Our Purpose

All of our group members continuously face similar ethical dilemmas resulting in the inability to provide competent and safe care that patients are entitled to. We as a group, have decided to come together to develop a plan on how we, as nurses, can affect change. It is vital for nurses to empower one another and provide support during stressful situations in the workplace. Equality in the work environment reduces power imbalances. Lastly, it is imperative that nurses unite to have stronger voices in creating policies and rules that ensure the best outcomes for the patients are achieved.

Ethical Situation

A situation arose where a nurse could not live out the value in providing safe, compassionate, competent and ethical care occurred on a busy evening shift on a sub-acute floor. On this particular evening, the nurse had 7 total-care heavy patients, and was expected to administer numerous medications, and provide evening care. During that evening, two of this nurses’ patients fell, and she also had to attend to her partner’s patient, who also had a fall. After ensuring all patients were uninjured, administration of medications, and completion of all assessments, the nurse barely had time to provide evening care. Two of the patients went to bed without being washed. The nurse was unable to do hourly safety checks on her patients, and she felt as if she had gone all evening without seeing some of her patients. She had to stay after her shift to complete two incident reports.

This experience affected the nurse deeply, and she did not feel in the least that she was safely providing care to these patients. The speed at which this nurse had to complete her tasks put her and her patients at risk, and the whole shift felt chaotic. This incident occurred approximately three years ago, and she still has not accepted another shift on the sub acute floor.

The barrier the nurse faced in being able to live this ethical value occurred at an organizational level, and is brought back to budget cuts. This heavy workload occurred because of the cost associated with hiring more nurses, or care aids, to reduce the workload. Another issue may have been staffing issues for this floor; turnover may be high, as other nurses may have similar experiences.

ETHICAL SITUATION


Assess the Ethical Situation from a Micro, Meso and Macro Context

(NURSING WORKLOAD AND PATIENT SAFETY, Carayon, P., Gurses, A. n.d.)

Who is Involved in this Situation?  Micro Context




















  • Due to higher workloads, nurses and health care professionals have a higher workload than ever before due to (a) increased demand for nurses, (b) inadequate supply of nurses (c) reduced staffing and increased overtime, and (d) reduction in patient length of stay.

  • Patients
    • Nursing workload can impact patient safety.  The following is the relationship between nursing workload and:

      • Lack of time
        • Nurses who have a heavy workload may not have sufficient time to perform tasks safely, apply safe practices, or monitor patients, and may reduce their communication with physician and other providers.

      • Lack of Motivation
        • Nurses who have a heavy workload may be dissatisfied with their job, thus affecting their motivation for high-quality performance.
        • Lack of motivation or commitment to high levels of performance, along with high workload can create frustration and contribute to the development of negative attitudes towards one’s job.

      • Nursing Stress and Burnout
        • Nurses who have a heavy workload may experience stress and burnout, which can have a negative impact on their performance.
        • Reduced physical and cognitive resources are available for nurses to perform adequately.

      • Nursing Workload and Errors
        • Hi cognitive workload can contribute to errors, such as slips, lapses or mistakes.

      • Violations
        • High workload conditions may make it more difficult for nurses to follow rules and guidelines, thus compromising the quality and safety of patient care.  For example: inadequate hand washing, which leads to the spread of infection.

    • Reduced patient satisfaction can occur if nurses are unable to provide enough time for their patients and family members. 


(DEVELOPING AND SUSTAINING EFFECTIVE STAFFING AND WORKLOAD PRACTICES, RNAO 2007)

  • At the micro level, the physical work demand factors include the requirements of the work, which necessitate physical capabilities and effort on the part of the individual.  Included among these factors are workload, changing schedules and shifts, heavy lifting, exposure to hazardous and infectious substances, and threats to personal safety.

  • Cognitive and psychosocial work demand factors include the requirements of the work, which necessitate cognitive, psychological and social capabilities and effort (e.g. clinical knowledge, effective coping skills, communication skills) on the part of the individual.  Included among these factors are clinical complexity, job security, team relationships, emotional demands, role clarity and role strain.

