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The ambiguity of altruism in

Original Manuscript
The ambiguity of altruism in
nursing: A qualitative study
Nursing Ethics
ª The Author(s) 2017
Reprints and permission:
Anna Slettmyr and Anna Schandl
Karolinska University Hospital Solna, Sweden
Maria Arman
Karolinska Institute, Sweden
Background: For a long time, altruism was the basis for caring. Today, when society is more individualized,
it is of interest to explore the meaning of altruism in nursing.
Methods: In all, 13 nurses from a Swedish acute care setting participated in two focus group interviews
performed as Socratic dialogues. Data were analyzed using a phenomenological hermeneutical method.
Ethical considerations: Ethical issues were considered throughout the process according to established
ethical principles. Informed consent was obtained from all participants, confidentiality regarding the data
was guaranteed and quotations anonymized.
Findings: Altruism created a sense of ambivalence and ambiguity, described as a rise of sovereign
expressions of life caused by “the other’s” need, but also unwillingness to take unconditional
responsibility for “the other.”
Conclusion: Society’s expectations of altruism and nurses’ perception of their work as a salaried job
collide in modern healthcare. Nurses are not willing to fully respond to the ethical demand of the patients. In
case of a disaster, when nurses personal safety, life and health may be at risk, there might be reasons to
question whether the healthcare organization would be able to fulfill its obligations of providing healthcare
to an entire population.
Caring, ethics, individualism, interdependence, Løgstrup, Martinsen, phenomenological hermeneutical,
Socratic dialogue
Altruism is the principle or practice of concern for the welfare of others.1 In nursing and caring science,
altruism is related to love, compassion, and responsibility.2 In an ideal altruistic caring relationship, the
encounter with fellow human beings is based on a genuine desire to alleviate suffering.3 Nursing as a vocation
is historically closely related to altruism.2 Today, vocation as a phenomenon has come to be associated with
negative wordings, such as sacrifice, subservience, and obedience, and is in a modern discourse regarded as
Corresponding author: Anna Slettmyr, General Intensive Care Unit, Department of Perioperative Medicine and Intensive Care,
Karolinska University Hospital—Solna, 171 76 Stockholm, Sweden.
Email: [email protected]
Nursing Ethics XX(X)
the opposite of professionalism and paid work. Anyhow, Martinsen reminds us that the vocation originally
meant a responsibility attached to the patient and to our fellow human beings who suffer.3
Historically, society in the Nordic countries was built on solidarity and equality.4 This structure has
gradually changed with time, and today’s healthcare is governed by economic incentives where efficiency,
patient flow, and balanced economy play important roles. Social changes, like secularization and an
increased individualistic focus, influence all individuals in society which naturally also affects nurses and
the entire healthcare system as an organization including attitudes among the staff. In a more individualized
society, where autonomy and integrity are highly valued, altruism and compassion may be considered as old
fashion expressions of healthcare.5
In altruism, the unselfish act to take care of another lays the unspoken expectation of the nurse as a good
and virtuous woman, which implies submission and an unselfish devotion to the care of others,6 in contrast
to modern healthcare where nursing is seen as a more technical profession.7 Still, these changes of perception may induce a risk that patients’ vulnerability and dependence are perceived as unnatural and remain
unseen.5 The nurses may no longer be willing to stand up for the patients and their families in situations
where they may end up in a moral dilemmas regarding their obligation to care for “the other” versus a duty
to protect her/himself and family (for example, in a new pandemic influenza).
Still, altruism is of great importance for nurses’ motivation and career.8–10 Though important, nurses
were less likely to state altruism as a motivator to entering the profession than other non-medical health
professions.9 In contrast to this, other studies show that altruism has been undermined over time and is not as
highly valued today as it used to be.11,12 Thus, the modern individualistic philosophy of life may contribute
to a changed approach to altruism, where such an attitude is not natural or are no longer perceived as
important for nurses. This in turn may have the consequence that modern healthcare may face the problem
that healthcare personnel are not willing to care for patients, especially if their own personal safety, life, and
health may be at risk.13 The phenomenon altruism and the willingness among nurses for self-sacrifice is
here a key question and of interest to investigate. The aim of this study was to explore how nurses perceive
the meaning of altruism in today’s healthcare.
