Editor’s note: In March 2016, Leah Curtin RN,ScD,FAAN, a living legend in nursing for her work in ethics, was asked to address the American Nurses’ Association meeting on the ethics of staffing. What follows is a summary of her remarks.
One of the things about having a graduate degree in linguistic analysis is that it makes one very particular about the use of language. For example, one of the problems for me in giving a speech about a “conversation” is that it is by definition informal, oral, and interactive! Moreover, there are principles that are supposed to guide them. Called the Gricean Maxims, they really help clarify matters – and they do involve ethics. For example, the first Grician Conversation Supermaxim is to try to make your contribution one that is true, which automatically means that you do not say what you believe to be false nor do you say that for which you lack evidence.
Another one of Grice’s maxims involves quantity, which merely means that you make your contribution as informative as is required and do not go into such detail as to pull the conversation off track. This suggests that what you add should be relevant. While tersely stated this maxim is quite problematic for the purpose of discussing safe staffing: numbers of patients, education of nurses, experience of both nurses and patients, amount and type of support staff, patient acuity, nursing specialization, the nurses’ and the patients’ age, comorbities, presence or absence of family, and even the architecture of a building can affect what is safe staffing. That being said, there has been so much research done in the last 20 years, it can honestly be noted that so much medical, nursing, and systems research has been published that we know that something as simple as ratios of patients to RNs improves care, and also that the experience of nurses improves care, and that the education of nurses improves care.
The subject of safe staffing
Because this subject is complex, the next Grician Supermaxim is critical: what you say must be clearly expressed and easily understood. This requires that all parties to the discussion:
- avoid obscurity of expression
- avoid ambiguity
- avoid unnecessary verbosity
- present their contributions in an impassionate and orderly manner.
Those who follow the cooperative principles in this conversation further the purpose of staffing that is safe for the patient, safe for the nurses, and safe for the institution. For example, the American Nurses Association contends that ensuring adequate staffing levels has been shown to:
- reduce medical and medication errors
- decrease patient complications
- decrease mortality
- improve patient satisfaction
- reduce nurse fatigue
- decrease nurse burnout
- improve nurse retention and job satisfaction.
The Federal regulations (42CFR 482.23(b)) require hospitals certified to participate in Medicare to “have ‘adequate’ numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed,” but the regulations do not say what is “adequate” nor who determines this. Does Medicare know when staffing is not adequate? The Joint Commission acknowledges a link between positive patient outcomes, quality, and safe care, to that of effective staffing. However, The Joint Commission staffing standards indicate that staffing effectiveness is composed of the number, competency, and skill mix of staff in relation to the provision of needed care and treatment:
HR.1.20 The hospital provides an adequate number and mix of staff consistent with the hospital’s staffing plan.
HR.1.30 The hospital uses data from clinical/service screening indicators and human resource screening indicators to assess and continuously improve staffing effectiveness.
HR.3.10 The nurse executive establishes nursing policies and procedures, nursing standards, and a nurse staffing plan(s).
Yet, in spite of the data, these fairly ambiguous statements allow health care facilities to continue to operate at or below minimum levels.
The subject of ethics
As far as ethics is concerned, the first principle is – and always has been – do no harm. In ethics, people always come before things – and this includes a bottom line. Making money, saving money, or even losing money simply is not an ethical excuse for harming anyone. If you cannot afford to provide a service, then you do not put forth to the public that you will provide it – otherwise it’s fraud. If this means you will go out of business, then perhaps you ought to go out of business. What good are “services” that harm people anyway? This is clear, easy to understand, and it demands safe staffing. Are there exceptions? Yes, but the exceptions should be limited to times of natural disaster or war (both of which require a plan). Any other exceptions should be few and far between: There is no acceptable ethical reason that excuses unsafe staffing as anything other than a rare exception to the rule.
Health professionals, and those who earn their livings by employing, organizing, and enabling their practice, assume additional obligations by the very nature of who they are and what they do. Health professionals earn their livings by intervening in the lives of others who, by definition, are made more vulnerable because they often cannot define nor treat, nor even mitigate their illness – or even the threat of illness. The greater their danger, the greater their vulnerability. For this reason, in ancient times, those who would work in these areas were required to get up in the public market place where they sold their services and to promise to the gods and to the people that they would
- do no harm to them
- act in their best interest and protect them from exploitation
- be masters of their craft
- share information and successful techniques with one another.
