Equitable Allocation of Nursing Time and Care: A Case Study

Background

Case 1: Equitable Allocation of Nursing Time and Care

Traditionally nurses tended to believe that they could not have much control over the allocation of resources at the micro-level. In the community, in long-term care facilities, and acute-care settings, nurses accepted their assignments and tried to meet expectations.

More recently nurses have realized that they ought to take action when they are unable to practise according to their professional standards. Through professional and labour organizations they can work to improve nurses’ employment conditions. Nonetheless, nurses may sometimes need to make hard choices about how they allocate their time. One resource that individual nurses do have some control over is their own time and nursing care—but under present circumstances, that is becoming one of the scarcest resources in the health care system. In such situations, nurses have to make difficult decisions about the competing needs and demands of various individuals.

Lesedi Abebe works in the pediatric intensive-care unit of a community hospital. The unit is now at maximum capacity, with three children: Sarah, a profoundly developmentally delayed three-month-old baby; John, a three-year-old trauma victim admitted the previous day; and Omar, a five-year-old who is post-surgery.

Sarah is awaiting transfer to a specialty hospital for cardiac surgery. John is on a ventilator, requiring constant care; he is not expected to survive. Omar is ready for the step-down unit as soon as a bed becomes available. He is extremely anxious about leaving the protective environment of the unit.

The unit is usually staffed by two nurses, but on one particular shift Lesedi’s colleague has gone home ill, and no critical-care nurses are available for relief. Even with two nurses, it is a challenge to attend to the needs of these three children.

Left on her own, Lesedi anguishes over the question of how she should set priorities with her limited time. She is faced with the need for micro-allocation decision-making. Lesedi decides to use the distinct criteria of need, equality, likelihood of benefit, and urgency.

The challenge for Lesedi is illustrated in a study of how ICU nurses spent their time, which indicated that 52 per cent was spent providing direct patient care and 20 per cent reviewing clinical information and documentation (Douglas et al., 2013). These high care requirements of ICU patients make Lesedi’s task especially challenging. As well, pediatric ICUs are known to be sites of considerable moral distress for nurses (Garros et al., 2015).

Case Study: Equitable Allocation of Nursing Time and Care

Organizing her options in terms of the criteria of need, equality, likelihood of benefit, and urgency will help Lesedi to achieve clarity about the choices she must make. First, regarding clinical need, she sees that all of the children require her care as they are all very ill. Lesedi has essentially two options. One option is to divide her time and care evenly among the three children. This option, however, is incompatible with considerations of need and likelihood of benefit, and even if equal would not be fair or equitable. The three children, after all, have unequal needs, and allocating them equal shares of her time will not be fair. A second option is to rank the children in terms of needs. Lesedi knows that deciding who is most needy is hard to do. How will she decide? She decides that the child with the greatest need is the child that is most seriously ill, and she will distribute her time with each of them accordingly. After assessing the children, she decides that John is clearly the sickest of the children, and therefore needs the greatest amount of attention. She then thinks about who will benefit the most. Although John would probably benefit the most in the short term, in the long term that care would probably not make a great difference. Omar, who is on the road to recovery, requires very little truly “critical care,” although he might benefit greatly from support and attention because he is so anxious. Lesedi’s attention to Omar would probably have little short-term gain in terms of his medical condition, but could make a difference to him in the long run. Sarah’s needs are great, yet what benefits can be expected down the road, and what “quality of life” can she expect?

Whatever comfort and satisfaction Lesedi takes from being able to devote considerable time to one child will be spoiled by the painful knowledge that this care will be at the expense of one or both of the other children. The situation is a “zero-sum” game in which one person can win only at the expense of someone else losing. Who will be the loser in this decision?

If Lesedi devotes the least amount of time to John, it could be that he will die sooner than he otherwise would have if given more care. Even if she is unable to provide him with lasting benefit, she could at the very least make his dying easier, and provide added comfort to his family. Omar’s life is not in imminent danger, but in neglecting his need in favour of the others she may be contributing to his poor adjustment to hospitalization and recovery. Sarah’s long-term prognosis may not be very good regardless of how much time Lesedi gives her, but this patient is certainly very sick and would benefit from more attention. If Lesedi decides to assign Sarah the lowest priority, will she be making a “quality of life” judgment and communicating to Sarah’s family the message that Sarah’s life is less valuable than that of the other children? Lesedi understands that some groups in society “are systematically disadvantaged (which leads to diminished health and well-being)” (CNA, 2017, p. 19). She reflects that in some way it may be that she is evaluating whose life is more valuable than another’s. She is uncomfortable with this process. She believes each child’s life is equally valuable, no matter how long they will live and what disabilities the child has.

