Ethical staffing--there can be no compromise: safe staffing is an ethical issue. Nurses need moral courage and organisational support to ensure they work in an environment where they can practise ethically and patients receive the best care possible.

Safe staffing is about the right number of nurses with the right kinds of skills, at the right times, for the right patients in the right environment. The Committee of Inquiry into Safe Staffing and Healthy Workplaces, arising from the 2004 multi-employer collective agreement for district health board nurses and midwives, has investigated these requirements and we are looking forward to reading the report and supporting the recommendations. Happily, this issue which we are so focused on in New Zealand is also the theme for this years International Nurses' Day on May 12. The International Council of Nurses has provided a kit which is bursting with useful information about how to make the argument for safe staffing. (1) For example, it makes the obvious Link between unsafe staffing and patient outcomes. It refers to nurses feeling compromised when there aren't enough staff and it provides evidence of negative effects on nurses' health. The kit also mentions the negative effect that international recruitment has on nursing numbers in developing countries. What seems to be missing from the kit is the argument that safe staffing is an ethical issue.

Why is safe staffing an ethical issue?

To be fair, an oblique reference is made to the ethical obligations of the nurse on page 12 under the heading "Professional liability" (1) It warns nurses that they may be held professionally liable for care. This suggests nurses have an ethical obligation to provide care and that if they don't provide it, they may be called to legal account. This can eventuate even when there are not enough staff to provide adequate care. That professional and legal liability is a reality for health professionals in New Zealand and has been most starkly demonstrated in the recent High Court trial of a midwife in Dunedin. While this particular case does not appear to have been about unsafe staffing per se, the fact that it happened will be a reminder to midwives and nurses of their accountabilities. For the individual nurse, ethical responsibility is a key aspect of professional judgment. This kind of judgement involves intellectual reasoning and moral decision-making. It requires moral and ethical knowledge. All nursing acts are ethical acts. Nurses require the right number of nurses with the right kinds of skills, at the right times, for the right patients in the right environment in order to practise ethically. If the nurse judges there are not enough staff to provide safe care, s/he is ethically compromised. S/he has too many people to care for and not enough time. S/he experiences this as knowing what patients need but not being able to provide the necessary care. Not being able to do the right thing leads to anger, frustration and a sense of betrayal. The name for this progression from ethical knowledge and practice to emotional disorder is moral distress. (2) There can be benefits from this because it can provide the basis for practice change and learning.

But what about those nurses whose moral distress is not alleviated? At an individual level they are likely to suffer ill health and burn out. The significant consequence for safe staffing is that they will leave the job and leave nursing. This action will exacerbate the very situation that drove them to distress. Even fewer nurses will be left to face an even greater number of patients. I have talked with many nurses who can identify with this situation. It is one of the explanations for the nursing shortage both here and overseas. It becomes harder to recruit nurses, patient care costs and complaints increase, and there is bad publicity.

Moral courage

At an individual level, moral courage can act as a counter to moral distress. This involves taking a stand in the organisation in which the nurse works. One way of doing this is to complete an incident form when there are not enough staff available to provide safe care. The British Columbia Nurses Union (BCNU) calls such forms Professional Responsibility Forms. In British Columbia nurses report the event and circle the nursing standard they have been unable to meet. As well as lodging it with their employing organisation they also copy it to their BCNU delegate. It is then up to the employing organisation to read the form and act on it (3). This will convince nurses that completing such forms is worthwhile. It will show it is possible to solve problems in an open way without risk. At an organisational Level, providers must create an environment which convinces nurses:

* that they are working in a constructive culture,

* that they can have good relationships with their medical and management colleagues;

* that they have sufficient influence in the workplace; and

* that the ethical complexity of their work is recognised and respected.

When these elements are evident the organisation will gain a reputation for providing a morally comfortable climate. Only when these things are attended to will moral distress go away and nurses stay. Those responsible for embedding safe staffing in our health facilities should ponder on these things. After all, supporting ethical nursing practice is probably the most efficient way of improving patient outcomes.

References

1) International Council of Nurses (2006) Safe Staffing Saves Lives: Information and Action Tool Kit. Geneva: International Council of Nurses.

2) Corley, M. C. (2002) Nurse moral distress: A proposed theory and research agenda. Nursing Ethics: An International Journal for Health Care Professionals; g: 6, 636-650.

3) British Columbia Nurses" Union Professional Responsibility Complaints Form./zm opeiu-15 G:\users\COMMUNIC\CAMAPAIGN\2003\PRF\BCNU PRF Retrieved 24/03/06

NZNO professional services manager Joy Bickley Asher