In fact, the word professional is derived from the word profiteer, which means “to promise publicly.” Today these promises are codified in practice acts, standards of practice, and case law.
Staffing is the distribution of an essential good. In this case, the type, amount, and safety of the care available to patients. The amount may be dictated by patient characteristics (Blind? Incontinent? Deaf? Aged? Conscious? Confused? Cooperative? And so on.). The safety of care depends on the number, education, experience, and fatigue of caregivers, as well as whether and to what extent that caregiver is supported by ancillary staff.
Everyone who has anything to do with providing patient care is responsible for safe staffing.
Nurses themselves are responsible for assessing patients and determining how he or she can best distribute that precious resource that is herself or himself. The unit manager is responsible for distributing staff according to the needs of all the patients on the unit. The director, for all the patients in that service. The CNO for all the patients in the institution, and so on. The administration and board of an institution or system are accountable to all the patients and to the community for the safe distribution of all services offered to and for their communities. The “type” of service to be delivered may be defined by specialty, acuity, and intensity – and, in the case of administration and institutional boards, their institution’s capacity to safely deliver such care.
The scope of the obligation differs, but the content does not.
What research reports
Fortunately, a great deal of study and research has been done in the last two decades to help determine safe care. It is not my purpose to present all of it, but rather to point out that a great deal is known about what constitutes safe care, so there really is no justification in saying, “We just don’t know.” Or “The data are inconclusive.” Or “It’s just a judgment call.” These statements, every one of them, are at the very least, untrue. We do know. For example, a 2007 meta-analysis of nurse staffing and related outcomes indicated that a decrease in nurse/patient ratios alone (from 1.3.3 to 1.7.6) decreased the odds that patients will suffer nosocomial sepsis by 43%, cardiac arrest by 34%, medical complications by 41%, unplanned extubations by 45%, and respiratory failure by an astounding 60%. All studies done since then – not some, but all —support these findings. Although the percentages may differ, the conclusions do not.
To put it in a nutshell, a synthesis of the research on nurse staffing and patient outcomes indicates that:
- Ratios of RNs to patients are important. Consensus seems to be emerging supporting a staffing ratio range between 4 and 6 patients per nurse in most hospital inpatient settings; and a range between 1 and 2 patients per nurse in critical care settings. However, ratios should be modified by the nurses’ level of experience, the patients’ characteristics, and the practice environment.
- High quality and frequent clinical interaction among RNs and MDs is important to safe care.
- There is increasing evidence that turnover and fatigue, as well as high patient load, contribute to errors, recidivism, length of stay, and costs.
- Especially since the advent of mandatory staffing ratios, there has been increasing evidence of the importance of maintaining adequate support staff for nurses.
The bottom line…
Ethics has to do with trying to determine what is the right thing to do in a given situation. The integrity of the answer is, to a large extent, determined by the validity of the information upon which the decision is based. We have a good deal of valid information, and more studies are being published almost daily from researchers in all health-related fields in the most respectable of journals. We have the data. We know we put patients at risk if we do not staff according to the data. The ethical conversation is over.
The question now becomes a moral one: what do we actually choose to do about what we think is the right thing to do? If we do not handle the moral question, it soon becomes a legal one.
In the spirit of a “conversation,” I do hope that some of you will share your views on this subject with me and the readers.
Selected references
American Nurses Association. Nurse Staffing.
Kane RL, Shamliyan TA, Mueller C, et al. The association of registered nurse staffing levels and patient outcomes. Med Care. 2007;45(12):1195-204.
Grice P. Logic and conversation. In: Cole P, Morgan J, eds. Syntax and Semantics. 3: Speech Acts. New York, NY: Academic Press; 1975; 41-58.
