By Stacey Kusterbeck
As part of the research for her dissertation, Denise Waterfield, PhD, APRN-NP, CCRN, ACAGNP-BC, interviewed and observed 25 critical care nurses. Many seemed upset and frustrated during their shifts due to an overwhelming workload, and there was not much in the way of resources to provide relief.
Waterfield asked nurses if they felt guilty or distressed about anything related to a patient’s symptom management. One nurse recounted caring for a confused, agitated patient. The nurse knew a sitter was needed to keep the patient oriented and safe. However, no sitters were available due to low staffing, so the nurse did the next best thing — administer anti-anxiety medication.
The patient’s heart later went into an abnormal rhythm, a known side effect of the medication. “It is not certain that the medication caused the abnormal rhythm. But the nurse felt distressed about that possibility,” says Waterfield, a former nurse specialist for the University of Nebraska Medical Center College of Nursing Kearney Division.
Waterfield was curious if this kind of situation was unique to the culture of this particular research site, or if it was a universal issue. To learn more, she and a colleague reviewed the literature to examine the ethics of relationships between nurse managers and nurses, with a focus on workload. “The nursing shortage that healthcare has experienced for many years now adds to the workload of the remaining bedside nurses,” Waterfield laments.
Waterfield and her colleague searched the literature from 2017-2021 regarding care ethics related to nursing workload in acute settings.1 Ethical dilemmas, shared moral burden, time pressure, and managerial support were key issues.
A care ethics perspective is needed to alleviate nursing workloads, including strengthening workplace relationships and promoting empathy. For nurse managers, says Waterfield, “the important consideration is to focus on workload on their units and share the moral burden that bedside nurses are experiencing.”
Many nurses reported experiencing moral distress because they missed clinical deterioration in a patient because of overwhelming workload. “If managers are present on the units and recognize those situations in real time, they are able to role model how to handle those moments,” Waterfield says.
However, the nurse manager-nurse relationship needs bolstering in some organizations. “Proactive strategies to integrate a care ethics approach to nursing management can help replace moral burden with moral agency and thus improve patient care and reduce burnout,” Waterfield concludes.
Managers may experience moral distress themselves because they cannot support frontline nurses. Sometimes, it is because the organizational culture prioritizes other responsibilities (e.g., attending meetings). On the other hand, in their literature review, Waterford and her colleague also uncovered cases in which nurse managers actively failed to support nurses. Some managers accused staff nurses of insubordination unless they worked overtime. Other hospitals shortened orientation to hasten the process of nurses working on their own without a preceptor because of staffing shortages. “Managers are pressured to prioritize efficiency over patient-centered, evidence-based practice,” Waterfield notes. “The moral burden needs to be shared at the organizational level.”
Managers must be present on the units to spot ethical dilemmas, and intervene. For example, nurse managers can allocate someone else to answer the call lights during a nurse’s shift change. If a patient experiences delayed care, the nurse and the manager can talk through the details of what caused it. If the managers themselves need support, ethicists can help.
“Ethicists can help nurse managers to develop moral agency and resilience in nursing staff. This can come in the form of unit-based ethics rounds, including instances of patient care impacted by workload,” Waterfield suggests.
The nursing shortage is unlikely to improve in the foreseeable future. “When more nurses are asked to work overtime and to take double shifts, patients as well as nurses are at risk,” says Paul Hofmann, DrPH, LFACHE, ethics consultant and former hospital CEO.
In an observational study, researchers found the odds of 30-day mortality increased by 16% for each additional patient added to a nurse’s workload.2 “Patients, their families, staff members, and the hospital are all likely to be compromised,” Hofmann warns.
Hospitals rely on travel nurses to fill vacancies, but those nurses typically are unfamiliar with the organization’s culture, values, and policies. “Ethicists can perform an invaluable role by working closely with senior management and medical staff leaders to develop collaborative initiatives to acknowledge the problem’s magnitude and, more importantly, to engage nursing representatives in developing creative solutions,” Hofmann offers.
REFERENCES
- Waterfield, D, Barnason S. The integration of care ethics and nursing workload: A qualitative systematic review. J Nurs Manag 2022; Jun 15. doi: 10.1111/jonm.13723. [Online ahead of print].
- Lasater KB, Aiken LH, Sloane D, et al. Patient outcomes and cost savings associated with hospital safe nurse staffing legislation: An observational study. BMJ Open 2021;11:e052899.
Ethicists can perform an invaluable role by working closely with senior management and medical staff leaders to develop collaborative initiatives to acknowledge the problem’s magnitude and engage nursing representatives in developing creative solutions.
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