospital mortality in critically ill patients: a retrospective multi-Centre study. Crit Care. 2010;14:R25.

Lactic acidosis. N E Madias, Kidney Int. 29Madias NE. Lactic acidosis. Kidney Int. 1986;29:752-74.

The microcirculation is the motor of sepsis. C Ince, Crit Care. 94SupplInce C. The microcirculation is the motor of sepsis. Crit Care. 2005; 9(Suppl 4):S13-9.

Dengue haemorrhagic fever with unusual manifestations. S Nimmannitya, U Thisyakorn, V Hemsrichart, Southeast Asian J Trop Med Public Health. 18Nimmannitya S, Thisyakorn U, Hemsrichart V. Dengue haemorrhagic fever with unusual manifestations. Southeast Asian J Trop Med Public Health. 1987;18:398-406.

Increased aerobic glycolysis through beta2 stimulation is a common mechanism involved in lactate formation during shock states. B Levy, O Desebbe, C Montemont, S Gibot, Shock. 30Levy B, Desebbe O, Montemont C, Gibot S. Increased aerobic glycolysis through beta2 stimulation is a common mechanism involved in lactate formation during shock states. Shock. 2008;30:417-21.

Lactate metabolism in chronic liver disease. J B Jeppesen, C Mortensen, F Bendtsen, S Møller, Scand J Clin Lab Invest. 73Jeppesen JB, Mortensen C, Bendtsen F, Møller S. Lactate metabolism in chronic liver disease. Scand J Clin Lab Invest. 2013;73:293-9.

Liver and intestinal lactate metabolism in patients with acute hepatic failure undergoing liver transplantation. N D Murphy, S K Kodakat, J A Wendon, Crit Care Med. 29Murphy ND, Kodakat SK, Wendon JA, et al. Liver and intestinal lactate metabolism in patients with acute hepatic failure undergoing liver transplantation. Crit Care Med. 2001;29:2111-8.

Metformin-induced lactic acidosis: a case series. J Silvestre, S Carvalho, V Mendes, 10.1186/1752-1947-1-126J Med Case Rep. 1126Silvestre J, Carvalho S, Mendes V, et al. Metformin-induced lactic acidosis: a case series. J Med Case Rep. 2007;1:126. https://doi.org/10.1186/1752-1947-1-126.

Plasma leakage in dengue hemorrhagic fever. A Srikiatkhachorn, 10.1160/TH09-03-0208Thromb Haemost. 1026Srikiatkhachorn A. Plasma leakage in dengue hemorrhagic fever. Thromb Haemost. 2009;102(6):1042-9. https://doi.org/10.1160/TH09-03-0208.


Care-managers' professional choices: ethical dilemmas and conflicting expectations

Siri Tønnessen
Gøril Ursin
Berit Støre Brinchmann
Care-managers' professional choices: ethical dilemmas and conflicting expectations
10.1186/s12913-017-2578-4R E S E A R C H A R T I C L E Open Access
Background: Care-managers are responsible for the public administration of individual healthcare decisions and decide on the volume and content of community healthcare services given to a population. The purpose of this study was to investigate the conflicting expectations and ethical dilemmas these professionals encounter in their daily work with patients and to discuss the clinical implications of this. Methods: The study had a qualitative design. The data consisted of verbatim transcripts from 12 ethical reflection group meetings held in 2012 at a purchaser unit in a Norwegian city. The participants consist of healthcare professionals such as nurses, occupational therapists, physiotherapists and social workers. The analyses and interpretation were conducted according to a hermeneutic methodology. This study is part of a larger research project. Results: Two main themes emerged through the analyses: 1. Professional autonomy and loyalty, and related subthemes: loyalty to whom/what, overruling of decisions, trust and obligation to report. 2. Boundaries of involvement and subthemes: private or professional, care-manager or provider and accessibility. Conclusions: Underlying values and a model illustrating the dimensions of professional responsibility in the care-manager role are suggested. The study implies that when allocating services, healthcare professionals need to find a balance between responsibility and accountability in their role as care-managers.

Introduction

Care-managers are professionals working in purchaser units in community healthcare. They are responsible for the public administration of individual decisions and deciding on the volume and content of care services allocated to a population [1]. As the need for nursing and healthcare generally exceeds available resources, the allocation of healthcare services often implies ethical dilemmas [2,3]. To support healthcare professionals with difficult moral decisions they encounter in their daily practice, ethics reflection groups have been established in various clinical settings [4]. Even though there is a growing body of research connected to healthcare professionals taking part in ethics reflection groups [4][5][6][7][8], few studies have looked at the ethical dilemmas care-managers discuss as participants in such groups. The aim of this study, therefore, was to gain insights into the ethical dilemmas and conflicting moral expectations care-managers encounter in their daily work as they discuss these dilemmas in ethics reflection groups and to discuss the clinical implications of this.

Background

As in many other Western countries, the Norwegian healthcare system is based on a liberal welfare model funded from the state budget [2]. The overall intention with regard to how public healthcare is organised is to ensure a just allocation and equal access to services as well as transparency in the decision-making process [9]. In the last decades, ideas from New Public Management have influenced the organisation of healthcare services in Norway [1]. In community healthcare, a purchaserprovider service (PPS) commonly aims to divide the responsibilities and duties of the care-manager purchaser and provider of services to clarify the role and power of the care-manager [10]. Hence, care-managers in the purchaser unit are public administrators and allocate services. Meanwhile, the health services to patients are provided by professionals working in a provider unit (called 'providers'). This means that care-managers have a specific responsibility to allocate services fairly, which is often described in terms of a tension between individual good (particularity) and aggregated/collective good (utility/benefit) [11].

The introduction of a PPS is mainly intended to create competition between providers within the community [12] and establish quasi markets in the national health services [13] or, at least, marked reforms [14]. The establishment of PPSs within national health services is aimed at improving cost containment, efficiency and organisational flexibility and responsiveness to the services patients' need [15]. There is little consensus on how caremanager functions should be formulated or organised to achieve these goals [13]. A general assumption, though, is that the care-manager is able to articulate the needs and wishes of the population and make plans for service delivery [15].

Contrary to the stated goals of the PPS organisational framework, research indicates that it actually leads to reduced flexibility regarding allocation time and in responding to the shifting demands of patients [3,16]. In practice, providers and care-managers often cooperate closely to provide help in the best way possible to meet individual patient demands [17,18]. Other studies indicate that care-providers use individual strategies that allow for flexibility and cooperation rather than rigid interpretation of laws and regulations [19][20][21]. Hence, this way of organising healthcare servicesthe introduction of PPSsseems to disturb the providerpatient relationship and has implications for the quality of care and the idea of patients as unique persons who cannot be standardised as (if ) mass products [22].