Applying the philosophy of Løgstrup
The theoretical framework of this study was grounded in Knud Ejler Løgstrup’s14 philosophy and interdependence, which is the origin for “the ethical demand,” “the sovereign expressions of life,” and the
responsibility for “the other.” According to Løgstrup, interdependence is the basic prerequisite for human
life. Interdependence means a mutual unconditional dependence with the following responsibility for each
other as human beings.14 “The ethical demand” arises from a unique situation in the encounter with “the
other” and cannot be planned or anticipated. This in turn gives rise to what Løgstrup14 calls “the sovereign
expressions of life,” such as trust, hope, and mercy.
Kari Martinsen and collegue15,16 has applied the philosophy of Løgstrup to nursing and points to the
ethics that is inescapable in encountering human vulnerability as in nursing care. Martinsen describes the
nursing profession as a commitment, a will, and a responsibility to prioritize the other’s needs, which can be
understood as an altruistic action. She also describes the link between the vocation and Løgstrups thoughts
when she says that the vocation is about love of man and to meet him with respect. Vocation can be
understood as the “ethical demand” emanating from “the other,” the obligation is thus a claim to take care
of the other’s life put in the hands of another human being.2 Løgstrups philosophy of interdependence and
responsibility for each other as human beings are based on caring science relevant to the professional
assignment to care. Also, the “ethical demand,” “the sovereign expressions of life,” and the compassion
and love of neighbors are phenomena understood as the basis for an unselfish action for another, both as
fellow human beings and as professionals and nurses.14,15 In this study, the theoretical framework, based on
Slettmyr et al.
the philosophy of Løgstrup and the theories of Martinsen, was used as the basis for studying the unselfish act
for “the other,” that is, altruism.
The term “the other” was used to describe the other person in an encounter, from a phenomenological
standpoint, inspired by philosophy of Løgstrup14 and Levinas and Nemo.17
Research design
The design was a qualitative empirical study where data have been reached in Socratic group dialogues with
clinically experienced registered nurses. In Socratic dialogues, the lived experience is reflected upon and
discussed from ethical viewpoints; in this study, the concept and phenomenon of altruism were presented as
topic and phenomenon for reflective discussion.
Participants and research context
The study was conducted in a university hospital in Sweden. A purposive sampling was applied and participants with varying experience and demographics were recruited. A total of 13 registered nurses who worked
in an acute care setting at the hospital were interviewed, 6 of the nurses had specialist training in intensive care
or emergency care, and 7 of the nurses were under specialist training in intensive care. These participants
formed two separate focus groups. Demographic data for the participants are presented in Table 1.
Table 1. Demographic data of the included registered nurses.
Total number (invited)
Men, number
Women, number
Age range (mean years)
Number of years as nurse
Number of years as specialist nurse (out of years as nurse)
Specialist nurse
Nurses under specialist training
6 (9)
25–60 (38)
7 (15)
27–44 (35)
Data collection—the Socratic dialogue
The focus group interviews18 were conducted in September 2013 and February 2014. The interviews were
performed as Socratic dialogues,19–21 which is an interview method that permits a philosophical deepening
of the phenomenon by investigating participants’ clinical experiences. For the nurses to have a common
starting point, the dialogues started with a joint reflection regarding the question “What is altruism?”
Thereafter, the nurses were asked to describe a self-experienced altruistic situation that occurred in their
everyday clinical practice. Then, the whole group reflected upon how these examples could be considered to
be altruistic actions. These reflections were further discussed to gain a deeper understanding of their
experiences. The nurses were also asked to define, in writing, what altruism meant to them in relation to
today’s healthcare. The individual definitions were discussed and compared in an attempt to reach a
consensus definition. Each dialogue lasted for a little more than 2 h in total, according to the description
above. The participants contributed in various extents to the dialogues, some did have a lot of thoughts about
altruism, while others contributed less to the joint reflection. The dialogues were recorded to ensure
verbatim transcription and were transcribed by the first author (A.S.).
