Reflections - Ethical Implications of the Nursing Manpower Crisis, Shortage and Staffing
The problems of geographically scattered shortages of nurses and the pervasive inadequacy of nursing staffing patterns that are responsive to patient needs are in part, ethical dilemmas that cannot be easily remedied. In the lexicon of bioethics, these nursing problems fall into the category of distributive justice issues or allocation of scarce resources. There is a literature that has been developed around the question of what to do when there is simply not enough of a given resource, in this case, nurses and nursing, to go around. Should one distribute that resource in a way in which each person receives an equal share? Is a principle of equality sufficient to meet basic claims of justice and fairness? Should scarce resources be distributed according to need, with the sickest patients receiving the greatest measure of nursing attention? Should the life expectancy or the age of the patient play a role in who gets what? Somehow, each of these principles of microallocation seems unsatisfactory as it is easy to think of cases in which each of these principles seems unethical or falls short of what we want to provide to individual patient, all patientss and their families and communities.
For example, it doesn't make sense to provide equal amounts of nursing care to individual patients as their needs may be vastly different. We try to take account of this by suggesting staffing ratios for types of patients in different settings, i.e. fewer patients assigned per nurse in settings like intensive care units and larger numbers of patients per nurse in newborn nurseries, outpatient clinics. Staffing ratios are a sort of rough or first cut at establishing what is minimally necessary in specific settings in order to deliver safe care, but staffing ratios have limited utility in two respects: 1) they provide only a rough gauge of what may be needed , and 2) we haven't had the power to implement staffing ratios on a widespread basis so we cannot rely on them to reliably demarcate what is minimally necessary. Nonetheless, I think that staffing ratios are one imprecise but practical and ethical way of planning and distributing nursing care resources.
We like to think that providing nursing care according to patient need is what we're educated to do and that with a given group of relatively similar patients, we can allocate nursing care across the group in an even handed way. Even with relatively similar patients, the principle of equality quickly breaks down when there is simply not enough nursing care to go around. If each patient receives too little, then the fact that we have attended to each patient equally is small solace because we fall below what is useful to each patient.
In addition to distribution or allocation of nursing resources according to need or on an equal basis, we might deal with problems of shortage by planning nursing care so that we can provide the greatest good for the greatest number, a kind of utilitarian calculus or cost/benefit approach to distribution. The classic inadequacy in utilitarian thinking as a solution to allocation problems is that providing the greatest good for the greatest number may allow for an unacceptable level of harm for a few. That is, if we only look at numbers of patients served, we inevitably overlook those who, although small in number, may be entirely left out. Nursing has had a historic commitment to those who are undeserved, and to those who are vulnerable or disenfranchised. Therefore a utilitarian approach of providing the greatest good for the greatest number overlooks our value commitments and would not be ethical from the nursing point of view because of the uncounted or excluded minority.
The discipline of modern nursing, and by this I mean nursing since 1950, has not clearly reckoned with scarcity of nursing services as a pervasive feature of the healthcare environment. Our textbooks, for example, principles of medical surgical nursing and the like, explain the clinical care of patients as if each nurse has the time to do all that is required although in reality that may never be the case. This gap between the ideal and the real which is probably an inevitable feature of entry into practice for many professionals is particularly wrenching for new nurses because, we have as our work output, the welfare of real people, who can stare us in the eye, laugh, wince or even suffer and die. Historically, the problem of scarce nursing resources has been viewed as a problem for medical triage, or principles of management like Florence Nightingale would have applied in the Crimea in caring for wounded soldiers. But modern nurses working apart from wartime settings do not expect to have to make tough decisions about who will receive needed care and who will not and yet this is the reality of modern health care both in inpatient settings as well as in hospices, homes and community settings.
In addition to the fact that we are surprised by our work situation in which the ideal and the real diverge so dramatically, we are also faced with an environment in which we have little control over work demands. The inability to plan or to feel in control of the work setting is one of the chief predictors of workplace stress. When nurses have no control or even say about: 1) the length of the workday; 2) the setting in which they may be assigned to work; or 3) the features of a minimally safe and decent work setting, then circumstances conspire to produce higher levels of nursing errors, burnout and general disenchantment with nursing as a satisfactory or rewarding career. The moral situation in nursing has been described as that circumstance in which the nurse, no matter what she does, cannot achieve a good outcome for patients. It is this situation which is the result of poor or unsatisfactory staffing patterns that results in nurses turning away from the profession and the resulting nursing shortage. So in summary, the problems of nursing shortage and achieving appropriate staffing patterns are inherently ethical problems that have profound consequences for nurses and the populations that we serve.