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Ethics and Patient Safety

Subject: Nursing
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The Ethical Implications of Inadequate Staffing in a Healthcare Organization

In most countries, including the US, persistent nursing shortage is a common challenge that affects the beliefs and values of the professionals. For many nurses, issues of inadequate staffing hinder their ability to fulfill professional obligations to patients optimally. As a result, some tend to complain of emotional stress and job dissatisfaction, especially if burnout ensues (Oh & Gastmans, 2015). Ultimately, the nurses are more likely to end up in dilemmas, where they either have to choose to prioritize their professional mandate for their patients or opt to care for their own welfare and needs.

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Accordingly, although nurses are ethically required to protect patients from harm during their service, the resultant dilemma of shortage in staffing increases their workload, which intensifies the likelihood of poor patient care (Frith, Anderson, Tseng, & Fong, 2012). In other words, in the face of overworked nurses who are emotionally distraught and professionally dissatisfied, the goals set by the hospitals for caring for several patients at once are unrealistic and thus lead to poor quality care.

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Moreover, due to the decrease in the satisfaction that nurses get from the increased workload, most nurses find it hard to make proper and moral decisions. Under normal conditions, the emotional stability of nurses, which is partly a consequence of job satisfaction, forms the moral compass for decision-making. However, during acute shortages of staff, nurses are continuously under pressure to meet set goals of care while struggling to remain happy and satisfied with their work (Ulrich et al., 2010). Although some institutions compensate nurses for the overtime worked, the decrease in job satisfaction, in reality, means that nurses cannot offer care to patients out of intrinsic morality and are therefore likely to settle for the basic minimum instead of optimal service.

Strategies to Help Plan for and Avoid Inadequate Staffing

To avoid inadequate staffing in nursing, it is critical to understand the main pitfalls that cause the problem. For example, one of the main contributors to the issue is the commonly used top-down scheduling approach, where unit managers assume the responsibility of determining the number of employees per shift. Whereas the system allows for ease of management, it limits the input and involvement of ordinary nurses in the staffing process. Therefore, the first solution to the problem is to include all nurses in staffing (Gooch, 2016). In hospitals, the distribution of the scheduling of tasks allows nurses to request rosters according to their preferences and satisfaction. The outcome is improved productivity, especially since managers tend to have more free time to monitor junior nurses and focus on motivating their employees.

The second common issue that results in the shortage is staffing is inflows, where managers pay little regard to match nurses with the needs of patients. In many hospitals, unit managers tailor staffing to their specific needs, which eliminates the possibility of implementing an organization-wide strategy. In practice, that means that whereas some units are likely to send their nurses home for leaf due to low patient turnout, others will probably pay their workforce overtime to compensate for the increased workload (Gooch, 2016). Therefore, to resolve the issue, an organization-wide system is needed to match the workforce with the needs of patients and improve interdepartmental communication and visibility.

Finally, shortage of staffing occurs due to the lack of standardized policies in health institutions. To avoid nursing shortage in an organization, regulations about holidays, overtime, and incentive programs ought to be standardized in the organization (Gooch, 2016). According to researchers, employees are more likely to be motivated by the equal and fair treatment that ensures equity in an organization. In other words, standardization of staffing practices promotes the perception of equality and eliminate actual inequalities in treatment of workers.

The Impact of a High Patient to Staff Ratio on Quality of Patient Care

According to Jarrar, Abdul Rahman, and Shamsudin (2015), increasing patient to nurse ration is associated with the negative outcome of care. Typically, higher patient to staff ration creates a mismatch between the flows of clients and the level of nursing. It increases the workload of nurses, which lowers the overall outcome of care. In contrast, lower patient to nurse ration improves safety in care. Due to the more workload, nurses tend to be more dissatisfied with their jobs, and are thus likely to be negligence in care. The result is increased hospital stay for patients, due to the poor care offered by overworked and underappreciated nurses. Some researchers also report an increase in the mortality rate in cases where the patient to nurse ratios exceed 8:1, especially in settings where the clients require more critical care.

Analytically, the negative outcome of patient care that results from the high client to nurse ration is a function of low motivation, burnout, moral discouragement, and reduced job satisfaction. Since higher ratio translates to more work for nurses, and in some cases without the added incentive of overtime pay, most experience burnout. It reduces their ability to make moral and ethical decisions since they are inclined to favor their wellbeing at the experience of the patient. It also results in demotivation, not only with the job but also with their career, which if not addressed in time, is likely to cause negligence and potential changes in the profession. Overall, high patient to nurse ratios lower the quality of care offered to clients (MacPhee, Dahinten, & Havaei, 2017).