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The analysis included a dialectic movement between the three phases of the phenomenological hermeneutical method: naı̈ve understanding, structural analysis, and comprehensive understanding.22 The text was
repeatedly read in its entirety and a naı̈ve understanding was formulated based on the authors’ preconceptions. Thus, two separate naı̈ve understandings were formulated, compared, and discussed until consensus
was reached. In the subsequent structural analysis, a more distanced approach to the text was used. The
dialogue text was divided into meaning units relevant to the purpose of this study and condensed into
everyday language. Among the meaning units, similarities and differences were sought, and through
reflection and interpretation, meanings of the phenomenon of altruism emerged. These meanings formed
subthemes, which after further analysis were combined in three relational contexts, with an overall main
theme. To create a deeper overall understanding of the phenomenon, a comprehensive understanding was
formulated from the naı̈ve understanding and the structural analysis, in relation to the research question,
preconceptions, and the theoretical framework.
To strengthen the credibility and trustworthiness of the interpretations and descriptions, the authors
continuously discussed the analysis process. The analysis phase lasted for approximately 1 year, which gave
enough time for thoughtfulness and reflections.23
Ethical considerations
Ethical issues were considered throughout the process according to established ethical principles.24 To
participate in ethical reflections can be both challenging and educational, and the dialogue leader, a nurse
herself, was respectfully aware of this. The participants were informed about the voluntary nature of
participating, and informed consent was obtained from all of them. Confidentiality regarding the data was
guaranteed and the quotations were anonymized. The Regional Ethics Review Board in Stockholm, Sweden
approved the study (2013/1702-31).
Naı̈ve understanding
The meaning of altruism was not something the nurses reflected upon in their everyday clinical work.
However, during the dialogues, the topic inspired a diversity of thoughts and feelings and the nurses started
to realize that altruism was actually playing a role in their professional life. A totally unselfish act, without
any personal gain, was seen as an unrealistic or even utopic act. The most common opinion among the
nurses was that altruistic acts were based upon the maxim “treat others as you would like to be treated
yourself,” where compassion and empathy were implicit. Altruism also meant making small as well as large
sacrifices for the patient. However, less demanding altruistic acts in the caring relationship dominated the
self-experienced examples. The meaning of altruism was described in terms of doing “the little extra” for
the patient, that is, going further and doing something that was not expected of them in their daily work. It
was expressed as “prioritizing ‘the other’s’ needs before your own.” Sometimes, the altruistic actions
resulted in positive feedback from patients or their families. Such appreciation was highly valued by the
nurses. They also stated that the feeling of “making a difference” for “the other” contributed to a sense of
having meaningful work. However, to act altruistically also meant risking criticism from colleagues. Yet,
being criticized increased the feeling of sacrifice, which in turn made the altruistic act feel even more
altruistic. The nurses implied that they based their altruistic actions on knowledge and professionalism and
not on character traits or virtues, such as goodness. They denied that nursing was vocational work, even
though they felt that society expected or even demanded altruistic behavior from nurses.
Slettmyr et al.
Structural analysis
The meaning of altruism was related to the person herself/himself, to “the other” in the caring relation, and
to the nursing context, which formed the three subthemes of the structural analysis. In each subtheme, the
nurses’ perceptions of altruism veered from uncertainty about the meanings of altruism to its meaning for
their clinical work. Thus, the main theme was “The ambiguity of altruism.” Quotes were used to illustrate
the meanings of the phenomenon of altruism.
The ambiguity of altruism: the professional self. The nurses defined altruism as making larger sacrifices, which
were considered as being of high value. Yet, they argued that this was not something everyone could
achieve. To make immense sacrifices at work, at a personal cost, was perceived as something extreme of
remote importance. Altruism within the profession was often perceived as making small sacrifices—
sacrifices that did not involve any personal cost for the nurse, but could be of great value to the other
person. Altruism was expressed as “treating others the way you want to be treated yourself,” based on the
idea of “how would I feel if it was me.” The phenomena “empathy” and “altruism” were perceived to be
closely related. Still, the nurses stated that professional knowledge, experience, and compassion were seen
as the foundations for altruistic acting. The nurses wanted to be appreciated for the work they conducted but
they did not want to be called angels, which were perceived as a disparagement of their professional worth:
I am not an angel; I am here to do my job. I am good at it, and I like it as well.
Altruism implied a feeling of “making a difference for the other person” and thereby creating a sense of
meaningfulness in their work. This motivated them to further altruistic behavior. The nurses were driven by
a kind of inner satisfaction, where “doing good” induced a sense of meaningfulness:
I do it for myself. There are so many patients in need of care and treatment, and I find it meaningful to take care
of them.
