A recent review of healthcare professional workforce statistics and trends points to a disturbing reality: Significant shortages will continue to impact organizations for the foreseeable future. Physicians, nurses, allied health workers and a wide variety of support staff roles are all forecasted to be in short supply through mid-century.

Leaders are regularly confronted with access-to-care issues resulting from these shortages and often must decide whether to hire expensive contract labor, overtax their staff, or limit or even close services. Such choices can introduce a variety of ethical conflicts, raising questions such as:

• How would patients be affected by necessary service closures?
• How are staff impacted by constantly having to “stretch” to do more to keep vital services available?
• Are the transient staff available through staffing agencies capable of providing the level of care necessary, and how do we know?
• What effects does the organization experience from constantly having to operate in this pressure cooker environment?

Healthcare leaders face these dilemmas practically every day, and their impact on the well-being of the organization, its people and leadership is often underappreciated. The timely and judicious introduction of an ethicist or individual trained in ethical reasoning, as well as the application of ethics resources, such as ethical decision-making frameworks, can help mitigate the impact of these challenges until the results of macro approaches to projected workforce shortages can be felt. Below are several ideas to get started. 

 

Everyday Decisions Have Ethical Dimensions

Because the staffing choices leaders face are so commonplace, it can be easy to lose sight of the ethical dimensions inherent in them. The way decisions are made concerning issues like organ allocation, or, as was the case during the COVID-19 pandemic, which patients receive ventilators, are obviously moral choices about the allocation of scarce resources, which are readily appreciated. These decisions bring the ethical principle of justice into focus, requiring leaders to carefully weigh their costs and benefits. It is often typical for ethics professionals to become involved in helping with the decision-making process and follow-up evaluation for these types of issues.

However, how often has it happened that an ethicist is invited to discussions regarding responses to inadequate resources for safe staffing of our programs and services? Is it recognized that the same ethical threads run through these challenges as in the organ and ventilator examples? Would it even occur to leaders to have an ethicist or someone with ethics training participate in management meetings as they work through the daunting questions of how to continue to provide safe care in the face of dwindling and inadequate human resources?

An important first step to enhanced, ethically grounded decision-making is recognizing that a leader’s decision to limit services, stretch existing staff to fill gaps or contract with temporary (and often expensive) labor is a classic “allocation of scarce resources” (justice/fairness) dilemma.

Deploying Ethical Resources

With the understanding that persistent shortages of key human resources do present challenging ethical decisions comes the recognition that engaging ethics resources to assist in decision-making processes can be beneficial. It is an understatement to say that many decisions weigh heavily on the minds of the leaders who are charged with making them. The introduction of an ethicist, therefore, is a gift that leaders give themselves. And, the application of ethical decision-making frameworks provides a road map to assist the leader in what are often emotion-heavy discussions and decisions.

Although the weight of the ultimate decision continues to rest upon the leader, a comprehensive ethical decision-making process helps gain support for making the decision and evaluating its impact—and having a confidante along the way is far more desirable than carrying the burden alone. Further, the use of an ethicist in these leadership discussions and decisions may, in fact, decrease stress and bolster leader resilience in the long term.

Communicating Openly and Honestly

In this time of healthcare human resource shortages, those who are employed want to know that their leaders understand the impact of the shortages on their work and that they are committed to improving their work experience. In addition, it has been clear that people working within the healthcare system want to know that their leaders are making ethical decisions.

At every opportunity, leaders must communicate openly and honestly with stakeholders about the challenging workforce shortage environment and its impacts on the organization. Have at the ready solid answers to why a program might be closing or how long a department will have to work shorthanded without respite. And have answers to questions about why a decision was made to invest in expensive contract workers in lieu of pursuing other needed resources.

When a leader can describe a shortage-related decision as having been arrived at using an ethical decision-making process—and can clearly articulate the cost-benefit analysis that was done before the decision was made—stakeholders will then have assurances that decisions have a strong ethical basis.

This type of communication helps build and maintain trust in leaders. It is far more effective than often-used (and trite) responses such as, “It’s not in the budget,” “Everyone just needs to work smarter, not harder,” and “Everyone needs to get used to it because this is our new normal.”

Allocating scarce resources is a necessity that every healthcare system has likely been performing since its inception. The difference today might be that resources are not allocated using traditional cost-benefit methods but, rather, in a “which is the lesser harm” or “lesser of two evils” mode. This is extra taxing on leaders. Introducing ethicists and ethical decision-making resources is a powerful tool to reduce stress on leaders while ensuring a systematic approach to making tough decisions with an ethical basis.

Susan A. Reeves, EdD, RN, CENP, is system chief nurse executive for Dartmouth Health, Lebanon, N.H. (susan.a.reeves@hitchcock.org).