Research also highlights that care-managers transform politics into daily practice [23] and points to the tension between managing needs and risks, between user autonomy and protection [24], and the idea that 'the rationale for decision making seemed to be more about what was defensible than what was right' ( [25]:1424). Meanwhile, care-managers transform the needs of elderly people into organisation services using their structural and intentional power [26] and adapting to the restrictive approach in relocation decisions rather than considering the needs of the patient [27].

Reviewing the literature on care-managers, several studies have argued that new public management (NPM) and care organisation using a PPS model represent an economic discourse [28][29][30], one that may lead to discrepancies between professionally accountable obligation and professional autonomy that negatively impact upon service quality [31]. Notably, accountability obligations may be more extensive than the degree of autonomy that professionals are permitted to exercise [32]. Furthermore, the care-managers make decisions that affect client outcome and overall system resources [33], while decision-making is influenced by the collective wisdom of the team, the role of family and the messiness of the process [34]. There is a tension and ambiguity that influences care-managers' working conditions, thus contributing to increased stress levels and resultant staffing problems and affecting the quality of service given to older people in particular [35]. A study based on the experiences of care-managers reveals that they believed that relationships with patients have the greatest impact on patient satisfaction, while the support they provide clinicians has the greatest impact on clinician satisfaction [36]. Other literature describes how professional standards are being pushed to their limits [37] and how workrelated stress has increased [38].

As mentioned, NPM implies a shift from an ethical to an economical discourse. This shift does not mean that ethical dilemmas are absent; rather, they are transformed and enacted within the practices of care-managers. This article highlights how care-managers struggle with ethical issues in a purchaser unit. Hence, the purpose of this article is to investigate the ethical challenges and dilemmas that professionals face in the provider office encounter while negotiating between economic, political and care values in their professional role. The role they play is defined as the set of behaviours, rights, norms and obligations regarding how professionals are supposed to act according to their position in the organisation, where role conflicts arise when these expectations are mutually exclusive [39]. Relatedly, in this article, ethical dilemmas involve care-managers having to make decisions but experiencing conflicting expectations as moral values conflict in a specific situation [11]. Moral values are taken to be values that derive from the significant moral intentions people have in upholding such things as human life, freedom, welfare, dignity, autonomy and justice. [11]. Through understanding the ethical dilemmas encountered by care managers, we can better focus on their decision-making practices to meet the diverse needs of patients and caregivers.

Methods

Study setting

This study is part of a larger ethics project initiated by the community healthcare sector in order to strengthen moral awareness among healthcare professionals employed in municipal healthcare services. As part of this project, ethics reflection groups were established in various clinical settings in municipal healthcare services in a city in Norway. A researcher (BSB) was contacted and invited to participate in the ethics reflection groups to conduct the related research [40][41][42].

Ethics reflection groups focus on supporting healthcare professionals in dealing with moral issues [4]. In the groups, the participants reflect on ethical issues from their daily work. The point of departure is concrete situations from the participants' own clinical experience, and the focus of the reflection is on moral values and reasoning [43]. The group dialogue is facilitated by a trained facilitator (usually the head of the department or someone working in the clinical setting), fostering a structured reflection process. The aim of ethical reflection is to promote the participants' moral reasoning and ethical awareness by reflective dialogue, and the objective is to ascertain the best possible solution to the dilemmas encountered [43].

In this article, we present some of the ethical challenges that emerged in the ethics reflection groups with care-managers within a purchaser unit.

Design

The study had a qualitative design, as the objective was to understand how social experience is created and given meaning [44]. The underlying assumptions in this study were that reality can be interpreted in multiple ways and that understanding is dependent on subjective interpretation, the aim of the study and the questions asked [45]. In line with this perspective, data were analysed and interpreted according to a hermeneutic methodology as described in Kvale [45] and Kvale and Brinkmann [46].

Data collection and sample

Data consisted of 320 pages of verbatim transcripts from 12 group meetings with care-managers in the purchaser unit in the Norwegian city mentioned. The participating care-managers were healthcare professionals, such as nurses, occupational therapists, physiotherapists and social workers. The groups met twice monthly from April to December 2012, and each meeting lasted for up to 1½ hours.

A group leader in the purchaser unit led the discussions, which were systematically structured to help steer the issues discussed. Researchers from a university (BSB and GU) participated in the group meetings as observers, but their role changed somewhat over time. Sometimes the group leader challenged the researchers to take part in the conversation, especially if it had slowed down. For example, the leader might ask, 'Do you have anything to say to this?' or 'Now we are a bit stuck, can you help us go further'? Thus, the group leader drew the researchers out of a purely observational role into a more participatory one.

The participants in the reflection group were informed verbally and in writing about the research project, and all participants signed an informational approval form (informed consent). The study was approved by the Norwegian Regional Committee for Medical and Health Research Ethics and registered by the Norwegian Centre for Research Data. All the data were anonymised and handled confidentially.

Data analyses

The analyses were started by ST and BSB reading the transcriptions from each group reflection and noting which ethical issues or moral concerns the caremanagers introduced in the sessions. Hence, we gained a sense of the whole, that is, of the various ethical issues that were most prominent in the 12 group discussions [45,46]. Next, we read the text from each group meeting more thoroughly. While reading, quotations representing ethical challenges or conflicting expectations were underlined and different moral values were noted in the margin. For each group meeting, an overview was made of quotations representing different ethical challenges, conflicting expectations and the values involved. This is in line with Kvale's [45,46] first level of interpretation, aiming at understanding the caremanagers self-understanding of the dilemma they encounter as reflected in each group meeting, through the eyes of the researchers.

In three of the 12 group discussions, the ethical issues concerned the working environment; therefore, since the focus of this study was on care-managers' ethical dilemmas when allocating services in their encounters with patients, we chose to omit these. This left us with the data from nine group meetings. In these meetings, the participants raised dilemmas about how to handle different expectations and how to balance the various values at stake (e.g. autonomy and responsibility) that were relevant for this study.

