Abstract
Nurse-patient ratio is an issue that continues to cause serious ethical dilemma in the modern healthcare organizations. On one hand, hospitals have been grappling with the challenges occasioned by underfunding, compelling hospital administrators to cut the number of their staff in the backdrop of the increasing number of patients. On the other hand, nurses are facing increasingly challenging and complex personal, professional, interpersonal, and institutional issues as fulfill their mandate of addressing patients’ needs while safeguarding their values. These are dilemmas that can be resolved by striking a balance between policy and institutional needs.
This paper would introduce a case study involving the nurse/patient dilemma and review the literature to shed more light on the gravity of the issue. The paper will proceed to analyze the dilemma in the case study based on frameworks of ethical decision-making. Finally, the paper would shift its focus on legal considerations and policy implications of the nurse-patient ratio dilemma before presenting a summary of the importance of the issue.
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The Case Study
AV, a registered nurse (RN) working at a skilled nursing facility, has been in charge of 2 RNs and four aids. Her shift starts at 3pm and ends at 11pm and her day’s work involves handling more than 40 patients/residents with different conditions. She assesses the patient’s vital signs, conducts full-body skin assessment, implements skin care, supervises aids, passes medication, admits patients, answers internal and external calls, receives medication from the pharmacy, and updates physicians about the patients’ health status.
At times, AV finds the demands of her work too much because her unit is understaffed with RNs and aids. The workload puts her into a position where she cannot give care that meets the standards of nursing practice. She has to address issues that range from patient falls and disappearance of assistants who are unwilling to work to unreported assessments and unruly patients. She has reported to have missed after-fall assessments and wrongfully delegated tasks to nurses and aids who have no capacity to perform them. Recently, for example, AV was performing a fall patient’s skin assessment when she discovered a quarter-size new ulcer on his toe. She had been overwhelmed by her work and asked an aid to check the integrity of the skin at bedtime. It was her mistake because she should not have delegated such a task to the aid, who could be overwhelmed by her assignments. The aid had reported that everything was fine after the patient’s skin assessment, but AV believes that the ulcer could not have grown that big if the aid would have seen and reported the ulcer in time, it would not have grown that big in less than 24 hours.
Review of the Literature
The ethical dilemmas discussed above represents a classic example of missed nursing care. Suhonen and Scott (2018) used their study to explore the issue of missed nursing care and the ethical dilemmas that it causes to healthcare organization. In this case, missed nursing care occurs when an aspect of nursing care is delayed or omitted altogether, with adverse patient outcome. In their day-to-day work, nursing activities and processes end up unperformed, either consciously or unconsciously, especially due to limitations in nursing resources. As Dunn and Moore (2016) note, low RN staffing levels tend to result in missed nursing care in health care organizations. Often, hospitals assign limited number of patients to many patients, but avail to them few resources to handle them, leading to incidents of missed nursing care.
From ethics point of view, missed care is both a process and an outcome in healthcare organizations that are understaffed (Scott et al., 2019; Nordström & Wangmo, 2018). In a typical hospital, prioritization and decision-making are phenomena that take place every day when nurses are assigned many patients at a time and when urgency of needs has to be considered. Nurses’ prioritization and decision-making in hospitals where nurse-patient ratios are low leave patients vulnerable to unmet psychological and emotional needs. In such cases, RNs are either unable or unwilling to respond accordingly to the needs and concerns of patients, giving rise to missed nursing care. Rising reports of missed nursing care have also been attributed to the rigidity of tools that auditors use when measuring certain aspects of nursing care (Suhonen & Scott, 2018). With emphasis turn to holistic nursing care models, the use of rigid, mechanical, or task-oriented tools paint nurses professionals who have failed to meet the needs of patients, thus, missed nursing care is implied.
Factors affecting workloads and their impact from nurses’ perspective have been explored in literature. In one study by Hegney et al. (2017), it was found that hospitals’ financial constraints and unpredictability of trajectories of patient illness have emerged as serious hurdles to the provision of high-quality nursing care. Hospitals have adopted cost containment measures and this means they have to limit the number of staff and skill-mix they employ. With the many patients on the line and wide variation of the disease acuity to handle, the nurses are forced what care they would provide and to whom. Together, these factors are directly correlated to poor patient outcome. In this case, the concept of nursing care rationing has been introduced by Suhonen and Scott (2018) to explain the causes of missed or delayed care. Nurses’ prioritization of care occurs because they have reduced capacity and resources to complete care. On one hand, implicit care rationing involves nurses failing to provide or withholding care due to inadequate staffing levels, skill–mix, or time. On the other hand, explicit care rationing occurs when the organization-level decision-making about resources allocation is poor. In both cases, nurses and nurse leaders struggle to manage patient care because of accountability demands.
