- Dwayne Potenteau
During one of my experiences in hospital I was assigned to a nurse in Telemetry. The nurse (we will call her Susan) had been on shift for about an hour and was already working at a torrid pace. In addition to the clients she had to monitor which were 8 in total, the Rn was also assigned 6 patients to care for. Most of the clients were from ICU or had been assigned to her due to the overflow from the emergency department. One patient in particular (Mrs. Smith) had multiple symptoms starting with hepatic encephalitis with ascites and varices, diabetes, and had been admitted due to atrial fibrillation which had been downgraded to a controlled rate of atrial fibrillation when the nurse came on. The time needed to care for this complex client had to be somehow scheduled into the nurses’ duties to care for the clients on telemetry in conjunction with the other 5 clients. The new order for Mrs Smith had also been changed and a new large dose of 22 units of rapid and 42 units of NPH insulin had been modified by the physician. The nurse questioned the order and stated her concerns over the dosage but was told to administer and monitor the client. The dosage along with the limited amount of time to monitor the client posed a larger concern for developing hypoglycemia. The nurse then called in her manager stating the issues of providing care with limited time and nursing complex patients. The manager stated that the nurse just has to deal with it as there was no help available at this time. Reflecting on the experience I felt stressed and a little overwhelmed at the idea of being responsible for so many patients with little time, resources and support. I responded to the situation by providing some relational practice as this was a community experience and I could not actually do much but shadow the nurse. The nurse did not have the time or adequate support in staff to care for the clients other than their immediate urgent needs. The biggest ethical issue I had was determining how could a nurse fulfill their nursing duty to provide safe, compassionate competent care with limited resources.
The rising costs of health care have increased the number of clients the nurses must care for and are under stress to keep costs down. As a future nurse, this means taking on a larger workload. When resources are low nurses face the problem of fulfilling the ethical responsibility of prioritizing care while trying to maintain a high professional standard of client centered care for all patients(Canadian Nurses Association[CNA], 2008). The other ethical concern is where do we go to express our concerns when issues such as limited resources prevent us from performing our ethical duties? The last is the amount and quality of care we give when our nursing values are compromised by limited resources.
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The aforementioned issue revolves around the allocation of resources also known as rationing of care. In nursing, rationing of care can be defined as the withdrawal of necessary components due to the lack of resources (Carryer, 2014; Tonnessen, Nortvedt, Forde, 2011).The reasons for rationing of resources for health care can be linked to 3 main levels. Societal where funding for health care is provided from the government, Institutional, where health authorities and agencies determine which programs receive funding, and individual where professionals determine how to treat individual clients (CNA, 2000). Nurses face the scarcity of resources on a daily basis. This type of infrastructure pressures have forced nurses to make ethical decisions such as distributive justice(Tonnessin et al. 2011). Tonnessin et al. (2011) states that distributive justice is the allocation of resources to those who need it most. The In order to decipher who receives care nurses often need to make these decisions quickly and effectively. To make these decisions, nurses often call upon their own prioritize their clinical judgements. The hastened assessments and interventions increase the chance of reduced patient care outcomes (Papastravou, Andreou, Vryonides, 2014). The imbalance between time to care for the client and the stresses of limited resources leads to moral distress in deciding what is best for the client as the individual or community as client. Susan had shown that she was torn between serving all her clients and attending to the most critical.
Corporate Influence Allocation
Utilitarianism is defined as the benefit of the whole outweighs the benefits of the individual. By maximizing time allotted for in caring for the client, the nurse performs only the most necessary procedures. This process deviates from the individualistic care that is required in nursing. Reduction in time allocated for patients, reduced beds, and lengths of stay all lead to reduced care and capacity for choice in a client’s health (CNA, 2000). Part of the reason for the stresses can be linked to the health care system that determines allocation of resources. According to the CNA, corporate values and resulting policy are determine resource allocation through the ideology of economics and scarcity (CNA, 2000). The ideology revolves around the notion that economics and unattainable resources contribute to and justify limited resources for nurses(CNA, 2000). Urban (2014) furthers the corporate culture of scarcity by noting that nurses have come to accept the idea of reduced time, staff, and resources as part of their normal working environment. The fact that nurses had to work with inadequate resources while still being fiscally responsible and giving safe effective care had to has lead many nurses to a state of moral/ethical distress.
The concept of moral/ethical distress is changing. Even the Code of Ethics which is the governing body for assisting nurses in their decision making has modified over the years. According to the CNA the word “expectation” had been removed in the 2008 definition of ethical/moral distress (CNA, 2002). Although the definition encompasses what nurses feel when working with limited resources the removal of the word shows an acceptance of the changing culture. The actual definition for ethical/moral distress has changed so has the duty to “assist persons to achieve their optimum level of health in situations of normal health, illness, injury, or in the process of dying” (CNA, 1997, p.8). The removal of this component of nursing duty clearly shows the effects of limited resources. In particular the omission of the word “optimal” has been removed from the standards, and only found in the definition of global health (CNA, 2008). The removal of the word optimal contradicts the actualization of limited beds for patients and bedside care. The contradiction can heighten the difference in how nurses have been educated in providing care and the care they actually give. The discrepancy in giving care due to limited resources leads directly to moral distress. The leading element of moral distress is the lack of time spent with the patient (CNA, 2000). Limited time leads to reduced care, opposing ethical values of how a patient ought to be treated.
Moral Community for Nurses
Moral Community is defined as a community where values are understood and used to guide ethical actions of the community (CNA, 2008). Although the actual issue of limited resources may not be directly addresses at the nursing level within a hospital, setting up a moral community in the department is a good first step. Nurses have knowledge in direct patient care and the education to determine what role and working environment they want to participate in. In order to address moral distress due to limited resources nurses need to work with their fellow nurses, managers, and policy makers to make these changes. Examples are nurses communicating on ethical issues through their unit and ethical committees in the hospital. Park notes that nurses tend to deal with ethical issues using their own beliefs and values rather than using ethical committees. In addition Kalish (2009) notes that repercussions on speaking about on ethical issues may deter nurses from participating in ethical discussion or committees. To have the courage to face the stresses of the current nursing environment nurses must embrace moral courage. Moral courage is the ability of a nurse to remain loyal to their moral belief or principle when faced with fear or threats (CNA, 2008).
The role of moral courage and ways to address ethical concerns, and moral ethical dilemmas can also be found in nursing associations such as ARNBC (Association of Registered Nurses of BC), and CRNBC (College of Registered Nurses of BC). Since 2005 CRNBC had moved from an association towards a regulatory body and in doing so, had left gaps in how nurses can communicate ethical issues such as limited resources. One of the resources that has been available since 2013 is ARNBC. ARNBC’s mandate to provide communication and act as a voice for the nurses of BC, and also work towards sustainable practices and support structures for nurses (ARNBC, 2015). Since 2005, nurses had no real place to communicate ethical issues such as limited resources and although they had the union, no real avenue to tackle the policy issues or to influence change in their community. In order to improve working conditions ARNBC can support nurses through inter collaboration, and supporting professional practice and advancement of the profession. Through these avenues, nurses now have a way to address their ethical concerns not solely focused on limited resources.
Another avenue to address limited resources is through CRNBC. Through crnbc nurses can address the limited resources by defining the issue, communication, documentation, and intercollaboration. Defining the issue in the case with susan, claritfication on allocation of 6 patients which is more than the standard amount of patients. Nurses should communicate their problems with their managers and coordinators.
When providing patient care, observation to what is present and what is influencing nursing practice is crucial to improving overall care. Limited resources leads to rationing of care resulting in less bedside care for patients and presents and ethical dilemma in upholding our
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