Why do I do this? Well, I want to have a job which I enjoy, and where I feel that I can make a difference. [ . . . ] But
I would not do it for free, I come here because I get paid, and because I like it, and because it is a meaningful job.
Only then can I think of altruism. It is, however, not my first thought. I do not wake up in the morning and think;
today I will perform altruistic acts.
If the nurses found their work to be without substantial meaning, motivation to do “the little extra” for the
other person was lost:
Sometimes you will find yourself in a position when you do not like what you’re doing; you have lost your
motivation and do not want to do this anymore. I did not want to change that diaper but of course I did it
anyway . . .
The nurses were aware of that lack of motivation in work could affect patients or their relatives
negatively. Therefore, they stated that it was important that each individual was responsible for his/her
own actions.
The ambiguity of altruism: “The other”. The nurses stated that altruism meant to prioritize the needs of the other
person before your own and protecting the other persons’ dignity when he or she was unable to do so
himself/herself. Altruism was described as doing “the little extra” for the other person, something that was
not normally expected or demanded from the nurse. “The little extra” could be anything from combing the
patient’s hair or allowing relatives to sleep an extra night at the ward to a more general responsibility for
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“the other” in the caring relationship. However, there was disagreement about what was considered to be
“the little extra” and what was supposed to be included in the nursing assignments:
What does “the little extra” mean? It is my job to do this. My job is to take care of the other person when he/she
cannot do it him/herself, to prioritize the other person’s needs. It is not something extra I do . . .
When an altruistic act resulted in a positive response from the other person, this was regarded as less
altruistic, since altruism was supposed to be a completely unselfish act. In spite of this, when an altruistic act
enhanced positive feedback, it was appreciated by the nurses and regarded as something positive:
. . . if I get something in return when helping someone else, is it not regarded as an altruistic act? All of a sudden,
it is degraded . . . because of my personal gain. Isn’t it a mutual gain? If I feel good doing something and at the
same time I can help another person, isn’t that twice as good . . .
Acknowledgement of the altruistic act resulted in a sense of satisfaction. The recognition could be
immediate, through direct positive feedback, expressed as gratitude. Or it could be delayed, like when
patients or their families on a later occasion acknowledged the benefit of the act. Such acknowledgement
could also play a role in the following way:
Nursing can be quite hard work, and is often badly paid. What motivates you to continue working as a nurse is the
positive feedback from the care recipient.
The nurses’ attitudes towards altruistic acts were pervaded by ambivalence. They were well aware that
altruism was defined as an unselfish act for “the other.” Still, they expressed a feeling of satisfaction when
being needed and important for the other person.
The altruistic actions were sometimes criticized by colleagues. If the nurses tried to be flexible and do
“the little extra” for the other person, they could be reproached by colleagues. Fear of criticism could
prevent them standing up for the actions they would like to do for the other person:
If there were many relatives visiting the patient at the same time, I sometimes told them, that only one or two at
the time could come into the patient’s room. It wasn’t so much for the patient’s safety as it was to prevent me from
being criticized by my colleagues.
The risk of receiving criticism when doing “the little extra,” enhanced the feeling of sacrifice and made
the nurses feel that they had acted for someone else without any personal gain. The criticism became a
validation of the altruistic act.
In contrast to doing “the little extra,” there was “conditional altruism.” Some of the nurses expressed
thoughts about when the other person did not deserve “the little extra.” Being too demanding, or not ill
enough, were reasons for being disqualified from receiving altruistic acts. The nurses also wanted patients
and their families to show understanding for the stressful working environment at the ward and to consider
this in their demand for care:
It is frustrating when they (the patients and their families) do not show understanding for our situation, “We just
received three acutely ill patients and that is why you have to wait for your turn”, but on the other hand, perhaps
we should just consider it from the patients’ perspective . . .
Some nurses were annoyed or frustrated about this, while others calmly stated that meeting other people
in a vulnerable situation was what being professional was about.
Slettmyr et al.