5 Comments.
I recently read an article written after Leah Curtin, RN, MA, MS, ScD(h), FAAN addressed an ANA meeting, the article was titled: A conversation about the ethics of staffing. I have often thought about staffing and all the complex issues that coincide with having adequate staff for our patients, but I have never thought about the ethicalness of having enough staff for our patients. I am writing to address the validity of Ms. Curtin’s argument that the issue of safe staffing is, in fact, an ethical argument for both nurse and patient. Having done plenty of research myself on the issue of safe staffing, I can say that all research addresses the negative effects to a patient when there is not adequate staff to care for the number of patients on a hospital floor. This would indicate that harm has been done to a patient. Ms. Curtin adequately addresses that the first principle of ethics is to “do no harm.” Yet, in hospitals and other care facilities throughout the U.S., nurses are working in environments that are failing them in the first principle of ethics and allowing harmful outcomes to occur. Let me be clear, harm, even unintentional, is occurring. And not just to the patient; nurses are being harmed in their increasing levels of burnout when having to care for acutely ill patients with multiple, complex co-morbidities. Nurses are being harmed when there is a “call-out” and the nurse is caring for more patients or the nurse is doing twice the work when they must complete the duties of an unlicensed assistive personnel, as well as their own duties. Nurses are being harmed when there is a shortage of nurses on their floor and, to cover shifts, nurses must pick up extra shifts to be “fully staffed” on any particular day. In an article titled “Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction,” published in JAMA, Linda H. Aiken, et. al, addressed the association between patient to nurse ratio and patient mortality. The conclusion stated that with higher patient to nurse ratios, patients have increased mortality rates, and “Nurses are more likely to experience burnout and job dissatisfaction.” At the end of the article, Ms. Curtin poses the question “What do we actually choose to do about what we think is the right thing to do?” The answer is to have a flexible staffing grid that is determined by the acuity of each patient. This would not be an easy feat, but for the safety of patients and nurses, this should occur. It is obvious that, as Ms. Curtin states “the ethical conversation is over,” and we as Registered Nurses must stand up, primarily for our patients, and then for ourselves, to address this complex issue that is safe staffing. The researched evidence proves that what is safe and best for patients and nurses alike, should happen.
Sincerely,
Amaret Velazquez-Newsome, RN
As the voice of the profession, the ANA could help more by:
• developing a policy or position paper condemning any bonus packages for CEO’s, CNO’s, and other hospital executives that could be affected by decisions to improve margin by cutting labor costs (reducing staff); and
• revising the wording in Standard 3.4 of the Code of Ethics for Nurses to increase protection for the bedside nurse who speaks up about staffing and other patient safety issues.
The 2005 Code of Ethics for Nurses with Interpretive Statements said explicitly:
“Under no circumstances should the nurse participate in, or condone through silence, either an attempt to hide an error or a punitive response that serves only to fix blame rather than correct the conditions that led to the error.”
In moving from a “non-punitive culture of safety” to a “just culture,” the 2015 Code states:
“…errors should be corrected and remediated, and disciplinary action taken only if warranted.”
“Only if warranted” gives complete discretion to management, and provides no protection to the bedside nurse. The wording is so vague and ambiguous that the Code can be used to justify any punishment. A nurse who speaks up may be subjected to increased scrutiny. If management watches and looks long and hard enough, they will find something to use as an excuse to say that disciplinary action is “warranted.”
I spoke up, and wound up in the cross-hairs. I am now a former med-surg nurse, working in hospice. The ANA needs to restore the 2005 wording or something similar to protect the bedside nurse who speaks up about staffing or other patient safety issues.
The only place where a nurse ratio of 1:6 has been shown to be safe is rehabilitation hospitals. In no way is a ratio of 1:6 safe on a general medical surgical floor.
Staffing is a big issue and one that the staff nurse is well aware of, however the majority of staff nurses do not say too much about it for fear of losing their job. It is proven that the patient has better outcomes and increased satisfaction when there are more RN’s working the unit. It is also proven that job satisfaction for the staff is greatly increased, turnover is decreased, and absenteeism is decreased which all increases the revenue for the facilities. There is a shortage of Nurses which will continue to grow over the next 6 years. This shortage is going to create even more work for the already maxed out nurse. Something needs to be done to change this problem. One thing I think would help is to increase the pay for nursing instructors so more people would go into that field and thereby more people would be able to complete nursing school. This would at least make a dent in the future shortage. I am one of those nurses who experienced compassion fatigue, secondary traumatic stress disorder and severe depression which had me off work for 2 months. We must do something to educate and thus protect our staff from these life changing disorders. Support groups, education, resources must be made available to help those caring for patients in their most vulnerable conditions.