The assumption that nurses are actively engaged in rationing care has been explored by Scott et al. (2019). Exploring ethical and philosophical aspects of rationed care, Scott et al. (2019) have argued that health service managers and policy makers have harbored a believe that nurses can still provide full care to patients even in the face of increased patient turnover and reduced staffing levels. In this case, nurses leave care undone or unfinished because of inadequate resources and increasing demands. In other word, because of variety of reasons, nurses find it difficult to perform or fulfill all patient care requirements. Other times, nurses cannot practically complete all aspects of patient care. More often than not, nurses are aware of the elements of care that are often left unattended or incomplete (McCarthy & Gastmans, 2015). However, nurses are unwilling to discuss these elements because missed care embodies a sense of lacking the capability to address all patients’ need. The topic also engenders a feeling of guilt and fear of being victimized among RNs. Despite these realities, there is a consensus within the nursing community and among other healthcare stakeholders that missed nursing care has negative connotations both on nursing and patient outcomes (Nordström & Wangmo, 2018). Care rationing raises serious ethical questions with regard to its justification based on resource scarcity or poor resource allocation, as well as its impact on nursing and patient outcomes.
Zamanzadeh et al. (2018) explore organizational barriers to delivery of compassionate care from the perspective of nurses. In this study, compassionate care flourishes when there is a collective responsibility of multiple healthcare stakeholders: nurses, nurse managers, hospital administrators, and policy makers. Stakeholders should work together to foster organizational culture that facilitates compassionate care. Issues that need to be addressed for compassionate care to be realized include workload for each nurse, nurse-patient ratio, and perceptions of value for compassionate care (Preshaw, et al., 2016). Compassion is a wide concept that reflects a number of attributes, such as the capacity to be sensitive to the suffering of others, motivation to support others, resilient to difficult emotions, emotional response to other people’s distress calls, and accepting that humans are prone to suffering without judging them (Dunn & Moore, 2016). Compassionate nursing care involves preserving patients’ dignity, actively listening to patients, and anticipating anxieties embodied by patients. In this case, it should be understood that nurses do not take care of patients in isolation, but within the broader context of their organizations, thus the need for a collective stakeholder involvement to achieve the goals of compassionate care.
Acknowledging that it is turbulent time for nurses, patients, and hospital, Philips (2020) explores the relationships between burnout, workload burnout, and decision to leave among nurses working in medical-surgical units. According to Philips (2020), nurse turnover is high in these units because medical surgical unit are stressful and require a higher nurse-patient ratio of highly trained nurses. These units mostly provide care for adult patients, most of whom are critically ill or recuperating from acute illnesses. Often, these nurses are assigned unrealistic workloads and handle multiple patients with complex/acute condition and at a higher risk of death or developing serious complications. High nurse workloads in medical-surgical units are associated with burnout, low job satisfaction, and high nurse turnover (Philips, 2020). Workload factors in these units are associated with patient acuity, frequent workflow interruptions, lack of organizational support, low nurse-patient ratios, and inadequate skill-mix levels.
Analysis of the Ethical Dilemma
The ethical dilemmas that nurse face while working nursing homes/skilled nursing facilities mostly emanate from unreasonable institutional standards of staffing and expectations. In healthcare, ethics focuses on promoting the health of patients, respecting their dignity, and fostering good relationships (Preshaw, et al., 2016). The case presented by AV can be considered an ethical dilemma involving individual and institutional rationing decisions. Often, AV and other RNs in the facility resorted to making decisions that are informed by assessment of patients’ needs, and prioritizing care to patients who needed it most. The nurses made decisions about time allocations to patients without reference to any set of guiding principles or rules that underpin the decision-making process. In this case, nurses made decisions without involving their colleagues and aids. Individual-based rationing not only makes work burdensome to themselves and others, but also makes decisions potentially dangerous and discriminatory.
Equally notably, AV’s case study presents evidence of intuitional rationing, such as the nursing home’s decision to maintain a low staffing and skill-mix level. When nursing staffing resources are reduced, nurses will have lesser time to care for patients (Dunn & Moore, 2016). Again, reduction of nurse staffing levels leads to intensification of the work done by each nurse, longer working hours, and in turn, burnout. Similarly, poor management and inappropriate resource allocation creates a situation whereby skill-mix is lacking or no enough qualified nurses to deliver the required patient care.