The next level of interpretation was to take the ethical dilemmasthe conflicting expectations, moral values and their interrelatednessto a higher level of abstraction. This entailed what Kvale calls 'common sense' and 'theoretical interpretation' [45,46]; it involves a variety of interpretations, going back and forth and trying to comprehend the main picture of the data while holding true to the transcribed data from the reflection groups [44,47]. Thus, we read the texts from the nine group meetings carefully again, interrogating the dilemmas, expectations and values in terms of the purpose of the study and ethics and asking ourselves 'What is this really about?' In this way, we were eventually able to identify subthemes and themes representing different dilemmas professionals in the purchaser unit seemed to encounter in their care-manager role. In five of the group discussions, the (two) subthemes that emerged related to the theme of autonomy and loyalty, and in the other four, the subtheme related to boundaries of involvement. Table 1 presents an overview of the two themes and related subthemes that emerged from the nine group discussions, which we elaborate on in the findings (below).

Strengths and weaknesses of the study

The data in this study was not originally intended as material for research purposes but was derived from ethics reflection groups initiated from clinical practice. This may be considered a strength, therefore, since the data collection was not steered by the researchers, so the participants were able to freely express the issues they wanted to discuss. The reflections were, however, facilitated by a group leader, which might have limited the participants' openness and honesty in the discussion. Another weakness may be that the researchers became involved in the discussions and were expected to contribute with their ethical competence when the conversation 'ran dry' , which may have influenced the material. Another possible weakness was that the researchers were not involved in posing in-depth questions, which could have enriched the material. At the same time, this can also be regarded as a strength because the informants were not interrupted and so could talk freely about what was important to them.

Results

Professional autonomy and loyalty

The theme of professional autonomy and loyalty concerns the challenges faced by informants in making independent, sound and diligent decisions based on their professional judgement. The first two subthemes identified relate to making administrative decisions; who/ what to be loyal to when allocating services, the patient or limited resources, and confusion when decisions made are overruled. The third subtheme relates to the balance between trust and obligation to report.

Loyal -To whom/what?

In the group meetings, issues about who or what to be loyal to when allocating services was a frequently discussed theme. The participants described how they are torn between the patient's need for nursing care and the pressure to allocate at a minimum level due to limited resources. As one group member said:

As care-manager, I struggle to meet expectations from involved parties. We are under great pressure due to limited resources; we grant too many administrative decisions and too much time. They expect us to spare Home Healthcare (HHC). It's a compound pressure. If there were enough nursing homes, patients would have been placed there. Instead, we increase the time granted in HHC services, but we know that HHC doesn't have these resources. We are squeezed; it's an enormous pressure.

The participants said that they are obliged to base administrative decisions on the patients' needs, but the pressure for minimum usage of recourses makes them unsure about what to measure, 'the patients' needs for services or the capacity in HHC to provide these services'. Either way, they describe challenges. If they grant services according to patients' needs, next of kin call and make claims because the HHC does not have the capacity to provide services according to the decision. As one participant said:

Then, next of kin call and say, 'She was promised this and that care, but this is not what she's getting.' I feel like we're 'playing an office' as to what our responsibility is. All the time, you're stuck between a rock and a hard place. How are we supposed to be taken seriously? This is a major problem.

Participants described how the construction of services is complex at several levels. In order for the healthcare services to be considered reliable among patients and their families, they have to match with needs, grant services and performed services. Sometimes professionals at the provider office have to grant services according to the capacity in HHC rather than in line with their professional judgments. This is particularly problematic, as they have to defend a decision that is not legitimate. As one participant said: Furthermore, they have to prioritise between patients' needs and fiscal constraints, which they describe as political, rather than executive, which makes them question the connections between responsibility, loyalty and transparency within the system:

What is loyalty without responsibility? And what are we responsible for? A sound and diligent service and to notify if the service is inadequate and insufficient.

[…] One needs to fix what isn't working. Isn't that a part of the concept of responsibility? […] Responsibility and transparency aren't contradictions. What I experience now is the responsibility is to shut up and keep your cards close to your chest, and you are irresponsible if you open up. I think this is totally wrong.

Decisions overruled

The participants also described how politicians and chief municipal executives sometimes give in after pressure from next of kin and impose changes to administrative decisions on care-managers. Hence, their professional judgement in the role of care-manager is overruled. One participant said:

Next of kin sent emails here, there and everywhere, all the way to the top. […] In the end, the whole municipality was involved.

[…] The mayor didn't want bad publicity about the case, so he came and contacted the manager of the purchaser unit and our administrative decision was overruled.

In this situation, the participants faced compound pressure from the mayor and deputy mayor, and experienced their professional judgement as less important than following political instructions. This was described as confusing, causing them to question their own judgement and responsibility. They also wondered if politicians can rightfully overrule them; pertinently, they felt, their decisions were sound and diligent professional judgements, and legitimate changes in administrative decisions should only be made when based on changes in the patient's situation, not due to pressure from next of kin or politicians.

At the same time, participants explained how similar situations had been resolved differently by the former mayor. This indicates that the political establishment does indeed have an impact on the work care-managers do in the PPS. The care-managers said that politicians and administrative superiors should respect their professional judgement.

Trust and obligation to notify

Participants reported that a part of their responsibility is to allocate services to people in vulnerable situations, such as young parents with drug problems. In some situations, they gain insights into people's private lives and receive in-depth information about difficult life conditions. Hence, care-managers struggle to balance client confidentiality and the obligation to notify, for example, in order to protect children from unhealthy living conditions, even though these patients tend to 'pour their hearts out' to them. Moreover, care-managers at the purchaser units gain the trust of their clients, which creates further issues:

Our clients say, 'I thought you were here to help me, but you didn't. When people ask for help, and then you experience that what you say is brought forward [to the authorities], it feels like betrayal, like going behind our backs. ' We do say that, according to the law, we have to put forward information, but the law is one thing and how it feels is another.

Whether or not to diffuse information is a professional judgment, one that is important in terms of the perception of a trusting relationship; decisions on matters of this sort can be a time-consuming activity.

Boundaries of involvement

The participants often discussed ethical challenges concerning the boundaries of involvement and the difficulty of setting limits for themselves in their roles as caremanagers. The subthemes here were balancing the private and professional, being a care-manager or provider, and being accessible.

Private or professional?

In one group meeting, the discussion revolved around how the participants set limits in their private lives regarding their professional roles as care-managers. This challenge presents itself when patients or next of kin want to be friends on social media, such as Facebook, or when they call the care-manager at home. One participant said:

If I am personable and pleasant in the encounter with next of kin, they misunderstand and send friend requests on Facebook.

[…] Facebook is private, but it's difficult to ignore friend requests. Home is private, and I don't want to drag work home.

The care-managers said that it is difficult to ignore friend requests, even though they do not have a relationship based on friendship as such. One participant said that she accepted a patient as friend on Facebook, and later she was asked on a date. Several participants suggested that official guidelines setting boundaries for relationships between professionals and patients might be helpful. However, they also said they understood that sometimes the patient and next of kin can have a desperate need to contact them.

