Placing ethics at the heart of safe staffing: debates on safe staffing are bound to fail if they do not include ethics at their centre.The paucity of adequate ethical debate within health care in general, and in the area of safe staffing in particular, has tong been of concern.
This apparent paucity of moral debate is not, however, merely a problem within the health care delivery system itself. It occurs within nursing as welt. Consider, for instance, some of the key documents produced by nursing sources over the years on the topic of safe staffing. In the International Council of Nurses' 2006 document Safe staffing saves lives. Information and Action Tool Kit, the word "ethics" appears but once and very briefly, in relation to the international recruitment of nurses.
In the Australian Royal College of Nurses' (2003) document entitled Submission to the Australian Council for Safety and Quality in Health Care Discussion Paper: Safe Staffing, ethics turns up again, only once, this time in a fist of national nursing networks. Finally, NZNO's own 65-page document Report of the Safe Staffing/ Healthy Workplaces Committee of Inquiry (2006) contains 249 instances of the use of the word "nursing" but no instances at all of the word "ethics", although it does mention "professional liability" in relation to care. All around us there is ample evidence that no debate on safe staffing can properly proceed without first placing ethics at the heart of the debate. (1,2,3)
Nursing remains a largely altruistic, benevolent and caring profession that stilt operates within society under a type of social contract, regardless of what modern spins are placed on this rote. I do not easily accept that nurses have "thrown in the towel" when it comes to delivering health care with the best of moral intentions. Indeed, I know of plenty of nurses who have not done so, but who, like me perhaps, are now finding their moral foundations severely disturbed by recent events. A great number of these events are, in fact, not personal failures but disturbances to the contextual mechanisms that normally enable nurses to practise within their expected duty of care and their long established moral codes and mores. In this regard, we now seem to face one moral crisis after another within health care, caused not by those few nurses who inexplicably choose to behave immorally or amorally, but by faulty staffing and skill-mix ratios, morally dubious management practices and unsafe workplaces. These barriers to good practice are as much of ethical concern as any argument about the professional responsibilities of nurses and doctors. Indeed, it is virtually impossible to maintain the latter without the former, and vice-versa perhaps.
An age of techno-science
We now appear to live in an age where moral appeals to ethical first principles within health care, such as, for instance, the "first do no harm" principle in medicine or "the hospital should do the patient no harm" in nursing, seem to be either taken for granted or simply considered irrelevant in the wider scheme of things. This era is dominated by techno-science and economic expediency, where words such as "quality" and "efficiency" and "risk management" are commonplace, but words such as "ethical duty", "beneficence" and "avoiding harm" are largely relegated to either academic literature or political rhetoric.
Words today often mean quite different things to different people, and frequently any old collection of placating language is offered to the public with more than a fair share of irony. In such an age, which seems to represent the perpetual Orwellian nightmare scenario, safe staffing, healthy workplaces and even health care itself are part of a national tottery involving those with the highest linguistic capital.
Yet for all that, the majority of nurses know what good health care means, and are fully aware, one way or another, of their professional responsibilities and duty to care. The majority of our patients--or "clients" if you wish to use new speak--are predominantly vulnerable. We accept we should care for them with professional skill and dedication; and we continue to believe in a health system where providing safe and "harm less" care is the norm for all.
Our hospitals, however, are not always such havens for the vulnerable, and they harm their patients in a number of ways, including actions that can lead to premature and unnecessary death. Some of these deaths, perhaps many, are attributed to individual error, often by a physician. There is evidence that in developed nations such as our own, iatrogenic causes of death are often much more common than most would believe. (4)
However, in an ethical analysis of the most significant incidents in our hospitals over the last decade, a great deal of evidence highlights not just the moral responsibility that each and every health professional must accept and exhibit, but also that such a responsibility is a shared one.
Consider the 1998 report by the Health and Disability Commissioner into Canterbury Health Ltd, and perhaps one of the more recent reports from the same office concerning "Mr A" and Capital Coast Health. (5,6) In both instances, patients died from a variety of preventable causes. Lives were lost, not necessarily because nurses and doctors couldn't care less, but because that care had to be offered within a context of "carelessness", ie in the absence of safe staffing and healthy workplaces. This context was laid bare by the Health and Disability Commissioner of the day who offered reasons such as:
* lack of appropriate policies and standards by the Ministry of Health;
* insufficient funding, or monitoring and cooperation from the funding authority;
* poor hospital management practices;
* failure to heed clinical staff advice; and
* substandard care with insufficient staff and levels of skills. (5)
In the case of Mr A at least, individual nurses and doctors were also castigated by the Commissioner for their Lack of care and attention. (6) But the Commissioner also vented equal measures of moral outrage on those who allowed morally dubious and highly unsafe situations to occur without finding better ways to deal with them, either at the time or sometimes even afterwards. In short, needless deaths have occurred, not necessarily because individual nurses and/or doctors chose to behave unethically, but because of the lack of adequate staffing leading to safety issues. Such deaths are the result of a type of shared neglect of one form or another. This is as much a moral as a national disgrace.
Who is morally responsible?