The most appropriate ethical framework to resolve the ethical dilemma created by individual and institutional rationing would be the utilitarian approach. In utilitarian ethical approach, healthcare organizations, nurse managers, and RNs would be committed to decisions and actions that produce the least pain and distress to patients and their families. The first step in implementing this framework would be creating a system of classification that describes actions and decisions that would produce pain and distress against those which have the potential of producing pleasure or happiness (Brown University, 2020). This framework would help nurses in making decisions and choosing actions that involve both individual patients and the larger population of patients. The organization-wide decision-making should also be guided by the utilitarian ethical framework. In this case, the hospital should consider improving on the staffing level and skill-mix to ease nurses of burden involving burnout, high workloads, and long working hours. This strategy would eliminate the need for nurse rationing and ensure that patients get the highest attention and quality of care.
Utilitarian ethical framework aligns with some principles of biomedical ethics, such as beneficence and justice. Guided by the ethical principle of beneficence, the hospital and its staff would be committed towards helping patients (Cousins et al., 2021). With appropriate staffing standards, nurses would have sufficient time to provide care that ultimately benefits patients. The RNs would also be in a position to demonstrate a high level of professionalism that necessitates compassion care, kindness, active listening, and understanding. Justice, on the same would mean sound allocation of financial and nursing resources by the facility’s management (Cousins et al., 2021). With justice as a guiding ethical principle, nurses would be satisfied and patients/residents would not be overlooked or abandoned. Together, beneficence and justice would reduce incidents of nurse misses, whereby patient’s health care needs are omitted, incomplete, or completely unrecognized (Nordström & Wangmo, 2018). In the case study presented by AV, unreasonable institutional standards of staffing and expectations had created situations where nurses would become too overwhelmed to notice a fall patient had developed new ulcers on the toe. Reasonable staffing would means that such incidences would be unheard of in the future.
Legal Considerations
The legal considerations that have been affecting the staffing dilemma in the hospital include malpractice, negligence. Currently, the nursing home where AV works lacks an effective policy framework for guiding how the wards should be staffed and the number of hours each RN and aids should work each day and per week. Absence of this policy framework exposes the hospital to regulatory actions related to malpractice and negligence. Malpractice and negligence lawsuits against nurses continue to be on the rise despite effort to educate nurses about the responsibilities they have on patient (Croke, 2003). Nurses are sued for malpractice if they get involved in behaviors or actions that are considered improper or unethical or when they demonstrate lack of skill and unprofessionalism in their work. Negligence lawsuits, on the other hand, arise when nurses’ actions or failure to act cause injury or death of a patient.
Recently, an amendment to CMR 150.007 was made to enhance operational and staffing standards in hospitals categorized as Level 3 and below. Under the new law, which will come into effect on 1 Oct, 2022, this hospital would be required to be compliant to sufficient staffing standards, include setting the minimum hours of care per patient per day at 4hours. It would be mandatory for these patients to be taken care for by a certified nursing assistant. The nurse-patient ratio of 1:10 set by the bill would pave way for ethically just care.
Policy Implications
Standards for nurse staffing is an issue that been considered broadly in the U.S. policy-making and legislation. This means that nursing homes and hospitals that do not adhere to the mandatory staffing standards established under state laws can face a legal action. The rationale behind this legislation is that meeting the mandatory standards of RN staffing increases nurse recruitment and job satisfaction, improves patient outcomes, and addresses the issue nurse shortage (Tevington, 2011). To achieve these goals, the nursing home where AV works should establish a staffing committee that would working with nurses and hospital administrators to develop and implement RN staffing plans that would foster a positive working environment for nurses and deliver optimal patient outcomes.
Some of the issues that may act as barriers to the development of effective RN staffing plans include financial costs, conflict of interests between hospital administrators and nurses, and lack of consistency in implementation. However, with clear goals and communication among the stakeholders, a reasonable model of staffing would have many benefits for the hospital. These benefits include improved patient safety and better quality of patient care (Tevington, 2011). There are also economic implications of developing and implementing high standards of RN for the hospital. Managed care has led to the introduction of Medicare and Medicaid services, which means that hospitals that post better results in patient satisfaction and outcomes stand to benefit from higher reimbursement (Nordström & Wangmo, 2018). Under the current circumstances, the hospital in AV’s case study would continue poor quality of patient outcomes of incidences of fall, low patient satisfaction, high staff turnover, and nurse misses in assessments and other areas of care.
Conclusion
AV’s case is about a nursing home that has set staffing standards and expectations that are unreasonable. She works for 8 hours every day and her shift is characterized by burdensome tasks despite having a limited number of RNs and aids to assist her. Her excess workload has been overwhelming her and this has often led to nurse misses. From the literature, nurse misses, which occur when there is low nurse-patient ratio, lead to poor patient outcomes. To address the ethical dilemma emanating from understaffing, the hospital should come up with a staffing plan that limits the number of hours that a nurse works for per shift and that reduces the number of patients that each nurse handles at a time. This staffing plan would ensure than nurses have adequate time for each patient.
References
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