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Department: ETHICAL PROBLEMS

Ethical Problems

Salladay, Susan A. PhD, RN

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doi: 10.1097/01.NURSE.0000484971.16229.09
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SHORT-STAFFING

Forget the tough talk and take action

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At a staff meeting last week, the nurses had a heated discussion about short-staffing and troubling nurse-patient ratios on our unit. The manager listened to our concerns and shared some feedback, but she offered no real solutions. Afterward, a male nurse made a crack that a bunch of guys wouldn't put up with receiving that kind of nonanswer to such serious concerns. Some nurses got mad at him for his seemingly sexist remark, but others felt he was right to point out the brush-off we received from our manager. How should we respond to our colleague—and to our manager?–V.C., IND.

Let's take the focus off the language and look at the real ethical issue here: your professional obligation to ensure patient safety. Nurses sometimes complain that staffing is short without fully looking at the big picture and asking “why?” To find viable solutions, take the initiative with some thoughtful research and teamwork.

Rationally assess your concerns and document them by detailing all specific incidents of risks that patients and nurses face due to short-staffing. Then decide (with, not in opposition to, your manager) how to share the facts with nursing administration.

Be prepared to show evidence that staffing ratios or assignments don't meet staffing standards appropriate for your unit's patient population and acuity. If the unit is functioning with its budgeted number of staff, check the literature from relevant professional organizations to find support for why the staffing plan is subpar. Another option is to partner with the manager to find out if the unit is benchmarked using any commercially available or hospital-based comparison tools to determine where your unit stands in relation to other similar units or patient populations. Using trends in nursing quality measures such as the fall and pressure ulcer rate might also lend visibility to quality issues often associated with inadequate staffing.

Is overtime being worked at such an extreme level that everyone is tired and feeling overwhelmed? Be ready to show the overtime data and offer possible solutions—for example, creating and/or utilizing a float pool.

The staff and manager are in this situation together. It's time to put aside the tough talk and use some critical thinking skills and emotional intelligence to tackle the problem.

COMMUNICATION

Promoting the profession or herself?

As a NICU nurse, I strive to build close and trusting relationships with parents and provide meticulous care for the babies in the unit. I work with caring, talented nurses but most of us are pretty humble about our skills. However, a new staff member makes a point of telling parents every last detail about what she's doing and why, and takes extra time during her shift to immediately respond to a parent's every concern, no matter how trivial. I know we nurses should promote our profession and show confidence in our knowledge, but some of us feel as if she's just trying to one-up us. Her behavior seems self-promoting and unprofessional. What's your advice?–Y.G., PA.

As you know well, parents of fragile newborns are understandably frightened and concerned. Much of what your new colleague is doing, as you describe it, sounds like appropriate nursing care: telling parents the details of what she's doing and why, and taking extra time to respond to parents' concerns. My guess is that you and your colleagues do much the same to ease parents' concerns. Perhaps your new colleague is anxious about working with such talented nurses. You've set the bar high and she's trying to live up to your standard.

Ethically speaking, in fairness to all of you, take the time to get to know her better before making any judgments—and base your opinions on fact, not fiction, rumor, or assumptions. As you develop a more welcoming relationship with her, you may find that those feelings of “one-upmanship” start to fade, to be replaced with positive regard and respect.

FIDELITY

Taking a principled approach

During a presurgical assessment, my 24-year-old patient revealed that she's addicted to opioids. She also confessed that she's terrified about having severe pain after her surgery, but she didn't want the surgeon to know about her drug use for fear that he'd tell her parents (the surgeon and her father are personal friends). I tried to reassure her that the surgeon is professionally obligated to maintain confidentiality but she didn't seem convinced.

Knowing that she'd likely need higher doses of pain medication due to opioid tolerance and that the surgeon needs to know this, I shared this information with the surgeon. But I never told my patient that I did so, and she never asked. Was the way I handled this unethical?–G.G., CALIF.

From an ethical viewpoint, ask yourself if you broke a promise to her. If you reassured her by saying (or implying) something like, “I promise I won't tell anyone about this,” then you violated the principle of fidelity (faithfulness) in the nurse-patient relationship when you shared the information with the surgeon. The ethically appropriate approach would have been to tell her that to ensure safe patient care, you're obligated to share relevant healthcare information with her care team, then to reassure her that “this issue won't go any further than the medical professionals caring for you who need to know.”

When your patient has recovered from surgery, she'll need a skilled intervention that leads to appropriate treatment. If you haven't already, document any follow-up you have with your patient as she's recovering and share your assessment and recommendations with her surgeon.

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