Similarly, the care-managers explained that it is difficult to be professional if they become too emotionally involved. Hence, they try to avoid being care-managers for neighbours, friends or other acquaintances. As one group member said, 'If I am in doubt, I always ask the patient if it's ok for them that I'm managing their case'.

Care-manager or provider?

In some situations, care-managers find it difficult to find the right balance between being a care-manager and being a provider. This dilemma arises mainly when they enter the patient's home to map care needs. As one group member said:

Sometimes it's difficult just to stick to the caremanager role. It's is unnatural to distinguish administrative decisions from provision of care. It's an artificial distinction. Caring is about trust, how to reach out to patients and the patient's request and need for care in the situation here and now.

In one case, the home of a patient was extremely messy and dirty, but the patient did not want any help. The care-manager was a trained nurse, her experience guided her to exceed the expectations in her role as care-manager and she became a provider. Moreover, she claimed, practical work was necessary for patients to accept help from the healthcare system: I've taken out garbage and cleaned the apartment and given the patient a bath and a manicure to gain entry so they can accept help from HHC. It is easier [for them] to trust the service if you make an effort and show them you care.

Participants also described how the PPS model is too detailed to be useful because many providers only relate to the administrative decisions in a situation, so flexibility in the encounter with the patient vanishes. The administrative decisions limit the possibility of providing sound and diligent services in the real life context. As one care-manager said:

We've disfranchised judgement and flexibility from the provider organisation. The PPS organisation fails as it's steered in detail, so the providers can't think for themselves. If the administrative decision doesn't say they should dust, they don't dust, but if it says dust, they might not take out the garbage.

Accessibility

Another dilemma concerns accessibility. As one group member said, it is difficult to ensure easy access to services and at the same time run the purchaser office efficiently:

We need to introduce some boundaries to limit access to the care-managers, but at the same time secure accessibility for those who need necessary healthcare services from the purchaser office.

The care-managers discussed using information technology (IT) to reduce the workload, but they worried that this would limit access for vulnerable patients:

When you're sick, you're vulnerable, and especially the elderly might have problems using modern technology, and most of our patients are elderly. Access to the purchaser unit is relatively easy today; people only have to make a call or send an email.

The participants claim that introducing modern technology might be efficient for them in the purchaser unit; however, it might be time consuming and a disadvantage for many elderly patients.

Discussion

The main findings in this study, as presented in Table 1, concern how the care-managers struggle to find the balance between professional autonomy and loyalty and how they deal with setting boundaries of involvement in their professional roles. This might imply that they struggle to find the balance between particularity and utility/benefit in the situation and find it difficult to come to terms with and/or are uncertain about exactly what their responsibilities are in their role as caremanagers. In respect of the informants' efforts to balance utility/benefit and particularity, the findings illustrate that they also struggle to balance distance and closeness in their encounters with patients and next of kin. This can be interpreted as role confusion at both an individual and organisational level, as they meet contradicting expectations when values conflict. In Table 2, we have tried to capture the values in conflict related to the individual and organisational levels based on the themes and subthemes.

According to PPS, a primary expectation in the caremanager role is that resources be allocated fairly [15]. However, resources are limited, which implies a focus on utility and benefit [11]; at the same time, as patients, at least in Norway, they can legally claim services on an individual basis [48]. This dilemma between utility/benefit and particularity emerges as the consequence of an inherited dilemma derived from policymakers who decide what patients can claim through legislation, allocation of resources and the chosen organisation of healthcare services, which is expressed in municipalities as a capacity problem [3]. This dilemma is only expected to increase as medical possibilities to offer treatment continue to rise and more people need healthcare services as the population ages [49], medicalisation increases [50] and resources remain limited. Thus, it is argued that policymakers and politicians need to make changes in legislation and how healthcare is organised specifically to meet these challenges [3,51,52].

In the meantime, it is of the upmost importance that care-managers facing these dilemmas in their daily work gain insights that might help them make the best decisions possible. Our experience as nurse educators and researchers is that most nursing students start their education with a genuine desire to help and do good for people in need. These good intentions are elaborated further during their education as the fundamentals of nursing care, namely, to promote health, prevent illness, restore health and alleviate suffering in such a way that patients are cared for in a respectful, sound and diligent manner [53].

However, research indicates that students and newly graduated nurses are surprised by the discrepancy between the ideals gained through nursing education and the task orientation of clinical practice [54]. Newly graduated nurses say they want to do a good job and that they will quit their jobs if they have to compromise their professional integrity and feel they are not able to do good for the patient [55]. Studies indicate, however, that nurses and other healthcare professionals experience moral frustration and distress; that is, they know what the right thing to do is but are prohibited by organisational constraints, such as staff shortages, to act accordingly [35,56,57].

Moral distress has been widely discussed in the nursing literature [58,59]. In the classic article by Corley [57], this is mainly discussed at an individual level while emphasising the need for further development on the organisational/institutional level as moral distress is caused by institutional constraints. Hence, we found it interesting to try to capture how these two levels might be connected as related to the professional responsibility and sense of conflicting demands and unmet needs described in the findings in our study.

Dimensions of professional responsibility

In our effort to interpret and understand the findings illuminated in this study, we present a model for analytical purposes that suggests the connections between various dimensions of professional responsibility and the caremanager role (see Fig. 1).

Here, we make a distinction between the individual and organisational levels, as represented by the two horizontal arrows. At the individual level, care-managers balance between closeness and distance, while at the organisational level, they weigh up issues related to particularity as against utility/benefit. In real life, however, these two levels very much influence each other, as shown by the vertical arrow. According to the informants in our study, the organisational level influences the individual level more than the reverse, hence the different sizes on the arrows ends. In the theoretical discourse, ethical issues, such as closeness and distance as related to professional responsibility and particularity and utility/benefit as related to justice, are often presented as dichotomies. We have chosen to present these issues in the model rather as continua, however, and not as either/or, as a continuum seems more in line with the experiences of the informants when describing their clinical practice. Hence, in the care-managers experience struggles in trying to find a balancethe middle ground between the extremes on the continuum when making their professional judgments [34,37]. This is particularly the case where organisational limits are prominent.

