July 7, 2020

Irony in the Nursing Dilemma Between Patients and Productivity

This past week, I wrote about some aspects of the dilemmas and no-win situations nurses face frequently. Ultimately, I framed the discussion in terms of the dichotomy between patients and productivity. What’s the big deal with productivity? Isn’t it a good thing for nurses?

There is frequent emphasis in contemporary health care on the economic viability or profitability of organizations. As a result, nurses often feel called upon to choose between serving patients and their families and their productivity within the organizations for which they work. That dilemma places nurses in the position of choosing between “acceptable losses” in patient care and organizational productivity.

As every nurse can easily guess, the latter generally translates to professional performance metrics. I’ve heard it myself from management, although not during a performance evaluation. Without direct guidance from management concerning which horn of the dilemma to favor, in my opinion, ethical nursing practice requires that we “err” on the side of patient care.

In reality, this is not an error or a loss, whether acceptable or not, although it does call into question the ethical impact of scale in the provision of health care. Essentially, this is a question of to what extent care of one patient should be allowed to influence the quantity or quality of care of other patients.

The irony in such no-win situations is that, while in any case something is sacrificed, in few cases will management speak freely to guide decisions on the part of nursing staff. In virtually all cases, guidance in one direction implies guidance to violate organizational policy in the opposite direction.

A statement on the part of a manager to the effect that patient care should be provided according to institutional policy, even if it requires extending a shift beyond 12 hours, implies a statement directing the nurse to violate that same institution’s policy governing shift length and time clock usage.

Where is the “win” in this situation for nurses? In many cases, either the nurse works 12 hours and watches the clock in real-time to determine where best to cut corners, or the nurse challenges his or her endurance to provide patient care despite the fear that such extended hours may be noticed by management.

Either side of this major dilemma has a second-tier dilemma of its own. For the nurse who chooses to resist the pressure to cut corners and clock out on time, there follows the choice between task completion and thoroughness of documentation. On the other hand, when a nurse chooses to work longer than scheduled, he or she must decide whether or not to forego pay for those hours in exchange for freedom from easy detection by management.

In light of the foregoing, one way of framing the overall dilemma is to say that the “patients versus productivity” scenario forces the nurse to decide whether or not to bear some of the costs of health care for his or her patients as a way of minimizing the potential negative consequences of violating ethical principles.

One of the reasons, people enter the field of nursing is that they want to help others. Further, as nurses they learn to adapt to situations designed to be maximally therapeutic for others. However, to add irony to irony, they often neglect themselves. They serve others to their own detriment.

Now, this is one of the best reasons of all to promote the health of nurses. Strategies to help nurses to overcome this tendency or to avoid or cope with the patients versus productivity dilemma may go a long way to avoiding nurse burn-out and maintaining the overall health of nurses.

What are your thoughts on the patients versus productivity dilemma?

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