One of the most glaringly obvious truths I’ve seen played out repeatedly is that nurses in an acute care setting are continuously thrust into no-win situations. Patient care is frequently set at odds against economic productivity, even viability. This happens regardless of the measures taken by management to alleviate the inherent tensions of the health care industry between patients and profit or productivity. As soon as health care organizations approach a workable solution to a problem, it seems, there are always several more challenges to takes its place. What’s a nurse to do?
I don’t pretend to speak for all nurses, but I’ll tell you the stance I’ve taken relative to these tensions. I hope my thoughts on this topic will empower you, knowing that you will likely encounter similar circumstances.
My unit, which is a team made up of wound and ostomy nurses, a.k.a. the “wound team,” lives currently under the umbrella of a department made up primarily of various rehabilitation-related therapists. In fact, we are the only nurses in a large department, and much of what we connect with as a unit differs dramatically from the remainder of the personnel.
Things were not always so. During my first experiences of the wound team, while I worked on a general medical unit, the team were rather independent. Granted, I wasn’t a member of the team, so it wasn’t particularly relevant to me at the time how the unit was related to the institution. However, I received the distinct impression that its members were given a fair amount of latitude in their work-related decisions.
I understand that changed within the past couple of years with a restructuring of departments. Now, our workflow is superficially similar to the rest of our department in that we see patients throughout our hospital and we travel to outlying facilities that lack similar units of their own. However, as you might expect, that basic similarity doesn’t extend to the actual work being done with our patients or to our professional development needs.
I work as a registered nurse in a state that has no continuing education credit requirement for license renewal. There was a time not long ago when our institution did require that nurses obtain a modest number of CEs annually. When the institution’s policy changed to do away with even this requirement, my unit and a few others continued to require those CEs. However, that requirement was finally eliminated within the past year or two as well. I believe one of the major reasons offered at the time was budgetary, given the expenses incurred in providing CEs as an institution.
Why am I writing about all of this? Ultimately, a recurring theme in my nursing life has been that there is an ethical component embedded within all of the circumstances mentioned above. The decision-making calculus involves a difficult juxtaposition of the ethics of caring for people of infinite worth while doing justice to the individuals involved–both real and artificial or organizational.
Both people and the organizations in which they work function on the basis of self-interest. The no-win situations into which nurses are thrust so often result from the coincidence of expectations involved in nursing work, which all too often result in conflicts of self-interest.
Naturally we’re expected to care for each patient for the betterment of the whole person. On the other hand, we’re required to uphold and follow policies intended to maximize the economic viability of various scales of organization.
The impacts are far-reaching. What and how we chart are heavily influenced. (Recall my earlier discussions of the curation of meaning, here and here.) The time allotted for patient care is reduced, consistent with a focus on productivity. Both acuity and patient census are rising on average. Training requirements are often burdensome, maintaining quality, to be sure, but also enabling the organization to meet expectations set for it by various regulatory influences.
The list goes on and on, of course. I’ve never found these tensions to be surprising, though. They existed during my former career in life science research, in my experience as an educator, and before that in school.
I have always found it effective to deal with these conflicts by focusing on first principles and priorities. From these is derived one’s mission–the reason one enters the workplace to begin with. I determined before I ever applied to nursing school that I was going to live for a mission of Christian ministry in whatever career developments I experienced. I like to think I’ve done that thus far, even when doing so has come at a price.
To care for a patient is to care for a human being of infinite worth. As a human being myself, I am no less valuable than any one of my patients. Therefore, I am worthy of self-care as well as the care of others.
The same cannot be said of a health care organization, even if it is treated legally as an artificial person. Its status is derivative of that of an actual person; it is not on par with an actual person. At best, its interests are derived from the aggregate self-interests of individual people.
People are people, and things are things. Knowing the difference clarifies potentially confusing situations. When you are faced with a “patients versus productivity” dilemma, remember that no one can fault you for doing justice to the actual people involved.
How have you dealt with your own no-win nursing scenarios?