The word "neglect" tends to suggest that someone or some group or other has been neglectful, either deliberately or through indifference. The question is, therefore: "Who is morally responsible when a patient dies unnecessarily in a modern city hospital and there are too few staff to care for every patient in the ward in a full and safe manner?"
There are a number of possibilities, but here is perhaps a clue: "While generally the care provided by nurses through the 1996 winter was to the best of the nurses' ability, there is evidence to show that staffing numbers, skill mix and patient volumes affected nurses' ability to meet parent needs. The high utilisation of casual nurses during 1996 compounded skill mix difficulties and the ability to develop the expertise of the casual nurses. Staff did not always have adequate experience to cope with outliers. This situation compromised the quality and safety of patient care. While many potential system problems and staffing problems had been presented to management prior to the restructuring at Christchurch Hospital little was done to address them and this compounded the problems during the winter of 1996." (5)
And so to the final question: "What then, is the duty of care, and should nurses say no to unsafe staffing situations?" All those involved in delivering care--from the nurses and doctors on the floor, through to middle management to higher management, to the district health board and on to the Ministry of Health and the government itself--share a duty of care. It is both a Legal and a moral requirement that cannot be ignored or treated lightly. Yet, when I ask postgraduate nursing students, "What is the 'good' that is desired in nursing ethics?" they reply by first stating the shared moral norm that is something Like: "Meeting the nursing needs of our patients/clients in ethical ways." But then they go on to argue that to achieve this they have to either:
* compromise their ethics to satisfy the demands of the system; or
* subvert the system quietly for the good of their patients.
Nurses do exactly these things to try to achieve their primary aim. That nurses have to resort to such practices on a daily basis in our nation's hospitals is a sad and shameful indictment of a troubled and flawed health system that demands good clinical practices but does not supply the wherewithal for them to fully occur.
It is not a difficult argument. If there are only two nurses on a busy medical ward at night, one a registered nurse and the other an enrolled nurse, and the ward is admitting acutely ill patients and several of the existing patients are acute cases requiring frequent and highly skilled attention, then it is crass and callous to argue the nurses will just have to manage somehow because nothing can be done about it. Such hypocrisy, at any of the levels of responsibility, is nauseating to say the least A nurse cannot practise in a fully ethical sense under conditions where it is virtually impossible to deliver safe nursing practice Individual nurses and doctors cannot continue to be held morally accountable in those situations where it is clear to even the casual observer that the context cannot support the attempts of moral agents within to maintain good practices As it states in NZNO's recently published guide on nursing obligations in a pandemic or a disaster," ... the limit of what is expected of a reasonable nurse ... in that particular situation has been reached." (7)
Nurses are expected to cope with rapid change in a complex health system that values the "bottom line" and efficiency while sustaining excellence in caring and healing practices. Despite barriers to excellence in nursing practice, such as diminished resources, time constraints and perceived threats to quality of care, many nurses perform what is truly "good" work, even though they Live constantly in a state of "moral distress" (8)
As a recent nursing commentator said: "Good work in nursing is defined as work that is technically and scientifically effective, as well as morally and socially responsible. When nurses perform good work and remain committed to excellence, they experience fulfilment as they contribute to the well-being of their patients. Experienced nurses committed to excellence during challenging times serve as exemplars for others seeking to sustain a commitment to good work." (9)
It is our moral duty to ensure we do not loose any more good nurses and that the conditions they work in are safe and healthy for the good of all. We want a healthy workplace, but we need an ethical work environment first.
(1) Bickiey Asher, J. (2006). Ethical staffing--there can be no compromise. Kai Tioki Nursing New Zealand; 12: 3, 20.
(2) Woods, M. (2005) The moral purpose of nursing: ethics in action Koi Tiaki Nursing New Zealand; 11: 4, 2.
(3) Woods, M. (2007) Caring for people as persons: Revisiting a nursing ethic of care. Paper presented at the Australasian Nurse Educators conference, Te Papa, Wellington, October 4
(4) Starfield, B. (2000) Is US health really the best in the world? The Journal of the American Medical Association; 284: 4, 483-485.
(5) Health and Disability Commissioner (1908) Canterbury Health lid: A Report by the Health and Disability Commissioner April 1998 www.hdc.org nz/publications Retrieved 05/05/08
(6) Health and Disability Commissioner (2007) Capital and Coast District Health Board: A Report by the Health and Disability Commissioner (Case 05HDC11908) www.hdc.org.nz/complaints. Retrieved 05/05/08
(7) New Zealand Nurses Organisation (2008) Obligations in a pandemic or disaster: A guide for NZNO members. Wellington: author
(8) Codes, M.C., Minick, P., Elswick, R. K. & Jacobs, M. (2005) Nurse moral distress and ethical work environment Nursing Ethics, 12: 4, 381-390
(9) Miller, J.F. (2006) Opportunities and obstacles for good work in nursing Nursing Ethics; 13: 5, 471-487.
Martin Woods, RN, MA, PhD, is a senior nursing lecturer in the School of Health Sciences at Massey University, Palmerston North. This article amplifies an address he gave at NZNO's symposium on safe staffing and healthy workplaces in May this year.