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Nurse-patient ratios probably aren’t discussed in most nursing ethics classrooms. But it’s clearly an ethical issue. Check out this recent story out of Massachusetts:

Mass. Nurses Association demands mandatory nurse-patient ratios

The trade group representing nurses is pledging to put the “sweat equity” of its 23,000 members behind a push to impose statutory nurse-to-patient ratios, but hospital officials are decrying the proposal as running counter to the trend toward a health care system where providers are reimbursed based on the quality of care they deliver and patient satisfaction.

The Massachusetts Nurses Association on Monday outlined plans to press for passage of a 2014 ballot proposal if the Legislature does not act by the middle of next year to pass nurse staffing legislation, which would apply to acute care hospitals.

The proposal calls for one nurse for every four patients in medical/surgical units….

It’s clearly a complicated issue. Nursing ratios are of course crucial to patient care, in general, but I suspect it is very hard to describe a one-size-fit’s-all solution, which is more or less what regulation would require.

Note also the difficult challenge, here, from the point of view of responsible advocacy. The MNA wants to advocate from the point of view of patient safety, which is entirely appropriate. But any attempt to legislate nursing ratios will of course be perceived by some as an attempt to maintain employment levels for nurses.

Finally, note that this issue raises questions of interdisciplinarity and the role of allied health professionals. In some cases, nurse ratios are being reduced because nurses are being replaced (or supplemented) with other kinds of workers. Sometimes that will be a very bad thing (for patients). Sometimes that will probably be a good thing (for patients). Sorting out which is which is a significant ethical challenge.

Former Australian arts minister, Ros Bates, is facing criticism (and potential parliamentary censure) for claiming to be a Registered Nurse, when she had in fact allowed her license to laps.

It’s a bit of a tempest in a teapot. Bates is probably right that, in the context of parliamentary debate (rather than, say, in the context of being hired at a hospital), critics are “nit-picking” when the point to the difference between being a qualified nurse and being a registered nurse.

But the story is a good reminder of the social privilege that licensure implies. Compare: I’m a philosopher by training (that’s what my PhD is in). But no one ever gets in trouble for “falsely” claiming to be a philosopher!

This one isn’t really about nursing ethics, though it has plenty of implications for the ethics of nurse managers.
Hospital settles nurse’s discrimination suit.

After settling one lawsuit, a second was pending Friday against a Flint, Mich., hospital accused of honoring of a swastika-tattooed man’s request that African-American nurses not care for his newborn….

My main comment: The “customer” isn’t always right.

But fodder for discussion: what can (or do) hospitals do to handle such problems? What can or should they do when patients express preferences that are clearly discriminatory?

As has been widely reported, a recent study indicates that almost half of New Zealand nurses have considered leaving their jobs out of ‘moral distress.’ The high rate of moral distress among nurses is not surprising, given the morally-significant nature of their work. In fact, that’s a feature of clinical work of all kinds. I made this general point in reference to a specific clinical context almost a decade ago, in the Canadian Journal of Psychiatry, in an article called Treatment Resistance in Anorexia Nervosa and the Pervasiveness of Ethics in Clinical Decision making. Here’s a quote that sums up the main point:

But it is useful to remind ourselves that an ethical issue is not something that arises every few weeks in clinical settings, in those regrettable moments of crisis in which clinicians feel the need to seek advice from ethics consultants or committees. Ethical issues of an acute nature may (we hope) be rare, but ethics—the making of value judgements, of weighing our actions against shared standards—is a task inherent to clinical life.

As the New Zealand study illustrates, it’s a point that applies to nursing practice quite generally.

From PBS: Next Health Care Mandate: Flu Shots for Medical Workers?

Brandon Hostler’s arm is usually among the first extended for the annual flu shot at Ruby Memorial Hospital in Morgantown, W.Va. He is, after all, a registered nurse — he knows it can do some good.

But if that shot ever becomes mandatory, he will balk.

“I wouldn’t quit or switch jobs,” he said. “But we are health care professionals. We know the risks and the benefits, and to force us to do something like that and not have a say in it, I think it would be offensive and unwanted.”

This story nicely points out two different facets of one of the most important values in the world of healthcare, namely autonomy.

Why is autonomy important? On one hand, it is important for its own sake. We simply value the ability to choose for ourselves. On the other hand, we value autonomy because we generally believe that when people choose for themselves, they will choose better than when others choose for them. Both of those facets of autonomy appear in the story above. Some nurses are hesitant about the flu shot because they’re uncertain about whether the risks are worth the benefits; others think the benefits are there, but still want the freedom, for its own sake, to say “no thanks.”

But there are also limits on autonomy. And in particular, membership in a profession brings a whole bunch of such limits. The benefits of professionalism involve a kind of quid pro quo — society asks things in return. The hard question, of course, is whether any particular limit on autonomy — such as mandatory flu shots — is or should be part of that bargain.

When is unethical behaviour by a nurse not a matter of ‘nursing ethics’?

From the Wisconsin State Journal: “Nurse disciplined for using donor program credit card for personal use”

A registered nurse who used a Neenah hospital’s organ donor program credit card to take cruises and vacations with her husband has been disciplined by the state Board of Nursing.

The board suspended the license of Peggy Grambsch, of Poy Sippi, for six months on Jan. 26. It also ordered Grambsch to take a nursing ethics course and pay $750….

It’s hard to blame the board for requiring that Grambsch take an ethics course. But it’s hardly likely to be the right remedy here. First, the behaviour she engaged in is, as far a I can see, a matter of outright criminality, rather than subtly unethical behaviour. Secondly, to the extent that there are ethical issues here — misappropriation of funds is of course unethical, in addition to being illegal — I suspect such issues are not covered in most nursing ethics courses. If I were on that board, I would have insisted on a business ethics course, especially one with a section on financial integrity and ethics in the workplace.

Compassion Fatigue

Who cares for the care-givers?

From the Wall Street Journal: Helping Nurses Cope With Compassion Fatigue

New programs are underway to help nurses cope with compassion fatigue, an occupational hazard for caregivers that also puts patients at risk of substandard care….

Though the intense emotional demands on nurses are as old as the profession itself, researchers have only in recent years begun to study the effects of compassion fatigue, a form of burnout compounded by secondary traumatic stress….

It’s good to see that this article discusses the impact of compassion fatigue not just on nurses, but also on patients. But of course, while impact on patient care is the ‘trump card’ of the world of healthcare, it shouldn’t be forgotten that institutions of all kinds have a fundamental obligation to safeguard the mental and emotional health of employees.