The ambiguity of altruism: the society. The possibility for altruism was experienced as being restricted by
limited human resources and economic restrains. The nurses described how such economic considerations
made their moral obligations collide with the demands of the employer. They gave several examples of
situations where they wanted to do “the little extra” for the patients and their families, but the economic
aspects of healthcare hindered them:
Since someone from the healthcare personnel was ill, we did not have time to mobilize all patients. We were then
told by the head nurse to lower our ambitions and reduce the quality of care.
Nursing has by tradition been considered as vocational work. The nurses stated that this perception still
lingers and society expects altruistic acts from healthcare personnel. However, the nurses did not want to
acknowledge their profession as a vocation, but stated that it was a salaried job like any other.
Altruism is considered to be closely related to nursing. But why is it so? We have a nursing education, we do the
job that is assigned to us, and we get salary for this. It doesn’t have to be an altruistic act.
However, the character of the work assignment might contribute to this misinterpretation, as argued by
the same nurse:
We do take care of critically ill patients and their families in a strained situation, which may be an explanation for
why nursing is associated with altruism.
Comprehensive understanding
Altruism conveyed a sense of ambiguity and ambivalence among the nurses. On one hand, encountering “the
other’s” need caused an increase in sovereign expressions of life, such as spontaneous mercifulness and trust
which called for offering care. On the other hand, social and organizational structures require nurses to have a
more task-oriented and technical attitude towards the other person. A deeper motivation for engagement in “the
other” was expressed, but the expectations of altruistic acts within nursing collided with the nurses’ perceptions
of their own profession as a salaried job. Interdependence and natural responsibility for “the other” were
explicit in the nursing role and in the encounter as human beings, yet linked to ambivalence. A willingness
to engage in the caring relationship and stand up for “the other” was enounced. In the caring encounters, the
needs of “the other” were prioritized, which made room for “sovereign expressions of life,” and most nurses had
experienced receptivity to the “ethical demand.” Such actions created a feeling of meaningfulness and contributed to an ambition to perform further altruistic acts. However, so-called “conditional altruism” was also at
state and was expressed as an unwillingness to engage in “the other” if the altruistic act did not result in a sense
of reciprocity. In such situations, “constrained expressions of life,” like mistrust, was present. Critical comments from colleagues prevented the nurses from engaging in and taking responsibility for “the other.” This
resulted in a contradictory uncertainty about the impact of altruism in today’s nursing and healthcare.
The ambiguity of altruism was illustrated in the nurses’ narratives from daily practice where they described
its subtle influence in their work, patient and family encounters, as well as in relation to the society and
economic values. The nurses described the rise of “sovereign expressions of life” caused by “the other’s”
need which to some extent were restricted by a narrow frame, set by social, organizational, and financial
structures in healthcare. This resulted in a more task-oriented attitude towards nursing, something the nurses
seemed unaware of, but that pervaded the caring encounter.
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Interdependence, according to Løgstrup, is a great power, and whenever “the other’s” situation is not
received in mutual trust, it is devastating. This means that we are all in the hands of other human beings
and therefore also vulnerable in such situations.14 According to Martinsen,15 a caring relationship is
characterized by vulnerability, where patients and their families are dependent upon the nurse. The
expectation of trust, which is present in all interpersonal encounters in healthcare, makes the patient
vulnerable and gives power to the caregivers. Vulnerability is required for showing compassion for “the
other’s” suffering. In the nursing context, it is important for the patients and their families that the nurses
can relate to their own vulnerability as well as “the other’s” and use this to offer caring acts.15 To be able
to achieve this, trust in other human beings and compassion on the basis of unconditional interdependence are required as a part of the nurses’ professionalism. In the more individualized and self-centered
society, such trust and compassion may not be present.2 In the absence of interdependence in healthcare,
the others’ needs may risk to be neglected.
