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Department: ETHICAL PROBLEMS

Ethical Problems

Salladay, Susan A. PhD, RN

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doi: 10.1097/01.NURSE.0000513616.88679.75
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UNDERSTAFFING

Emotionally maxed out

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My stress level feels out of control, and I'm not the only nurse on our unit feeling this way. We've all heard the same advice on managing stress a thousand times, but with poor staffing occurring on a daily basis, how can we possibly set and keep realistic goals, avoid taking on more than we can handle, use sick days when needed, or even say “no” from time to time? It's difficult to promote the health of our patients when we're constantly challenged to promote our own health and well-being. Isn't it unethical to be caring for patients when we're emotionally exhausted?–P.L., W.V.

Simple answer: yes! Of course, the problem you describe is nowhere near that simple; it's complex and highly personal. Nurses everywhere work in high-stress situations; it comes with the territory. No magic number can measure at which point a nurse's stress level exceeds what's “safe” for patient care, so nurses are ethically obligated to determine their individual maxed-out point.

The Catch-22 in this ethical situation is that most nurses are so busy dealing with the demands of their job that they ignore the burnout they're experiencing. And most nursing administrators have such limited resources with which to address this issue that they may be slow to develop creative solutions to the problem.

As healthcare professionals, you and your colleagues have an obligation to take a proactive approach to staffing problems that affect patient safety. Discuss your concerns with your manager and present documentation linking understaffing with safety issues such as an increase in pressure injuries or falls. Offer potential solutions for easing the nursing workload that are practical to implement on your unit.

If necessary, take your concerns up the chain of command. Ethically, maintaining patient safety is everyone's responsibility.

CULTURAL COMPETENCE

Open to interpretation?

A post-op patient on our medical/surgical unit has limited English proficiency. We're using a professional medical interpreter to help us provide appropriate care. Last evening, I observed that the patient was grimacing and looked uncomfortable, but he refused to take the prescribed p.r.n. analgesic. Through the interpreter, I asked him repeatedly about his pain intensity level but he denied having any pain at all.

The patient's two adult sons and older brother were in the room at the time, and I'm wondering if he was denying pain due to their presence. I also wonder if questioning him about this in front of his male family members backfired. How should I have handled this?–B.W., FLA.

What do you know about your patient's cultural background and his beliefs about gender roles? It's those earliest influences from his youth that he may feel safest with now in the unfamiliar world of the hospital. Or, rather than being reluctant to acknowledge pain in front of his sons and brother, he may have been uncomfortable doing so in front of a nurse and/or medical interpreter, people he doesn't consider “family.”

Also consider the possibility that you could have misinterpreted the signs you observed. Could they have another meaning besides post-op pain? Investigate further by conducting a complete physical assessment.

Suggest to the healthcare provider that a referral to the hospital's pain management service may be valuable for your patient. Pain wears many faces. A detailed pain assessment by a caregiver who has expertise in pain management and time to work carefully with the right professional medical interpreter may help resolve this dilemma.

BETTER ED TRIAGE

Wanted: Creative problem solving

I work in a busy suburban ED that's constantly challenged by long wait times and poor patient satisfaction ratings. Many patients present with nonemergent health problems, leading to frequent delays. One night last month, the wait was so long that a patient left the ED without being seen—and later returned via ambulance after experiencing a myocardial infarction at home.

Some of my colleagues are critical of community members who use the ED inappropriately for minor complaints, saying this negatively impacts patients who truly need emergency services. Others believe that this kind of staff attitude is not only disrespectful but also unethical, because most patients who come to the ED for care have a reason that's important to them (even if we might disagree with their reasoning). Who's right?–C.H., TEX.

Trying to decide “who's right” takes valuable time and energy away from working together to help improve the service your ED provides to the community. The bottom line is that all patients in the ED have their own reasons for being there; our place is not to criticize their decision to seek care.

Keep in mind that many EDs nationwide are experiencing the same challenges and developing creative solutions. Check out nursing literature, look at the research, and explore evidence-based nursing practice to discover what solutions can work most effectively for your ED. One idea is to use a quick triage system and nurse practitioners in a “split flow” model that separates low acuity from higher acuity patients to shorten wait times; the nurse practitioner can manage minor complaints in a fast-track setting. Another approach involves creation of a rapid chest pain evaluation process in the ED to ensure that patients with concerning symptoms get immediate attention.

The Agency for Healthcare Research and Quality offers many practical strategies for improving patient flow and reducing crowding in the ED.1 For example, consider assembling a patient flow improvement team to identify roadblocks to patient flow particular to your facility. Do delays in lab turnaround or specialist consultations contribute to long ED wait times? Do patients board in the ED for long periods after admission before getting a bed on an inpatient unit? These situations can be major contributors to triage delays and increased ED wait times overall due to room blocking.

Pin down the factors slowing patient flow in your ED and use this information to create workable solutions. With teamwork, nurses can spearhead effective (not necessarily more) staffing, better space allocation, and genuine creativity in problem-solving so all your patients can receive the time and attention they need.

REFERENCE

1. McHugh M, van Dyke K, McClelland M, Moss D. Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals. Agency for Healthcare Research and Quality. AHRQ Publication No. 11(12)-0094; 2011. http://www.ahrq.gov/sites/default/files/publications/files/ptflowguide.pdf.
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