The Ethical Implications of Nursing Shortages

Introduction

Nursing is a well-respected profession that offers numerous benefits such as job security, personal fulfillment, a livable wage, etc. With all of these benefits, there is one big downside to nursing that affects hospitals and other healthcare settings all over the United States: nurse staffing. The topic of inadequate nurse staffing is a popular topic that is seen not only in hospitals, but in nursing schools and healthcare facilities, such as nursing homes. The shortage leads to longer hours and greater patient loads for available nurses, pressure to work additional shifts, as well as increased stress and higher risk of personal injury. With this growing problem, ethical dilemmas and poor patient outcomes become more and more common. In this paper, I will discuss the ethical implications of nursing shortages, including the effects on patient care and stress on nurses. Additionally, I will discuss expectations for this trend, as well as possible solutions.

Ethics of the Shortage and Effects on Patient Care

From an ethical standpoint, why do nurses continue to work longer hours and additional shifts if they begin to notice negative patient outcomes, personal stress, or the feeling of burnout? One reason is that many nurses honor their duty to their patients, to the point where they feel an obligation to stay longer, take on more, or come in on their day off when asked. This mindset follows Provision 2.1 of the ANA Code of Ethics for Nurses, which discusses the patient being the nurse’s primary commitment. It seems logical that when a unit is in short supply of nurses, any extra help would be better than no help at all. This means that nurses may be coming in to help despite having inadequate sleep and time to themselves; therefore, not having proper staffing on a unit may greatly impair the level of care that each patient receives. Here in lies the ethical dilemma. Is it actually better for these tired, overworked nurses to come in and work a shift when their judgement may be impaired? If they are unable to make informed decisions or perform their work responsibilities to the best of their ability, are patients receiving evidence-based, compassionate care? By taking on additional patients, are all patients receiving the care they need? Though it may be following Provision 2.1, working this way may be violating Provision 3.4 which highlights a nurse’s involvement in the promotion of patient health and safety.

In terms of principles of bioethics that are involved in this national problem, beneficence, essentially meaning to do good, comes to mind. When coming in for a shift or staying the extra hours, the nurse may feel that they are practicing beneficence. By working extra, there is one more nurse on the floor which would cut down on the number of patients that each nurse has, thereby allowing each nurse more time to use evidence-based practice and just spend more time with their patients. While this sounds positive, that may not always be the case. In theory, this extra help should allow each nurse practice with beneficence on the forefront of their mind, but in practice will likely cause stress and burnout. The nurse working extra is more prone having decreased professionalism and exhibiting increased irritability towards patients, potentially leading to untherapeutic nursing care. The same can be said for the nurses that have to take on additional patients to compensate for the lack of nurses. For these nurses, beneficence is being violated.

Nonmaleficence, a nurse’s obligation to do no harm, is another ethical principle that comes into question with short staffing. When staffing is inadequate to meet patient care demands, patient outcomes may be poor and may even lead to increased mortality rates as evidenced by a cross-sectional study from Jane E. Ball and colleagues. This study examined data of post-surgical patients from 300 general acute hospitals across 9 countries. They found that poor staffing, which led to missed nursing care activities, resulted in a significantly higher rate of mortality within 30 days of admission to the hospital. Each additional patient added to a nurse’s workload increased the odds of patient mortality by 7%. Based on this study, it appears that nurse poor nurse staffing ratios inadvertently violate the principle of nonmaleficence in that nurses are more likely to miss necessary patient care actions related to a lack of time with each patient. These actions include care such as patient education, sterile procedures, and passing medications.

In addition to nonmaleficence, the principle of fidelity may also be at risk. Fidelity means that a nurse is following through on what they say they are going to do. When a nurse has more patients than what the state or facility allows, there is limited time with each patient. While in a patient’s room, the nurse may tell that patient that they will be back at a certain time, or that they get them something that they need. The nurse may have every intention of doing whatever it is they promised to do but may be unable to do so because of time restraints.

Future of the Staffing Issue and Possible Solution

According to the American Association of Colleges of Nursing, the nursing shortage is projected to get worse as nearly one million nurses are expected to retire by 2030. Unfortunately, the upcoming classes of new graduate nurses won’t be able to fully replace the large group of retirees. By the year 2026, though the profession is expected to grow by 15%, over 200,000 more nurses would be needed to replace the large number of nurses retiring. One area that will be hit particularly hard is the nursing home, home health, and skilled nursing community. Patient acuity in these facilities will continue to rise at a rate much higher than nurse staffing can safely handle.

Is there a solution to this shortage of nurses? If there is no solution, what can be done to alleviate the strain on nurses and improve patient outcomes? One way to increase the number of nurses in the workforce, as well as improve patient outcomes, is to create an environment of safety (Wolf et al, 2017, p. 156). For example, when passing any type of scheduled controlled substance, the nurse administering the medication should have to have witness to verify that the correct medication and dose is being passed. This action would reduce medication errors attributed to fatigue, multitasking, or other factors, and better patient outcomes. If hospitals and healthcare facilities are known for making employee safety a priority, more nurses are likely to want to work there.

Another potential solution would be for every state to have a mandated maximum nurse-to-patient ratio, so that nurses aren’t forced to take on more patients than what is safe. This intervention may aid nurses in feeling value in the work they do, while also decreasing stress and burnout. Additionally, hospitals and nursing care facilities may need to provide incentives and sign-on bonuses for all employees, not just nurses. If the entire facility is more motivated, meaning nurses, physicians, unlicensed personal, and environmental services, the workplace as a whole is more likely to run smoothly. When all departments in a healthcare facility are performing at their highest potential, patient and employee experiences can be positively impacted.

Conclusion

In conclusion, the shortage of nurses is not only damaging to nurses, but to patients as well. With nurses either too fatigued and overworked, or too overwhelmed with their number of patients. When competent care cannot be provided, nurses may face ethical dilemmas on a daily work basis. Though the problem may continue to worsen, there are interventions that may need to be implemented to improve patient outcomes and reduce the strain on nurses.

References

• American Nurse Association. (2015). Code of ethics for nurses with interpretive statements. 5-9. Retrieved from https://www.nursingworld.org/coe-view-only
• Ball, J. E., Bruyneel, L., Aiken, L. H., Sermeus, W., Sloane, D. M., Rafferty, A. M., … Griffiths, P. (2018). Post-operative mortality missed care and nurse staffing in nine countries: A cross-sectional study. International Journal of Nursing Studies, 78, 10–15. https://doi.org/10.1016/j.ijnurstu.2017.08.004
• Ethical practice: NCLEX-RN. (n.d.) Retrieved from https://www.registerednursing.org/nclex/ethical-practice/
• Rosseter, R. (n.d.). Fact sheet: nursing shortage. Retrieved from https://www.aacnnursing.org/Portals/42/News/Factsheets/Nursing-Shortage-Factsheet.pdf
• Warino, L. (2016). Shift Work: An Ethical Dilemma for Registered Nurses. Ohio Nurses Review, 91(6), 8–9. Retrieved from https://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=123832100&site=eds-live
• Wolf, L. A., Perhats, C., Delao, A. M., Clark, P. R., & Moon, M. D. (2017). On the threshold of safety: a qualitative exploration of nurses’ perceptions of factors involved in safe staffing levels in emergency departments. JEN: Journal of Emergency Nursing, 43(2), 150–157. https://doi.org/10.1016/j.jen.2016.09.003