Staffing Shortages Create Moral Dilemmas, Injuries
By Stacey Kusterbeck and Gary Evans
As part of the research for her dissertation, Denise Waterfield, PhD, APRN-NP, CCRN, AGACNP-BC, interviewed and observed 25 critical care nurses. Many seemed upset and frustrated during their shifts due to an overwhelming workload, and there was not much in the way of resources to provide relief.
Waterfield asked nurses if they felt guilty or distressed about anything related to a patient’s symptom management. One nurse recounted caring for a confused, agitated patient. The nurse knew a sitter was needed to keep the patient oriented and safe. However, no sitters were available due to low staffing, so the nurse did the next best thing — administer anti-anxiety medication.
The patient’s heart later went into an abnormal rhythm, a known side effect of the medication. “It is not certain that the medication caused the abnormal rhythm. But the nurse felt distressed about that possibility,” says Waterfield, a former nurse specialist for the University of Nebraska Medical Center College of Nursing Kearney Division.
Waterfield was curious if this kind of situation was unique to the culture of this particular research site, or if it was a universal issue. To learn more, she and a colleague reviewed the literature to examine the ethics of relationships between nurse managers and nurses, with a focus on workload. “The nursing shortage that healthcare has experienced for many years now adds to the workload of the remaining bedside nurses,” Waterfield laments.
Waterfield and her colleague searched the literature from 2017-2021 regarding care ethics related to nursing workload in acute settings.1 Ethical dilemmas, shared moral burden, time pressure, and managerial support were key issues.
For nurse managers, says Waterfield, “the important consideration is to focus on workload on their units and share the moral burden that bedside nurses are experiencing.”
Many nurses reported experiencing moral distress because they missed clinical deterioration in a patient due to overwhelming workload. “If managers are present on the units and recognize those situations in real time, they are able to role model how to handle those moments,” she says.
However, the nurse manager-nurse relationship needs bolstering in some organizations. “Proactive strategies to integrate a care ethics approach to nursing management can help replace moral burden with moral agency and thus improve patient care and reduce burnout,” Waterfield concludes.
Managers may experience moral distress themselves because they cannot support frontline nurses. Sometimes, it is because the organizational culture prioritizes other responsibilities (e.g., attending meetings). On the other hand, in their literature review, Waterfield and a colleague also uncovered cases in which nurse managers actively failed to support nurses. Some managers accused staff nurses of insubordination unless they worked overtime. Other hospitals shortened orientation to hasten the process of nurses working on their own without a preceptor because of staffing shortages. “Managers are pressured to prioritize efficiency over patient-centered, evidence-based practice,” Waterfield notes. “The moral burden needs to be shared at the organizational level.”
Managers must be present on the units to spot ethical dilemmas and intervene. For example, nurse managers can allocate someone else to answer the call lights during a nurse’s shift change. If a patient experiences delayed care, the nurse and the manager can talk through the details of what caused it.
The nursing shortage is unlikely to improve in the foreseeable future. “When more nurses are asked to work overtime and to take double shifts, patients as well as nurses are at risk,” says Paul Hofmann, DrPH, LFACHE, ethics consultant and former hospital CEO.
In an observational study, researchers found the odds of 30-day mortality increased by 16% for each additional patient added to a nurse’s workload.2 “Patients, their families, staff members, and the hospital are all likely to be compromised,” Hofmann warns.
The result for some is “moral injury,” a feeling they have violated their own ethical code, been somehow betrayed, or seen others take actions they disagree with. The term was coined to capture the damage inflicted on combat soldiers, many of whom have seen things they cannot unsee, and return home with those quiet, 1,000-yard stares.
Wendy Dean, MD, co-founder of Moral Injury in Healthcare, began working with soldiers who were returning from Vietnam. “What these soldiers were experiencing was, ‘I know what the right thing to do is, but I’m being asked to do something different by my leadership,’” she says. “I have a choice. I can stand up and I can push back, or I can do what’s asked, but what that results in is a transgression of deeply held beliefs and expectations.”
Compounding longstanding dysfunction in healthcare delivery, the COVID-19 pandemic created similar conditions for healthcare workers.
“I know what my patients need, [but] I can’t get it for them,” Dean says. “In healthcare, those deeply held moral beliefs are the oaths that we took to put our patients first. In the context of the pandemic, we know all of us were in this bright awareness of our mortality. There’s a psychological construct called mortality salience, where when you’re faced with your own mortality, you become intensely aware of what your priorities are.”
If you are stuck, choose action over paralyzing dilemmas, Dean recommends. “When you’re feeling helpless, act,” she says. “A simple act of doing something can lead to less feeling of helplessness, hopelessness — it can even be the smallest step.”
REFERENCES
- Waterfield D, Barnason S. The integration of care ethics and nursing workload: A qualitative systematic review. J Nurs Manag 2022; Jun 15. doi: 10.1111/jonm.13723. [Online ahead of print].
- Lasater KB, Aiken LH, Sloane D, et al. Patient outcomes and cost savings associated with hospital safe nurse staffing legislation: An observational study. BMJ Open 2021;11:e052899.
As part of the research for her dissertation, Denise Waterfield, PhD, APRN-NP, CCRN, AGACNP-BC, interviewed and observed 25 critical care nurses. Many seemed upset and frustrated during their shifts due to an overwhelming workload, and there was not much in the way of resources to provide relief.
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