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The ethical complexities of nursing care rationing

Evridiki Papastavrou

RN, MSc, PhD, Assistant Professor, Department of Nursing, School of Health Sciences, Cyprus University of Technology

 
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Abstract

Recent studies into nursing care rationing indicate that nurses always ration their time and care, resulting to serious threats to the quality of care and patient safety. For example patient mobilization, hygiene, feeding, communication, patient support, teaching and discharge planning, surveillance and care documentation are regularly lacking or omitted. Significant associations were also found between care rationing and patient-related outcomes like falls, acquired nosocomial infections, pressure ulcers, increased mortality rates and low patient satisfaction rates. Hence there is clear empirical evidence showing that care and safety is severely jeopardized in contemporary nursing.

Recent studies into nursing care rationing indicate that nurses always ration their time and care, resulting to serious threats to the quality of care and patient safety. For example patient mobilization, hygiene, feeding, communication, patient support, teaching and discharge planning, surveillance and care documentation are regularly lacking or omitted [1-9]. Significant associations were also found between care rationing and patient-related outcomes like falls, acquired nosocomial infections, pressure ulcers, increased mortality rates and low patient satisfaction rates [7,10,11]. Hence there is clear empirical evidence showing that care and safety is severely jeopardized in contemporary nursing.

Nursing care rationing, the withholding or failure to carry out certain aspects of care because of limited resources, is both an economic and moral challenge. Economic, because care is delivered within several socioeconomic constraints and the various components of nursing must be budgeted; moral, because it requires judgments that potentially conflict with personal and professional values. According to the theoretical model of missed care12 the choice to complete, delay or omit items of care is influenced by an internal factor including values, attitudes and beliefs nurses hold about their roles and responsibilities that shape their behavior.

To discuss rationing from a moral perspective, we need to take account of the nurses’ deepest moral commitment, that is the equal worth of every life, independent of racial, economic or social stratification and equal right to care with no hierarchies of human worth. This is clearly stated in the preamble of the revised code of ethics published by the ICN, saying that “Nursing care is respectful of and unrestricted by considerations of age, colour, creed, culture, disability or illness, gender, sexual orientation, nationality, politics, race or social status” [13].

Scheunemann and White, [14] in discussing the ethics and reality of rationing in medicine propose three approaches based on radically different philosophical notions of justice. I found prioritarianism and the rule of rescue very similar to the justification of rationing offered in the nursing literature and very useful in explaining this old, nevertheless recently acknowledged problem in nursing.

When allocating medical resources for example, Prioritarians may give priority to the young over the old supporting the “life cycle principle” with the goal to give all individuals equal opportunity to live a normal life [14]. Several studies in nursing have demonstrated that nurses may unconsciously follow chronological age as a priority criterion when they allocate their time and care and that older patients with comprehensive needs are given low priority [15-18].

The “Rule of Rescue” [14] describes a powerful psychological impulse to attempt to save those facing death, no matter how expensive or how small the chances of benefit. When asked to set their priorities, nurses in several studies reported that in cases of severe staff shortages they will give their attention to saving patients’ lives (when there is an immediate danger, not considering the negative outcomes of rationing that patients may have in the long term, such as pressure sores). It has been also found that the nurses role and priorities are largely framed by the biomedical ethos leading to undermining important nursing values in health care such as holistic care, empathy and dignity [16].

Nurses claim that due to the financial limitations and the domination of economic values, [19] some degree of rationing in nursing care is unavoidable, also because patients’ needs are always unlimited. This assumption makes rationing ethically justifiable to nurses especially to the feelings of guilt or low self-esteem relative to their performance as a nurse, [2] although studies exploring the rationing outcomes on nurses are scarce. However, nursing care rationing remains an important organizational variable, that appears to be directly linked to patient outcomes and warrants further exploration.

References

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