Nurses should make ethical choices in staffing
Nurses should make ethical choices in staffing
Some urge discussion of managed care in ICUs
(Editor’s note: The following article is intended to encourage readers to think about management ethics in the workplace. Sources quoted are expressing their opinions only; their views are not intended as the last word on the subject.)
Is there a place for medical ethics in critical care nursing? Ethics plays a crucial role in patients’ end-of-life situations: How long should terminally ill patients be kept on expensive life-support systems? Are scarce medical resources better spent on the young, who generally don’t use as much, or should they be devoted equally to the elderly, who need services more often but may have exhausted their productive capacity for society?
These are ethical questions in search of answers. But for nurse managers, another set of ethical issues closer to home rarely is discussed in public, says Diann Uustal, RN, MS, EdD, president of Educational Resources in HealthCare, a clinical ethics consulting firm in East Greenwich, RI. Nurses need to be reminded that their decisions on adequate nurse staffing coverage should be based on what is truly best for patient care and outcomes, not on factors that involve higher productivity within the department or other non-patient-related priorities, she says.
Providers often forget what brings patients to hospitals in the first place: the level of nursing care, Uustal says. Yet financial considerations often take precedence over nurse-staffing requirements and may compromise good patient care, she observes. "Hospitals are struggling to devise an ideal nurse staffing formula. But they’re going about it with a set of mandates that don’t necessarily put the patient first or involve a benefit for that patient."
A number of bioethicists have expressed similar views in most other areas of health care. Essen tially, they say there’s an important need for ethics discussions in day-to-day decision making within health care systems, especially intensive care units, which deal almost daily with crucial clinical quality factors and end-of-life issues.
What’s driving this concern for ethics in health care? Managed care, Uustal says, but that’s only part of the issue. Hospitals also are at fault for aggressively trying to meet the financial demands of a system that today is largely driven by cost considerations, she says.
Critical care units are relying more and more on part-time nurses to staff their shifts. They are constantly looking for subacute care options. Staffing ratios are under constant review. Veteran nurses are being replaced with younger, less experienced staff and recent graduates. Meanwhile, patients find themselves in the middle of a raging debate over costs, Uustal notes.
Tougher issues now than before
But not everyone agrees. Sally Millar, RN, MBA, for instance, says there isn’t necessarily an ethics gap in critical care medicine or in health care generally. Millar is director of clinical support services at Massachusetts General Hospital in Boston.
"True, we’re facing much tougher ethical issues today than we have before," she says. "There are issues involving [the] right to die, pollution, [and] AIDS funding. But as health care professionals, our goals haven’t changed. However, the way we get to them may have."
More than a decade ago, the National Insti tutes of Health in Washington, DC, convened a panel of critical care nurses and physicians to arrive at a consensus on optimum delivery of critical care medicine. "An intensive care unit combines the capacity to provide needed care and technology with a potential to do great harm," the panel cautioned.1
It went on to say the following: "Within each ICU, [the] organization should be structured to insure proper care of the total patient." At the time, the NIH group didn’t factor in the potential effects of managed care on the ideal management of an ICU. That would come years later. But managed care is a reality that most administrators can’t escape from, like it or not, Millar observes.
Equipment brings about change
While it’s created financial limitations, it also has helped nurses and physicians work smarter and has brought them together to achieve the same results — rendering the highest possible level of medical care, she adds. "I can only speak about Mass General. But last year we undertook a major operational improvement that has greatly enabled us to improve patient care services. Is it a result of managed care? Yes."
One such change occurred in October when the hospital switched to an automated computer-driven medication ordering system. It’s taken from an extremely successful one introduced locally by Brigham and Women’s Hospital nearby.
"It has the potential to greatly reduce errors in our present medication ordering system and integrates clinicians throughout the hospitals so that everyone is working on the same set of criteria," Millar says. Innovations such as this one are examples of how providers are creating efficiencies from limitations.
Nevertheless, Uustal urges nurses to take a larger hand in balancing the scales. Decisions that affect patients are being made for budget considerations. Nurse managers in particular can help even out the playing field, she adds.
As concern grows over the balancing of cost effectiveness and delivery of care, the debate is likely to get stronger. Nurses are in a powerful position to help effect changes because they continue to be at the heart of the where health care is rendered — at the bedside, Millar observes.
Reference
1. National Institutes of Health. Consensus statement. Critical Care Medicine 1983; 4:1-26.
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