Summary of Ethical Dilemma: Low Nurse-Patient Ratio
There is an existing nursing shortage in America today primarily because of the increasing number of patients in the aging population, frequency of chronic diseases, an aging workforce, and the limited number of Americans taking up Nursing education to cover the growing needs for the profession. The nursing field belongs to the group of fastest-growing careers not only in America, but in other countries as well. However, the demand surpasses the supply of nurses, which results in high nurse to patient ratio. As a consequence, quality care that patients supposedly should receive from the medical industry suffers.
Studies reveal that the nursing shortage is not due to limited education or lack of nursing qualifications, but rather more because of nurses’ unwillingness to work in current conditions such as inadequate workforce planning and allocation plans, poor recruitment decisions, lack of retention policies, ineffective utilization of nursing skills, poor incentive structures, undersupply of new nursing staff, and insufficient career support (Parker, Lazenby, & Brown, 2013, p. 3). What is clear on all these is the huge effect this has in terms of health care delivery and outcomes.
Amy is a patient in the hospital and requires 24 hour nursing care. During a vacation trip, she slid and hit her head, which required that she undergo surgery due to head injuries she suffered. Her head injury resulted to Amy’s temporary loss of mobility and she is currently attached to a gastronomy tube to help in feeding her. Because she needs constant care, it is necessary that nurses are always available to attend to her and check on the stability of her vital signs.
However, because of the problems in the hospital, having a constant nurse companion to check on Amy’s condition is not possible because of the low nurse-to-patient ratio in the hospital. Some nurses have already complained of the work schedule that was given to them, which required most of them to work double shifts almost every day. Because of the low nurse-to-patient ratio, there were instances when Amy’s feeding schedule and medication were not followed to the dot, which led to complaints from Amy’s family. They pointed out that this could lead to more complications or extension of Amy stay in the hospital, instead of being able to recuperate faster. Thus, the nurse-patient ratio further becomes an issue as more patients are taken care of by a few nurses only (Keift, De Brouwer, Francke, & Delnoij, 2014).
Moral Distress Experienced
Based on the issue presented about the low nurse-to-patient ratio, the moral distress associated with this is stress both in the part of the nurses and in the family. Nurses know that they can still do more to help patients recover from their illnesses, but due to understaffing issues, nurses are not able to perform their jobs well (Parker, Lazenby, & Brown, 2013, p. 6). This is morally distressing because ethically, there are decisions and patient care methods that can be applied to patients, but due to lack of skilled nursing personnel, patients are not provided the necessary service and care that they deserve. Additionally, when nurses offer suggestions on how to improve processes and resolve the low nurse-to-patient ratio, in most cases, we are not acknowledged for our ideas and efforts related to the improvement (Wood, 2014). This is also a source of moral distress for us because it shows that we are not appreciated in our work environment (Parker, Lazenby, & Brown, 2013, p. 5). When it comes to the patient’s family, the stress is also in knowing that there are not enough nurses to care for their patients. Thus, the more they will be thinking about whether their patient will recover easily and faster from her injuries.
When these instances occur, most nurses feel emotional dissatisfaction at work and exhibit physical and emotional symptoms such as headaches, stomach pains, gastrointestinal issues, and feelings of anger, frustration, and guilt (Parker, Lazenby, & Brown, 2013, p. 6) for not being able to offer solutions to patients’ problems. However, when nurses feel that the organization supports and recognizes their efforts, including their clinical decisions and judgments are valued, then nurses’ moral distress lessens and job fulfillment increases (Parker, Lazenby, & Brown, 2013, p. 12).
Applying the Ethical Decision-Making Model to the Experience
When applying the ethical decision-making model, there are five stages that need to be fulfilled, namely, articulating the problem, gathering data, exploring strategies, implementing the strategies, and evaluating outcomes.
Articulating the problem. The main problem in this case is that there is a low ratio between nurses and patients, which affects the quality of care that is being allotted or given to patients, such as Amy. This is due to the nursing shortage occurring in the United States and some other countries. The desired state or goal is to ensure that the number of nurses per patient increases in order to improve the quality of care for the patients.