  • The Individual nurse factors include the personal attributes and/or acquired skills and knowledge of the nurse, which determine how she/he responds to the physical, cognitive and psychosocial demands of work.  Included among these factors are commitment to patient/client care, the organization and the profession; personal values and ethics; reflective practice; resilience, adaptability and self-confidence; and family work/life balance.


(NURSING WORKLOAD AND PATIENT SAFETY, Carayon, P., Gurses, A. n.d.)

Who is Involved in this Situation?  Meso Context




 

·       Several elements of the work system can affect nurses and their performance, safety, and well-being.

·       These work systems are causes or factors contributing to nursing workload.

·       From a meso context, factors that can lead to a heavy workload in nursing are the following:
o   Poor physical work environment – crowded and disorganized work environment
§  The condition of the work environment (noisy versus quiet; hectic versus calm) affects the overall effort spent by the nurse to perform her job.
o   Difficulty finding a place to sit down and document
o   Poor Condition of the equipment
o   Spending time searching for patient’s charts

·       It is important for hospital units to provide resources and social support for nurses to assist them in accomplishing their duties.
o   Different types of support such as informational, practical and affective support need to be provided to help nurses deal with negative aspect of their work, such as workload.

·       Work System
o   Any change in one element of the work system can affect other elements of the work system in positive/negative ways.
o   An example of this: work hour limits for physicians have affected nurse schedules.  Nurses are often required to work increased overtime to compensate for reduced physician hours.




·       Systematic Organization Impact of Nursing Workload
o   Heavy workload experienced by a nurse not only affects this nurse, but can also affect other nurses and health care providers in the nurse’s work system.
o   Understaffing may reduce time nurses have to help other nurses.  This lack of time may also result in inadequate training or supervision of new nurses.

(DEVELOPING AND SUSTAINING EFFECTIVE STAFFING AND WORKLOAD PRACTICES, RNAO 2007)

·       At the meso level, physical factors include the physical characteristics and the physical environment of the organization and also the organization structures and processes created to respond to the physical demands of the work.  Included among these factors are staffing practice, flexible and self-scheduling, access to functioning lifting equipment, occupational health and safety policies, and security personnel.

·       The organizational social factors are related to organizational climate, culture, and values.  Included among these factors are organizational stability, communications practices and structures, labour/management relations, and a culture of continuous learning and support.

·       Professional/occupational factors are characteristic of the nature and role of the profession/occupation.  Included among these factors are the scope of practice, and intradisciplinary relationships.



(DEVELOPING AND SUSTAINING EFFECTIVE STAFFING AND WORKLOAD PRACTICES, RNAO 2007)

Who is Involved in this Situation?  Macro Context
















·       At the macro level or external level, the External Policy Factors include health care deliver models, funding, and legislative, trade, economic and political frameworks (e.g. migration policies, health care system external to the organization).

·       At the macro level, the external socio-cultural factors include consumer trends, changing care preferences, changing roles of the family, diversity of the population and providers, and changing demographics – all of which influence how organizations and individuals operate.

·       The external professional/occupational factors include policies and regulations at the provincial/territorial, national and international level which influence health and social policy and role socializations within and across disciplines and domains.


References

Registered Nurses Association of Ontario (RNAO). (2007). Healthy Work Environments Best Practice Guidelines: Developing and Sustaining Effective Staffing and Workload Practices. Registered Nurses Association of Ontario (RNAO) Website. Retrieved February 13, 2011, from http://www.rnao.org/Storage/35/2935_BPG_Staffing_Workload.pdf

Carayon, P., Gurses, A. (n.d.). Chapter 30. Nursing Workload and Patient Safety -  Human Factors Engineering Perspective. Retrieved February 13, 2011, from http://www.ahrq.gov/qual/nurseshdbk/docs/CarayonP_NWPS.pdf

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