On the left side, between the horizontal arrows, we have placed the concept of responsibility, and on the right side, accountability. Responsibility and accountability are two dimensions emphasising different values and expectations about what care-managers are responsible for. As they move along the continuum, they go towards particularity and closeness, values related to the traditional concept of responsibility as professional conduct  [31,60,61]. In nursing, responsibility as a concept is closely linked to ethics and the expectations that the nurse voluntarily involves their capacity to act in a morally responsible way for the best interest of the patient [53,62]. Accountability is related to the practice of accounting and associated with individualism, competition, control and efficiency [60,61]; hence, we see the move towards distance and utility/benefit in the illustration. As public services draw heavily on ideas from NPM, such as PPS, it is argued that professionals need to bring responsibility 'back in, ' since accountability is something of a contradiction in terms in professional practice [60,61]. For the care-managers, it is evident that this balance is particularly difficult insofar as they are supposed to make professional judgements that rest on the values and expectations of their professional obligations as, for example, nurses, and the mandate and authority they hold in their managerial role as care-managers in the organisation.

These findings illustrate how difficult it is to merge the different expectations in the care-manager role. It seems, indeed, that care-managers rest their professional judgments at different places on the continuum depending on which values they emphasise in any one encounter with patients and how much pressure there is from the values and expectations representing the organisational level. Further, the continuum illustrates a main point, that both the patients and professionals are unique individuals who may place themselves at different positions on the continuum. Hence, it is important in a professional team that one can fill the continuum with different people to meet the patients' individual needs. However, the extremes involve pitfalls at both levels.

Implications for practice

The implications for practice at both individual and organisational levels may be understood as involving discussion of this continuum as a tool to develop and understand the care-manager role more thoroughly. At the individual level, it is especially important to consider the balance between closeness and distance in order to remain professional, that is, to keep some distance to maintain an overview while at the same time being sensitive to the patients' individual needs. The findings indicate two pitfalls in this respect: being too distant and being too private. The need for closeness and distance will vary as patients' and their needs differ, but the question of how close or how distant one can or should be as a professional while meeting the patients individual needs in a sound and diligent matter is the balance that care-managers need to find. Therefore, it is important that they do not lose their good intentions, which is decisive for moral sensitivity in encounters with patients [63]. However, the findings indicate that they need to protect themselves from becoming too involved; for example, the time when they are not at work is private time. To uphold a level of private autonomy-to find, that is, limits (boundaries) that help them distinguish between the different roles-seems to be important.

At an organisational level, there is a need to discuss the balance between particularity and utility/benefit, especially at the policy level, as it is the care-manager role to make decisions about budgets and organisational structure. It is evident that PPS not is in line with professional values, and the care-managers are prominent examples of how difficult it is to merge conflicting expectations stemming from a combination of two ideologies in one role. There is also, as indicated, a need for clarification of the care-managers' responsibility when decisions are overruled. This is an infringement of professional autonomy, and the legitimacy of such interference ought to be discussed according to the relevant legislation.

Conclusions

In this article, we have investigated how autonomy and loyalty and the boundaries of involvement are themes representing conflicting expectations in the care-manager role. The findings indicate that care-managers balance the opposing values of closeness and distance, on the one hand, and particularity and utility/benefit, on the other, and that these represent pitfalls at the extremes of two continua, the individual and organisational levels. Further, we have presented a model suggesting connections between these different dimensions of professional responsibility in the care-manager role, emphasising the distinction between the concepts of responsibility and accountability and discussing related implications for practice.

As far as we know, few researchers have captured the dimensions of professional responsibility as people in the care-manager role balance between clinical and managerial obligations. Hence, the findings are both relevant and important for care-managers as a point of departure for reflection and decision-making as well as for ethicists, clinicians and policymakers.

Fig. 1
1Dimensions of professional responsibility

Table 1 Results
1Theme
Subthemes
Conflicting expectations

Professional autonomy and loyalty
1. Loyal -to whom?
Patients`needs versus HHC capacity

2. Decisions overruled
Autonomy in professional decision-making versus political intrusion

3. Trust and obligation to notify
Client confidentiality versus obligation to notify

Boundaries of involvement
1. Private or professional
Patients`needs versus needs to be a private person in leisure time

2. Purchaser or provider
Responsibility versus accountability in the role as care-managers

3. Accessibility
Access for patients`-versus workload in the purchaser unit

Table 2
2Themes, subthemes and conflicting values Subthemes Loyalto whom? Decisions overruled Trust and obligation to notify Private or professional Care-manager or provider Accessibility Themes Professional autonomy and loyalty Boundaries of involvement Conflicting values Institutional level: Particularity -Utility/Benefit Individual level: Closeness -Distance
AcknowledgementsNot applicable.FundingNot applicable.Availability of data and materialsThe data that support the findings of this study are not publicly available because they contain information that could compromise research participants' privacy/consent; the data are, however, available from the authors upon reasonable request and with the permission of involved parties.Authors' contributions BSB and GU acquired the data; analyses and interpretations of the data were made by ST and BSB; ST wrote the main draft of the article and prepared it for submission; all authors made substantial contributions, revised the work critically and approved the final version.Ethics approval and consent to participate This study was approved by the Norwegian Regional Committee and registered by the Norwegian Centre for Research Data. All the participants consented to participate (informed consent).Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.• We accept pre-submission inquiries • Our selector tool helps you to find the most relevant journal Submit your next manuscript to BioMed Central and we will help you at every step:
Changing governance, changing needs interpretations. Implications for universalism. M Vabø, Int J Soc Social Pol. 313/4Vabø M. Changing governance, changing needs interpretations. Implications for universalism. Int J Soc Social Pol. 2014;31(3/4):197-208.

Looking back at the welfare state. Politics, govermental management and services. H Vike, J Debesay, H Haukelien, Oslo: GyldendalVike H, Debesay J, Haukelien H, editors. Looking back at the welfare state. Politics, govermental management and services [Tilbakeblikk på velferdsstaten. Politikk, styring og tjenester]. Oslo: Gyldendal; 2016.

The challenge to provide sound and diligent care -A qualitative study of nurses' decisions about prioritization and patients' experiences of the home nursing service. Oslo: Doctoral diss. S Tønnessen, University of OsloTønnessen S. The challenge to provide sound and diligent care -A qualitative study of nurses' decisions about prioritization and patients' experiences of the home nursing service. Oslo: Doctoral diss, University of Oslo; 2011.

Ethical challenges and how to develop ethics support in primary health care. L Lillemoen, R Pedersen, Nurs Ethics. 201Lillemoen L, Pedersen R. Ethical challenges and how to develop ethics support in primary health care. Nurs Ethics. 2013;20(1):96-108.