Gathering data. This poses a problem for patients and hospitals considering that nurses are considered to be a very important segment in the health care industry. They are always in the forefront when delivering service and care to patients, thus, when there is a low ratio between nurse and patients, it is always the patient who suffers. Nurses also took an oath where they said they will perform their duties to the best of their abilities (Keift, De Brouwer, Francke, & Delnoij, 2014). However, considering the issues associated with having low number of nurses, they are not able to fulfill their obligations as they feel tired and overworked already. It is very crucial that these concerns are addressed because this becomes the basis whether nurses will stay with a hospital or not. Following are some of the reasons for the low nurse-to-patient ratio, including the effects on the patients.
Restrictions in nursing program enrollment. In 2012, many students wanted to enroll in the nursing program, but due to short supply of faculty members to teach the course, classroom space limitations, and budget issues, among others, some U.S. nursing schools were forced to turn away about 80,000 students despite qualifying for the nursing program (Rosseter, 2014, p. 2). In another study conducted in 2002, the same problem was brought up in more than 15 states, including the District of Columbia. The nursing faculty shortage “point to a 12% shortfall in the number of nurse educators needed” (Rosseter, 2014, p. 3) as studies revealed projected retirements, unfilled teacher positions, and lack of nursing students being readied for the faculty positions would pose problems to the nursing education industry in the succeeding years (Medical Executive Council, 2016).
Near retirement age of some nurse practitioners. Based on a study and survey by the National Council of State Boards of Nursing and The Forum of State Nursing Workforce Centers in 2013, many U.S. nurses are already aged 50 or over, which is equivalent to 55% of the nursing workforce (Rosseter, 2014, p. 3). This has slightly increased from the study conducted in 2004, which showed that average age of nurses was already at 47 years old. Thus, the Health Resources and Services Administration projects that based on the current age range of nurses, over 1 million registered nurses will retire within the next 10-15 years (Rosseter, 2014, p. 3).
Changing demographics. Reports confirm that there will be a shortage of nurses as the so-called “baby boomers” grow older and need more help in taking care of themselves (Medical Executive Council, 2016). Because of this, there is the possibility of having lesser number of nurses and caregivers between 2010 and 2030 because the demand is higher than the supply when it comes to providing health-related care and service (Rosseter, 2014, p. 3).
Insufficient staffing due to overworked nurses. Due to rising health care costs, some hospitals are forced to trim down their nursing workforce. As a result, more nurses end up feeling tired and overworked because of mandatory overtime policies that hospitals implement to guarantee that their registered nurses would be available to work when the need arises. Although nurses are paid overtime pay, they end up deliberating whether to pursue their nursing career or change careers altogether (Medical Executive Council, 2016). Additionally, exhaustion and overwork contribute to nurse dissatisfaction when they know they are responsible to a big number of patients in the hospital (Stokowski, 2014). Because of this increased emotional stress on nurses, the quality of patient care decreases, which could further lead to nurses absconding from their profession (Rosseter, 2014, p. 3).
High nurse turnover rate. According to studies, high turnover rate is evident in new and younger nurses who only get experience as nurses prior to changing to other jobs. What they are not aware of is how much time and money are wasted from the time an individual is interviewed for recruitment, training, increased management expenses, and loss of productivity. The costs also include replacement of nurses, including recruitment, orientation, and training of new employees again (Keift, De Brouwer, Francke, & Delnoij, 2014). The loss of productivity during the training part is high considering that the newly hired health worker will take a while to understand the systems and processes, as such, the learning curve is low.
In the case of Amy, the problem is more on overworked nurses because of the shortage in nursing staff. Despite having the necessary gadgets and machines that can help Amy recover faster, there is just not enough nurses to attend to all the needs of all patients in the hospital. This proves to be a problem considering that Amy’s condition requires 24-hour care and supervision. Thus, not following the correct schedule in terms of feeding and medication administration could affect Amy’s recuperation.
