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.