The discovery of deliberation. From ambiguity to appreciation through the learning process of doing moral case deliberation in Dutch elderly care. S Van Der Dam, Jmga Schols, Tjm Kardol, B C Molewijk, Widdershoven, Gam, T A Abma, Soc Sci Med. 83Van Der Dam S, Schols JMGA, Kardol TJM, Molewijk BC. Widdershoven, GaM, Abma TA. The discovery of deliberation. From ambiguity to appreciation through the learning process of doing moral case deliberation in Dutch elderly care. Soc Sci Med. 2013;83:125-32.

Implicit and explicit clinical ethics support in The Netherlands: a mixed methods overview study. L Dauwerse, F Weidema, T Abma, B Molewijk, G Widdershoven, HEC Forum. 26Dauwerse L, Weidema F, Abma T, Molewijk B, Widdershoven G. Implicit and explicit clinical ethics support in The Netherlands: a mixed methods overview study. HEC Forum. 2014;26:95-109.

Outcomes of moral case deliberation -the development of an evaluation instrument for clinical ethics support (the euro-MCD). M Svantesson, J Karlsson, P Boitte, J Schildman, L Dauwerse, G Widdershoven, BMC Med Ethics. 1530Svantesson M, Karlsson J, Boitte P, Schildman J, Dauwerse L, Widdershoven G, et al. Outcomes of moral case deliberation -the development of an evaluation instrument for clinical ethics support (the euro-MCD). BMC Med Ethics. 2014;15:30. http://www.biomedcentral.com/1472-6939/15/30. Accessed 15 Sept 2016.

Evaluation of ethical reflections in community healthcare: A mixed-methods study. U Söderhamn, H T Kjostvedt, A Slettebo, Nurs Ethics. Söderhamn U, Kjostvedt HT, Slettebo A. Evaluation of ethical reflections in community healthcare: A mixed-methods study. Nurs Ethics. 2014. http://nej.sagepub.com/content/early/2014/04/01/0969733014524762. Accessed 15 Sept 2016.

) to the Storting. The Coordination Reform. Proper treatment -at the right place at right time. Norwegian White paper. Oslo: Norwegian Ministery of Health and Care Services. Norwegian Ministery, Care Health, Services, no. 47ReportNorwegian Ministery of Health and Care Services. Report no. 47 (2008-2009) to the Storting. The Coordination Reform. Proper treatment -at the right place at right time. Norwegian White paper. Oslo: Norwegian Ministery of Health and Care Services.

Organizational theory in public sector: instruments, culture, myth. [Organisasjonsteori for offentlig sektor: instrument, kultur, myte. T Christensen, P Laegreid, P G Roness, K A Røvik, Oslo: UniversitetsforlChristensen T, Laegreid P, Roness PG, Røvik KA. Organizational theory in public sector: instruments, culture, myth. [Organisasjonsteori for offentlig sektor: instrument, kultur, myte]. Oslo: Universitetsforl; 2009.

Ethics in nursing practice. A guide to ethical decision making. S T Fry, M-J Johnstone, Oxford: ICN, BlackwellFry ST, Johnstone M-J. Ethics in nursing practice. A guide to ethical decision making. Oxford: ICN, Blackwell; 2008.

Purchaser-provider splits in health carethe case of Finland. L-K Tynkkynen, I Keskimäki, J Lehto, Health Pol. 1113Tynkkynen L-K, Keskimäki I, Lehto J. Purchaser-provider splits in health care - the case of Finland. Health Pol. 2013;111(3):221-5.

From quasi-market to market in the national health service in England: what does this mean for the purchasing of health services?. R Lewis, J Smith, A Harrison, J Health Svc R & Pol. 141Lewis R, Smith J, Harrison A. From quasi-market to market in the national health service in England: what does this mean for the purchasing of health services? J Health Svc R & Pol. 2009;14(1):44-51.

Continuity through change: the rhetoric and reality of health reform in New Zealand. T Ashton, N Mays, N Devlin, Soc Sci Med. 612Ashton T, Mays N, Devlin N. Continuity through change: the rhetoric and reality of health reform in New Zealand. Soc Sci Med. 2005;61(2): 253-62.

Modernising public services: trends, ideas and practice [Modernisering av offentlig sektor: trender. T Busch, K Klaudi Klausen, J O Vanebo, ideer og praksiserBusch T, Klaudi Klausen K, Vanebo JO. Modernising public services: trends, ideas and practice [Modernisering av offentlig sektor: trender, ideer og praksiser].

Oslo: Universitetsforl. Oslo: Universitetsforl; 2011.

Organazing welfare -home healthcare in an idelogical time of change [Organisering for velferd-Hjemmetjenestene i en styringsideologisk brytningstid. M Vabø, 22NOVA ReportVabø M. Organazing welfare -home healthcare in an idelogical time of change [Organisering for velferd-Hjemmetjenestene i en styringsideologisk brytningstid]. NOVA Report; 2007. p. 22.

Public adminsitration forms in caring services -Mapping of municipalities using purchaser provider organizations [Forvaltningsreformer i pleie og omsorgstjenesten-en kartlegging av kommuner og bydeler med bestiller utførermodell. P Gammelsaether, Ressurssenter for omstilling i kommunene. Stjørdal; ROGammelsaether P. Public adminsitration forms in caring services -Mapping of municipalities using purchaser provider organizations [Forvaltningsreformer i pleie og omsorgstjenesten-en kartlegging av kommuner og bydeler med bestiller utførermodell]. Stjørdal: Ressurssenter for omstilling i kommunene (RO): 2006.

Home care in transition: the complex dynamic of competing drivers of change in Norway. M Vabø, J Health Org Mgt. 233346Vabø M. Home care in transition: the complex dynamic of competing drivers of change in Norway. J Health Org Mgt. 2009;23(3):346.

Welfarepolicy at the end of the journey. H Vike, H Haukelien, Norsk Sykepleierforbund. Velferdspolitikk ved reisens sluttVike H, Haukelien H. Welfarepolicy at the end of the journey [Velferdspolitikk ved reisens slutt]. Norsk Sykepleierforbund: Oslo; 2007.

Undermining the rules in home care services for the elderly in Norway: flexibility and cooperation. S Wollscheid, J Eriksen, J Hallvik, Scand J Caring Sci. 272Wollscheid S, Eriksen J, Hallvik J. Undermining the rules in home care services for the elderly in Norway: flexibility and cooperation. Scand J Caring Sci. 2013;27(2):414-21.

Coordination between health care professionals in community services -a qualitative study [Samhandling mellom aktører i kommunale helse-og omsorgstjenester-en kvalitativ studie av hjemmesykepleieres erfaringer. Bll Kassah, S Tønnessen, Kassah BLL, Tønnessen S. Coordination between health care professionals in community services -a qualitative study [Samhandling mellom aktører i kommunale helse-og omsorgstjenester-en kvalitativ studie av hjemmesykepleieres erfaringer].