The key participants in this problem are nurses, patients, and the hospitals or clinical facilities that offer patient care. On the nurses’ side, they are very much aware about their responsibilities, but because of the low ratio between nurses and patients, turnover rates increase as nurses feel the brunt of all the work and responsibilities are on them. Despite some hospitals offering overtime pay, some nurses do not grab the opportunity as they become stressed out and frustrated with all the responsibilities they have in caring for the patients (Mason, Leslie, Clark, Lyons, Walke, Butler, & Griffin, 2014). On the other hand, patients suffer due to this situation because they do not receive the proper services and care those healthcare personnel and facilities should provide them. Patients and their families also end up frustrated and even more depressed because of their situation as they are aware they are not receiving the kind of assistance that they deserve. As a result, either they have to spend longer time in the hospital or their situation worsens and passes away after some time (Shekelle, 2013). As for healthcare facilities such as hospitals and clinics, they also end up suffering because they have to turn away some patients due to insufficient nursing staff. This equates to losses in business and more empty or open beds.
While nurses may be involved in some bedside decision making processes, they do not have a hand when it comes to making decisions for the whole hospital, including how to resolve the problems on high nurse turnover or low nurse-to-patient ratio. Hospital administrators are the ones who need to study and analyze the situation and come up with valid strategies that will help all parties achieve their goals.
In this case, there are no specific cultural factors that define how a culture is affected by the problems of low nurse-to-patient ratio. This is because the problem is common in all countries in the sense that having a low nurse-to-patient ratio and high turnover rate affects the patients regardless of cultural background (Shekelle, 2013). Instead, the stakeholders, especially the nurses feel a certain guilt or moral responsibility towards their patients because they know how much the patients depend on them for care, service, and assistance. At other times, nurses even act as shock absorbers who listen to patients’ problems or concerns about their health and wellness.
Despite the grim prospects of having low nurse-to-patient ratio, many opportunities are still available for nurses all over the world. The elderly population will continue to increase, which means there will always be jobs for nurses in various facilities, such as hospitals, clinics, home-health facilities, and long-term care health facilities. If one’s passion is in education, there is also the growing need for nursing faculty members to help in educating and preparing students to become nurses or nurse educators. These are all mainly due to healthcare reforms the governments in each country are doing, thus, skilled nursing personnel will always remain in demand for years to come (NurseGrid, 2014). Other options include offering higher salaries to nurses considering the huge responsibilities that they are given. As a result, this can help in boosting the workforce, including the recruitment of new nurses and the retention of the already existing nurse workforce (Medical Executive Council, 2016). To further bolster the need for more nurses, it would help to increase minorities working as nurses to be able to address whatever cultural sensitive healthcare services and care required by a patient. In line with this is opening the opportunities to foreign nurses as well who will enter the United States under temporary working visas (Medical Executive Council, 2016).
Exploring strategies. Discussions about the problem on low nurse-to-patient ratios abound and have produced various possible strategies, including a state legislation that ensures nurse staffing quotas in various states (Foster Swift Collins & Smith PC, 2013). One of these is in the state of Michigan, which becomes the second state to implement a nurse-to-patient ratio, after California (Schultz, 2013). Through House Bill 4311 and Senate Bill 228, the “proposed legislation would require hospitals, including state-owned hospitals and state-owned facilities, to develop staffing plans that provide ‘sufficient, appropriately qualified nursing staff in order to meet the individualized needs’ of patients” (Foster Swift Collins & Smith PC, 2013). In this bill, for instance, the minimum nurse-to-patient ratio would be 1:1 for critical cases, and 1:4 for a behavioral health unit (Foster Swift Collins & Smith PC, 2013).
