A Conversation about the Ethics of Staffing

By Curtin, Leah | American Nurse Today, April 2016 | Go to article overview

A Conversation about the Ethics of Staffing


Curtin, Leah, American Nurse Today


April 2016 Vol. 11 Num. 4

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. …

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