Commentary on the Case Study

Given these limited and less than ideal options, the choice to be made is truly difficult. However, it is important to examine the situation Lesedi has been placed in, and look for alternatives. She realizes that the situation is unsafe for all the children. When she ranks them, she notes that they all need care, and they all have urgent needs. She decides not to try to decide who is more likely to benefit and who is more entitled to care. She contacts the nursing supervisor on call and asks for help in determining a response. For example, would it be possible to transfer one or more of the children to another critical care unit? Can their parents be asked to come and spend the night with the children, because the rooms do have beds available for a parent? Omar, in particular, seems an ideal candidate to be transferred. Indeed, the kind of emotional support he needs could be provided by people with less training than Lesedi, or, with guidance, even a parent or a volunteer. Alternatively, would it be possible to call on one or more staff nurses who, even without special training, could provide basic nursing care under Lesedi’s supervision? At the very least, Lesedi should receive advice and professional support from supervisors and colleagues. Are there any hospital policies or guidelines that might give some guidance on this matter? Probably Lesedi does not have time to check these documents, but the supervisor should have ready access to the policies and practices.

The case raises other issues that go beyond Lesedi’s immediate problem. When a hospital admits a child to an intensive-care unit, some might argue that this step in itself constitutes an agreement to provide the child with a certain standard of care. Hospitals are obliged to take whatever additional steps are necessary to ensure that nurses or other health professionals are not forced into situations like the one that Lesedi finds herself in—that is, of unilaterally renegotiating the standard of care. Lesedi is concerned with matters of justice such as this. According to the CNA (2017), nurses need to work to address organizational and other factors that have an impact on patients’ health and well-being.

Lesedi and the nursing department will want to consider how typical and common this situation is. Questions need to be asked and answered. Why, apparently, have no provisions been made for backup resources in such emergency situations? What prior decisions contributed to this crisis in the first place, and what future decisions will minimize the possibility of such crises, or at the very least provide greater support and guidance for decision-making? How should considerations of “quality of life” enter into these decisions about appropriate and beneficial treatment?

They might ask if a better administrative system can be developed for responding to children awaiting internal or external transfer. For the well-being of the nursing staff and the good of the children served by the unit, Lesedi will later be obliged to see that these issues are raised and dealt with in a thorough manner. She will undoubtedly experience a sharp learning curve. Until this incident she did not know what other resources were available in the hospital. She asks her colleagues and manager and learns that she can work with the hospital nursing council and her professional practice leader, and consult the clinical ethics committee. Following that consultation they propose that the unit hold an education event designed to help everyone understand the issues, and plan how to respond. Another suggestion is to conduct a multidisciplinary health team meeting in the unit. Staff would work together to find ways of preventing understaffing. Lesedi may consider following the hospital’s policy regarding reporting unsafe workload situations. Management may track these reports and look for trends and ways of avoiding these events. All the nurses will benefit as a result of the lessons learned from Lesedi’s experience.

Case 3: Question

1. Some nurses working in neonatal intensive care units have mixed feelings about the surgical and technological innovations that make it possible to “rescue” infants who would otherwise die. Discuss this issue with reference to quality-of-life considerations, whether care is beneficial or futile, and considerations of justice.

2. In the course of caring for children, nurses understandably develop more positive relationships with some children and their families than with others. To what extent might this influence the nurse’s allocation of his or her time among various children? Discuss with reference to therapeutic relationship and fairness.

3. What bearing, if any, might Sarah’s condition have on the decision about how much care she should receive relative to the others? Consider your position in relation to relevant principles of justice.

4. Allocation decisions of the kind with which Lesedi is faced can be extremely painful, and are bound to be emotionally charged. To what extent is emotion an obstacle to such ethical decision-making? To what extent might it be a precondition for it? What is the role of these kinds of situations in nurses’ experience of moral distress?