Implementing the strategy. Considering the huge impact of having low nurse-to-patient ratio in most states, I would support and join the nurses in their call and rally to have the bill approved when it comes to minimum staffing laws. This will surely make it easier for nurses to do their jobs efficiently and in return, will help patients recover faster from their illnesses. For both parties, their interaction will be one that is stress-free as they both know that they are giving whatever it takes to help someone feel better, while the other party knows that he or she is receiving the best care possible. Nurses will feel a level of achievement and satisfaction in being able to carry out their jobs well without the guilt of serving despite being overworked, which could affect the quality of their service. As for the hospital, it will also benefit them as much because they do not have to pay much for overtime salary if there is adequate staffing to attend to patients (Schultz, 2013) and with a good reputation, the hospital ends up gaining as more patients choose their hospital for the dedication of the staff and the quality of service given to patients.
Evaluating the outcomes. At this point, the ethical dilemma of low nurse-to-patient ratio has not yet been fully resolved, but the good thing is that there are measures being done to address the issue. For instance, foreign nurses are now being employed in order to add to the number of nurses working in a hospital. Additionally, nurses are getting more benefits and higher pay than before, thus, there are more students now who opt for a career in nursing. There are also career shifters coming from different occupations that see the value of becoming a nurse in terms of fulfillment in being able to help others as well as in the financial benefits and rewards that goes with the occupation.
How My Spirituality Affects Ethical Considerations when Caring for Clients
When an individual is threatened by an illness, it is one of those times when the patient begins to analyze one’s spirituality and how it can help in the healing process. In America, religion is pervasive although not many practice it especially in the medical profession (McCormick, 2014). In Vermont, about 91% of patients believe that their faith can help in restoring them back to health, while only around 64% of medical doctors say they believe in God (McCormick, 2014). In my case, I am also a strong believer that there is a supreme being helping health professionals in ensuring adequate care is given to patients. Prior to attending to patients, I would pray that everything that I do for the day will be for the benefit of the patient and will restore the patient back to health and wellness. Additionally, when we attend to patients in the hospital, it means sincerely considering all the needs of a patient in terms of his or her care issues. Thus, part of the task or responsibility is to talk and communicate with the patient and alleviate their fears (Yousefi & Abedi, 2011). For some, this can be done only through prayer.
Comparing and Contrasting Actions
When comparing my actions with the ethical decision-making model, my actions might show some differences on how I will handle the situation. In the ideal nursing practice, as a nurse I should attend to all the needs of the patient regardless of the situation and working conditions. This is because of the oath that I have taken before that I will dedicate my services to the care of the sick and to help them towards wellness. However, in reality and in considering the actual situation in the hospital, doing so is impossible because of the schedules given to nurses because of the working conditions. In some days, nurses are required to work two to three 12-hour shifts straight in order to fill up the nursing staff. But, this becomes a problem for nurses because working consecutive shifts for several days is really taxing to the body. Thus, some nurses end up feeling sick, which adds to the problem of having less nurses working in the hospitals when needed.
As a patient advocate, I cannot do much for Amy’s situation at the moment because it is not in my hands to address the problem. However, I join other nurses, patients, and families in ensuring that the bills that would ensure a minimum nurse-to-patient ratio is implemented in most of the hospitals, if they have not done so yet, because this would benefit not only the patients but the nurses as well. It means patients will be given the necessary health care and service appropriate for the patient’s condition and the health care provider also does not suffer from any untoward illnesses.
This low nurse-to-patient ratios presents tremendous impact on patients as well as on hospitals, clinics, and health care facilities. When a hospital has limited number of nurses to care for their patients, there is the possibility of new patients being turned away from hospitals and clinics because there is not enough care staff to assist the new patients (Ulrich, Taylor, Soeken, O’Donnell, Farrar, Danis, & Grady, 2015). On the other hand, those who are admitted in the hospitals suffer, too, as nurses are overworked and are stretched beyond their limits. Thus, nurses report for work tired, frustrated, and stressed out, which makes them more prone to committing mistakes (NurseGrid, 2014). This can be resolved if the government recognizes the impact of having low nurse-to-patient ratio in most states.
References
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