. J Norwegian, Of Welfare, Research, 19Tidsskrift for velferdsforskningNorwegian J of Welfare Research [Tidsskrift for velferdsforskning]. 2016;19(4):342-58.

New public management: the evidence-based worst practice?. J Siltala, Admin Soc45Siltala J. New public management: the evidence-based worst practice? Admin Soc. 2013;45(4):468-93.

Professions and values in transformation. K Beedholm, K Frederiksen, Professioner og vaerdier i bevaegelse: Når målet er det aktive patientskabBeedholm K, Frederiksen K. Professions and values in transformation [Professioner og vaerdier i bevaegelse: Når målet er det aktive patientskab].

. Michael, 12Michael. 2015;12(2):153-66.

Social work in the context of adult social care in England and the resultant implications for social work education. M Lymbery, K Postle, Brit J Soc Wrk. 045Lymbery M, Postle K. Social work in the context of adult social care in England and the resultant implications for social work education. Brit J Soc Wrk. 2010;bcq045:2502-22.

Risk management paradigms in health and social services for professional decision making on the long-term care of older people. B J Taylor, Taylor BJ. Risk management paradigms in health and social services for professional decision making on the long-term care of older people.

. Brit J Soc Wrk. 368Brit J Soc Wrk. 2006;36(8):1411-29.

The discretion and power of street-level bureaucrats: an example from Swedish municipal eldercare [Frontlinjebyråkraternas handlingsutrymme och makt: ett exempel från svensk kommunal äldreomsorg. A Dunér, M Nordström, Dunér A, Nordström M. The discretion and power of street-level bureaucrats: an example from Swedish municipal eldercare [Frontlinjebyråkraternas handlingsutrymme och makt: ett exempel från svensk kommunal äldreomsorg].

. Euro J Soc Wrk. 94Euro J Soc Wrk. 2006;9(4):425-44.

How the care-managers handle the process when older people consider relocation to a residential home. M Söderberg, A Ståhl, E U Melin, Brit J Soc Wrk. 458Söderberg M, Ståhl A, Melin EU. How the care-managers handle the process when older people consider relocation to a residential home. Brit J Soc Wrk. 2015;45(8):2423-40.

The ethics and politics of home care. K Bjornsdottir, Int J Nurs Stud. 465Bjornsdottir K. The ethics and politics of home care. Int J Nurs Stud. 2009;46(5):732-9.

Impoverishment of practice: analysis of effects of economic discourses in home care case management practice. C Ceci, Nurs Leadership (Tor Ont). 191Ceci C. Impoverishment of practice: analysis of effects of economic discourses in home care case management practice. Nurs Leadership (Tor Ont). 2006;19(1):56-68.

The neoliberal turn and the marketization of care: the transformation of eldercare in Sweden. K Andersson, E Kvist, Euro J Wom Stud. 223Andersson K, Kvist E. The neoliberal turn and the marketization of care: the transformation of eldercare in Sweden. Euro J Wom Stud. 2015;22(3):274-87.

Effects of New Zealand's health reengineering on nursing and patient outcomes. B Mccloskey, D K Diers, Med Care. 43McCloskey B, Diers DK. Effects of New Zealand's health reengineering on nursing and patient outcomes. Med Care. 2005;43:1140-6.

Health professionals' enactment of their accountability obligations: doing the best they can. A R Freeman, C L Mcwilliam, J R Mackinnon, S Deluca, S G Rappolt, Soc Sci Med. 697Freeman AR, McWilliam CL, MacKinnon JR, DeLuca S, Rappolt SG. Health professionals' enactment of their accountability obligations: doing the best they can. Soc Sci Med. 2009;69(7):1063-71.

How do case managers spend time on their functions and activities? BMC. E C You, D Dunt, C Doyle, Health Serv Res. 161112You EC, Dunt D, Doyle C. How do case managers spend time on their functions and activities? BMC Health Serv Res. 2016;16(1):112.

Factors that influence case managers' resource allocation decisions in pediatric home care: an ethnographic study. D Fraser, C Estabrooks, Allen M Strang, V , Int J Nurs Stud. 463Fraser D, Estabrooks C, Allen M. Strang V. Factors that influence case managers' resource allocation decisions in pediatric home care: an ethnographic study. Int J Nurs Stud 2009:46(3):337-349.

Working 'between the idea and the reality': ambiguities and tensions in care-managers' work. K Postle, 10.1093/bjsw/32.3.335Br J Soc Work. 323Postle K. Working 'between the idea and the reality': ambiguities and tensions in care-managers' work. Br J Soc Work. 2002;32(3):335-51. doi:10.1093/bjsw/32.3.335.

Perceived impact of care-managers' work on patient and clinician outcomes. P Carayon, A S Hundt, P Hoonakker, B Kianfar S Alyousef, D Salek, 10.5750/ejpch.v3i2.903Eur J Pers Cent Healthc. 32Carayon P, Hundt AS, Hoonakker P, Kianfar S Alyousef B, Salek D, et al. Perceived impact of care-managers' work on patient and clinician outcomes. Eur J Pers Cent Healthc 2015;3(2):158-167. https://doi.org/10. 5750/ejpch.v3i2.903

The exhausting dilemmas faced by home-care service providers when enhancing participation among older adults receiving home care. K Vik, A H Eide, 10.1111/j.1471-6712.2011.00960.xScand J Caring Sci. 26Vik K, Eide AH. The exhausting dilemmas faced by home-care service providers when enhancing participation among older adults receiving home care. Scand J Caring Sci. 2012;26:528-36. doi:10.1111/j.1471-6712. 2011.00960.x.

Older care research in the Nordic countries -a summary. M Szebehely, Ed, Nordic Council of Ministers: OsloSzebehely M. Ed. Older care research in the Nordic countries -a summary. [Äldreomsorgsforskning i Norden: en kunskapsöversikt]. Nordic Council of Ministers: Oslo; 2005.

Exploring social psychology. D Myers, McGraw-HillNew YorkMyers D. Exploring social psychology. New York: McGraw-Hill; 2012.

Ethical challenges related to next of kin. Nursing staff's perspective. S Tønnessen, B-A Solvoll, B S Brinchmann, Nurs Ethics. 237Tønnessen S, Solvoll B-A, Brinchmann BS. Ethical challenges related to next of kin. Nursing staff's perspective. Nurs Ethics. 2016;23(7):804-14.