The Medical Errors that Occur as a Result of High Patient to Staff Ratio

High patient to nurse ration is associated with reduced mortality, lower staff motivation, burnout, and increase in job dissatisfaction, which are factors that contribute to the occurrence of medical errors. In practice, common failures during the discharge of nursing duties that are evident in a hospital setting occur in areas of drug preparation, administration of medication, documentation, patient surveillance, and equipment use (Frith et al., 2012). The errors are commonly apparent due to the ineffective communication and reduced supervision that is experienced when nurses are overworked due to their few numbers compared to the flow of patients.

Moreover, although nurses are trained to notice and address the errors mentioned, most fail due to the emotional burden of the high patient to staff ratios. The increased workload and lowered motivation tend to overcome their coping abilities leaving them vulnerable to negligent practice. Instead of using constructive changes and modification to adapt to the increased workflow, most resort to shortcuts that are aimed at reducing the pressure of the job and increasing the rate of patient clearance. Ultimately, the adopted changes in practice become a primary contributory factor to the errors apparent in nursing (Hoskins, 2013). According to nurses, other common aspects such as poor physician handwriting, distraction, and exhaustion are the main causes of the errors of dose miscalculation, wrong documentation, incorrectly set up infusion devices, and confusion of patient medication that sometimes results from high client to staff ratio.

The Strategies an Organization Can Use to Plan for and Avoid High Patient to Staff Ratio Situations

Although no magical method has been proven effective in avoiding high patient to staff ration scenarios, some of the prescribed approaches require focusing on the supply and demand issues. On the supply side, some of the factors that hospital managers need to monitor include the keeping in touch with specialized and scarce nurses, ensuring availability of medical resources (besides staff) to match patient needs, and watching labor market trends. They should also have ready funds for overtime salaries, continuously improving the education capacity of health professionals in anticipation for changes and addressing other barriers to hiring nurses for short-term durations. The idea is to ensure that the human factor is not the only challenge that leads to errors associated with the high patient to staff ratio (Buchan & Aiken, 2008). For example, if nurses would work in an environment with the readily available medical resource, despite the increased workload, they are likely to adapt easily compared to others in a workstation with limited materials

On the demand side, hospital managers should regularly monitor epidemiologic and demographical trends and remain updated on macro-economic confusion and service use patterns. The objective is to ensure that the institution is prepared to rapid changes in the patient inflow, which is a necessary factor in helping nurses to be prepared physically, professionally, educationally, and mentally for changes in their level of activity and duty. It helps maintain a level of awareness and improves the coping skills of nurses before the workload increases.

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2. Frith, K. H., Anderson, E. F., Tseng, F., & Fong, E. A. (2012). Nurse staffing is an important strategy to prevent medication errors in community hospitals. Nursing Economics, 30(5), 288.

3. Gooch, K. (2016). 5 Staffing Strategies for Engaged Nurses and Better Patient Outcomes. Becker’s Healthcare, 1–14. Retrieved from http://www.apihealthcare.com/sites/default/files/5-Staffing-Strategies-for-Happier-Nurses.pdf

4. Hoskins, K. (2013). The possible role of burnout in nursing errors.

5. Jarrar, M., Abdul Rahman, H., & Shamsudin, A. (2015). The impact of patient to nurse ratio on quality of care and patient safety in the medical and surgical wards in Malaysian private hospitals: A cross-sectional study. Asian Social Science, 11, 326–332. https://doi.org/10.5539/ass.v11n9p326

6. MacPhee, M., Dahinten, V. S., & Havaei, F. (2017). The impact of heavy perceived nurse workloads on patient and nurse outcomes. Administrative Sciences, 7(1), 7. https://doi.org/10.3390/admsci7010007

7. Oh, Y., & Gastmans, C. (2015). Moral distress experienced by nurses: A quantitative literature review. Nursing Ethics, 22(1), 15–31.

8. Ulrich, C. M., Taylor, C., Soeken, K., O’Donnell, P., Farrar, A., Danis, M., & Grady, C. (2010). Everyday ethics: Ethical issues and stress in nursing practice. Journal of Advanced Nursing, 66(11). https://doi.org/10.1111/j.1365-2648.2010.05425.x

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