In this study, the nurses sometimes showed willingness to take unconditional and spontaneous responsibility
for “the other,” thereby enabling a caring relationship. In a previous study, it was shown that there was
willingness for altruism among nurses, but also an ambivalence towards the helping motive, especially regarding the unselfish focus on “the other.”25 In the dialogues, there was an ambiguity towards the concept of
altruism, where some nurses were willing to take unconditional responsibility for “the other” in most situations
and others were not. Some nurses did not fully respond to “the ethical demand” of the patients and their families,
which might have contributed to uncaring encounters, and therefore lead to unnecessary suffering for “the
other.”5 The individualistic attitudes in today’s society influence healthcare and nurses’ behaviors when caring
for patients. In previous research, the evidence for altruism’s importance in modern healthcare is contradictory
which may indicate that ambivalence in nurses’ attitudes towards the phenomenon exists.8–12
Today, the spontaneous acting for “the other” in the nursing context does not seem to be without
consideration. This is what Løgstrup calls “constrained expressions of life.” In contrast to “the sovereign
expressions of life” such as trust and mercy, “constrained expressions of life” revolve around oneself in a
self-absorbed or self-protecting way and encompass, for instance, mistrust, jealousy, and egocentrism.14 In
our study, “the constrained expressions of life” were expressed as “conditional altruism” where the nurses
expected that the patients and their families should take the nurses’ interests and needs into account when
demanding care. When the focus was no longer primarily on “the other,” the altruistic element became
secondary or absent, also in professional care. This may reflect the changes of modern society, where
individualism may lead to a desired contact in relations, where positive feedback gained from the patient
encounters may play an important role in self-realization.25 In such scenario, the nurses own well-being
becomes as important as the concern for “the other” as a patient. Anyhow, the caring relationship is
asymmetric and the focus should, as Northaug and Nortvedt26 say, be on “the other” and not on the
caregiver. Professional nursing should not be blind to working conditions or to healthcare workers’ interests, but these considerations should not be the primary focus in the caring situation.26
Altruism is closely related to nursing as a vocation. Even in today’s healthcare, the nursing profession is
best understood as a vocational occupation, where vocation is described as a personal and moral disposition
to “the other” in the nursing context.2,27 In our study, as in another previous study, the nurses distanced
themselves from this statement.28 At the same time, they expressed a motivation for the profession, closely
connected with their own identity, values, and behaviors. This might be interpreted as lasting deep traces of
vocational or altruistic motivation, although they hesitated to use such words.28 Here, dissociate from
something contemporaneous expressed as an important part of the profession, which becomes a
contradiction or an expression of the ambiguity to the phenomenon itself.
With some astonishment, we noted that the nurses did not reflect upon their professional responsibility for
“the other” in a broader context or out from society perspective, such as being exposed to contagious diseases
when caring for infected patients or being at risk for developing illnesses because of working conditions.29–31
Slettmyr et al.
Instead, the dialogues were focused on small sacrifices in daily work. Furthermore, the nurses did not express
any thoughts about what demands society would make in case of disasters, such as a new pandemic influenza,
natural disasters, or conflicts and war. Many nurses in Sweden have never been confronted with such
situations in clinical practice and that may be the reason for not reflecting upon this in the dialogues.
Questions like how much self-sacrifice can reasonably and justifiably be expected of nurses in such
situations were left unanswered. The availability of healthcare workers will be essential in order to provide
an effective response to, for example, an influenza pandemic. Policies should be formulated so they
contribute to a climate in which healthcare workers feel a personal moral responsibility to care for patients
despite an increased risk to their health.32 Therefore, future studies to investigate nurses’ attitudes towards
altruism when their personal comfort, safety, life, and health may be at risk are warranted.
The result of this study should be seen in light of its strengths and limitations. The study is empirical but
mainly included nurses from intensive care units, which may limit the transferability to other contexts. All
authors had preconceptions that influenced the interpretations of the text, experiences from both clinical
nursing and theoretical perspectives. However, the preconceptions have been controlled by thorough data
analysis and discussion among authors and by being open to a new perspective.
In today’s clinical praxis, the society’s expectations of altruism collide with nurses’ perceptions of their
profession. The nurses have to balance the paradigm of nursing as a vocation, where altruism has a natural
place, with the perception that the profession is a salary work like any other. Hence, we have found an
uncertainty about and an ambiguity towards altruism among nurses. This confusion is seen on a surface
level, yet signs of a deeper motivation to altruism still remain. The ambivalence may lead to the fact that
nurses do not always respond to “the ethical demand” of patients and to the expectations of society. Today,
many nurses also intend to leave the profession after only a couple of years, turning their back to the
vulnerable patient, which is a problem for healthcare organizations.33 In the utter case of a disaster, when
nurses personal safety, life and health may be at risk, there might be reasons to question whether the
healthcare organization would be able to fulfill its obligations of mobilizing nurses and providing healthcare
to an entire population.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
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