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Journal of Nursing Administration:
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Administrative Support for Addressing Staff Nurses' Ethical Concerns Regarding Staffing

Smith, Maureen K. MSN, ARNP, CS; Janzen, Sandra K. MS, RN, CNAA; Schaefer, Sandra MS, ARNP-C; Hixon, Andrea Kaye MS, RN, CNAA, CPHQ

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Maureen K. Smith, MSN, ARNP, CS, is Geriatric Psychiatry Nurse Practitioner, maureen, Sandra K. Janzen, MS, RN, CNAA, Associate Chief of Staff/ Nursing,, Sandra Schaefer, MS, ARNP-C,, Alcohol and Drug Treatment Program, Andrea Kaye Hixon, MS, RN, CNAA, CPHQ, Executive Assistant, Continuous Quality Improvement,, James A Haley Veterans' Hospital, Tampa, Florida

The nurse executive of a large, urban Department of Veterans Affairs (DVA) hospital became aware through an ethics committee survey that staff nurses had linked ethical concerns to staffing levels. Nursing representatives of a hospital ethics committee replicated Haddad's survey 1 1to identify the ethical concerns of registered nurses. The survey response return rate was 47% (n=187).

Results indicated that the most problematic and frequently occurring ethical concern of registered nurses was whether the distribution of nursing staff was adequate to meet the needs of patients. The nurse executive made a commitment to systematically address the staff's ethical concerns. The nurse executive organized a project team that consisted of two nurse practitioners who were members of the hospital ethics committee, a quality improvement expert, and the nurse executive.

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Use of Focus Groups

Focus groups are a sound choice for data gathering if the study is investigating complex behaviors, there is a broad diversity of opinion, and there is a commitment to listen and learn. Focus groups were chosen as the methodology to further explore views and concerns of the nurses in regard to staffing. The project team sponsored six 60-minute focus groups conducted by the quality improvement expert and attended by the nurse executive. Group size was limited to ten participants. Members consisted of medical-surgical, nursing home, rehabilitation, psychiatry, ambulatory care, operating room, and intensive care staff nurses.

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Focus Group Findings

Five themes captured the essence of the focus group discussions. The following are themes with a related clinical example:

Lack of control over fluctuation in daily workload. Staff nurses reported that daily workload fluctuations made it difficult for them to have a back up for staff absences or call-ins. With variability of emergency room and intensive care unit workload and high overall hospital acuity, it was hard to plan and provide for adequate staff to meet patient needs.

Inability to effectively meet workload demands. Nurses reported that when the right skill mix was not available, it was difficult to provide all care needed and required making a choice between completing baths and providing patient teaching.

Nurses setting priorities to meet workload demands found conflicting issues related to quality of care and meeting critical customer service needs. The nurses identified that increased patient turnover interfered with the timeliness of meeting patient needs. One cited example was the late delivery of pain medication.

Decreased team communication and interdisciplinary team effectiveness. The nurses desired greater family involvement in the treatment planning process.

Nursing staff's emphasis on promoting quality patient care rather than complaining of heavy workload. Staff nurse participants valued having extra time to provide emotional support to patient and families. None of the nurses complained of having to work harder, but rather focused on the need to provide the best quality of care to patients.

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Using the five themes, the nurse executive developed an action plan to support staff in addressing their ethical concerns related to staffing. Strategies included developing a core staffing plan with the ability to expand upward when the workload increases to control the fluctuations in daily workload, enhancing effective communication through interdisciplinary team building, and recognizing positive nursing efforts in the electronic nursing bulletin

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Focus groups were used successfully to clarify ethical concerns identified by staff nurses. The process of using focus groups worked well as it allowed nursing staff to better understand and define their perceptions. Involvement of the nurse executive to develop an action plan to address adequate staffing demonstrated administrative commitment to resolving ethical concerns of nursing staff.

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1. Haddad AM. Ethical problems in nursing. [dissertation] Lincoln, NE: The University of Nebraska, 1988.

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