Ethical challenges in everyday work with adults with learning disabilities. B-A Solvoll, E Hall, B S Brinchmann, Nurs Ethics. 224Solvoll B-A, Hall E, Brinchmann BS. Ethical challenges in everyday work with adults with learning disabilities. Nurs Ethics. 2015;22(4):417-27.

Experiences of moral challenges in everyday nursing practice; in light of healthcare professionals selfunderstanding. M Kristoffersen, F Friberg, B S Brinchmann, Nordic J Nurs Res. 364Kristoffersen M, Friberg F, Brinchmann BS. Experiences of moral challenges in everyday nursing practice; in light of healthcare professionals self- understanding. Nordic J Nurs Res. 2016;36(4):177-83.

Ethics reflection groups: just a 'time out' or a learning arena? [Refleksjonsgrupper i etikk: 'Pusterom' eller laeringsarena?] Etikk i praksis. S Tønnessen, L Lillemoen, E Gjerberg, 10.5324/eip.v10i1.1844Nordic J Appl Ethics. 1Tønnessen S, Lillemoen L, Gjerberg E. Ethics reflection groups: just a 'time out' or a learning arena? [Refleksjonsgrupper i etikk: 'Pusterom' eller laeringsarena?] Etikk i praksis. Nordic J Appl Ethics. 2016;1:75-90. https://doi.org/10.5324/eip.v10i1.1844

The sage handbook of qualitative research. N K Denzin, Y S Lincoln, Los Angeles: SageDenzin NK, Lincoln YS. The sage handbook of qualitative research. Los Angeles: Sage; 2011.

Interviews: an introduction to qualitative research interviewing. S Kvale, Thousand Oaks, CA: SageKvale S. Interviews: an introduction to qualitative research interviewing. Thousand Oaks, CA: Sage; 1996.

Learning the craft of qualitative research interviewing. S Kvale, S Brinckmann, Interviews, Los Angeles: SageKvale S, Brinckmann S. Interviews. Learning the craft of qualitative research interviewing. Los Angeles: Sage; 2009.

Qualitative data analyses: a methods sourcebook. M B Miles, A M Huberman, J Saldaña, Los Angeles: SageMiles MB, Huberman AM, Saldaña J. Qualitative data analyses: a methods sourcebook. Los Angeles: Sage; 2014.

Act 2011-06-24-30. Act relating to municipal health and care services. Norwegian municipal health and care services actNorwegian municipal health and care services act 2011. Act 2011-06-24-30. Act relating to municipal health and care services. http://app.uio.no/ub/ ujur/oversatte-lover/data/lov-20110624-030-eng.pdf. Accessed 5 July 2017.

Help wanted? Providing and paying for long-term care. OECD health policy studies. F Colombo, A Llena-Nozal, J Mercier, F Tjadens, OECD PublishingParisColombo F, Llena-Nozal A, Mercier J, Tjadens F. Help wanted? Providing and paying for long-term care. OECD health policy studies. Paris: OECD Publishing; 2011.

Medicalisation, expressions, forces and traditions [Medikaliseringens uttrykk, drivkrefter og tradisjoner. O Lian, Gyldendal Akademisk. Tjora a.(editor). Health sociology [Helsesosiologi. Analyse av helse. sykdom og behandlingLian O. Medicalisation, expressions, forces and traditions [Medikaliseringens uttrykk, drivkrefter og tradisjoner]. In: Tjora a. (editor). Health sociology [Helsesosiologi. Analyse av helse, sykdom og behandling]. Gyldendal Akademisk: Oslo; 2012.

The modernization of power in Norwegian home care services. K Christensen, Dahl HM & Rask Eriksen TAldershot: AshgateChristensen K. The modernization of power in Norwegian home care services. In: Dahl HM & Rask Eriksen T (editors.). Dilemmas of care in the Nordic welfare state. Aldershot: Ashgate; 2005.

Value-based management of public professionals. T Busch, Fagbokforlaget. Verdibasert ledelse i offentlige profesjonerBusch T. Value-based management of public professionals [Verdibasert ledelse i offentlige profesjoner]. Fagbokforlaget: Bergen; 2012.

International Council of Nurses (ICN). Geneva: ICNCodes of ethics for nursesInternational Council of Nurses (ICN). Codes of ethics for nurses. Geneva: ICN; 2006.

Responsible but unprepared: experiences of newly educated nurses in hospital care. L H Odland, T Sneltvedt, V Sørlie, Nurs Ed in Practice. 145Odland LH, Sneltvedt T, Sørlie V. Responsible but unprepared: experiences of newly educated nurses in hospital care. Nurs Ed in Practice. 2014;14(5):538-43.

Valuing professional pride and compensating for lack of experience. Home Health Care Mgt Pract. T Sneltvedt, V Sørlie, 24Sneltvedt T, Sørlie V. Valuing professional pride and compensating for lack of experience. Home Health Care Mgt Pract. 2012;24(1):13-20.

Nursing practice. The ethical issues. A Jameton, Prentice-HallEnglewood CliffsJameton A. Nursing practice. The ethical issues. Englewood Cliffs: Prentice- Hall; 1984.

Nurse moral distress: a proposed theory and research agenda. M Corley, Nurs Ethics. 96Corley M. Nurse moral distress: a proposed theory and research agenda. Nurs Ethics. 2002;9(6):636-50.

Living with conflicts -ethical dilemmas and moral distress in the health care system. S Kalvemark, A T Hoglund, M G Hansson, P Westerholm, B Arnetz, Soc Sci Med. 586Kalvemark S, Hoglund AT, Hansson MG, Westerholm P, Arnetz B. (2004). Living with conflicts -ethical dilemmas and moral distress in the health care system. Soc Sci Med. 2004;58(6):1075-84.

Moral distress reconsidered. J Mccarthy, R Deady, Nurs Ethics. 152McCarthy J, Deady R. Moral distress reconsidered. Nurs Ethics. 2008;15(2):254-62.

A question of trust. Cambridge: Cambridge UP. O O'neill, O'Neill O. A question of trust. Cambridge: Cambridge UP; 2002.

Bringing professional responsibility back in. Stds Higher Ed. T D Solbrekke, T Englund, 36Solbrekke TD, Englund T. Bringing professional responsibility back in. Stds Higher Ed. 2011;36(7):847-61.

. K Martinsen, Care, Oslo, AkribeMartinsen K. Care and vulnerability. Oslo: Akribe; 2006.

Sensibility and clinical understanding. P Nortvedt, Med Health Care Phil. 12209Nortvedt P. Sensibility and clinical understanding. Med Health Care Phil. 2009;1(2):209.