Hartrick Doane and Varcoe (2015) shared a story centered around a chipped coffee cup in their ground-breaking text, How to Nurse. The story setting is the transfer of accountability report. Registered nurses (RNs) are listening to the recorded report from the previous shift when five minutes into the report, one RN who had worked the night shift stormed into the room, slammed down a coffee cup and shouted, “Who chipped my cup?” A stunned silence from co-workers ensued. Getting no response, the RN shouted, again, “I want whoever did this to own up to it now!” Co-workers were immediately shocked and displayed a look of disbelief at the inappropriateness of her behavior; however, after exploring the outburst further, they discovered she had cared for a number of very ill patients with a novice RN for the entire 12-hour shift. Consequently, some patient care was left for the day shift staff to complete (Hartrick Doane & Varcoe, 2015, p. 411-412).

...emotions from small, inconsequential, and even petty events accumulate over time and contribute to negative work environments. This story may appear trivial and insignificant to some; however, when it is unpacked, it can symbolize how emotions from small, inconsequential, and even petty events accumulate over time and contribute to negative work environments. This story resonated with us because we believe it is a realistic depiction of the current work life of RNs in hospitals across Canada. Analogous to the chipped coffee cup, RNs are constantly challenged to provide quality nursing care, while resources are chipped away, in addition to their energy, pride, and ultimately, their capacity to fulfill holistic patient and family healthcare needs (Hartrick Doane & Varcoe, 2015). RNs undoubtedly experience frustration, exasperation, and a sense of powerlessness to change their circumstances, at least some of the time.

We further discuss how RNs routinely experience subordination and displacement (Campbell & Rankin, 2016; Rankin & Campbell, 2009; Rankin & Campbell, 2006) of their professional nursing judgment and knowledge by healthcare organizations despite knowing what is needed for the patients for whom they care. We demonstrate how use of standardized, efficient, and cost effective care routinely trumps the professional and ethical mandate of RNs to provide individualized patient-centered care. For example, many Canadian hospitals use care pathways to standardize clinical practice (Rotter, et al, 2013) and direct crucial interventions to occur at certain intervals throughout patients’ hospitalization (Rankin & Campbell, 2009). Rankin (2014) describes a situation on a surgical unit whereby a standardized care pathway does not adjust to the individual and complex needs of patients.

The silence of RNs leads many to experience tension and frustration, which can trigger displaced aggression harmful to themselves and the profession as a whole. We argue that working within the business model of healthcare silences and prevents RNs from voicing what is the right or best way to care for patients; it also unconsciously supports a culture of acceptance and suppresses nursing knowledge. The silence of RNs leads many to experience tension and frustration, which can trigger displaced aggression harmful to themselves and the profession as a whole.

It is time for members of the profession to speak up, support, and mentor those who speak out against the dominant culture and organizational discourse. It is necessary to expose the realities of the working lives of RNs in order for them to make a significant contribution to the health and well-being of patients. In this article, we discuss working in a restructured healthcare system and demonstrate how the business model of healthcare routinely undermines the professional knowledge of RNs and their ethical mandate to provide individualized patient-centered care, often causing tensions, strains, and ethical conflicts. We offer a call to speak up and out, and conclude with recommendations to assist RNs to understand the realities of their work life and improve their practice environments.

Registered Nurses Working in a Restructured Healthcare System

Within the past few decades of healthcare reform we have witnessed healthcare organizations shift from a treat-heal-care model to a more corporate or business paradigm... Within the past few decades of healthcare reform we have witnessed healthcare organizations shift from a treat-heal-care model to a more corporate or business paradigm, with emphasis on efficiency and cost outcomes as opposed to patient outcomes (Grinspun, 2000). This shift occurred in response to a variety of challenges, namely the mandate for public administrators to maintain an efficient, effective, and equitable system of healthcare delivery (Rankin & Campbell, 2006).

Medicare, Canada’s national health program, came under intense scrutiny in the 1990s. Provincial health system reviews highlighted Medicare services as too high and not sustainable (Rankin & Campbell, 2006). Each province was directed by the federal government to improve the quality and efficiency of healthcare services through managerial reform, using limited resources more effectively. Provinces responded in various ways by closing and merging hospitals; reducing bed numbers; and cutting staffing levels. A move to have acute patients out of hospitals more quickly to recover at home with family assistance was initiated (Rankin & Campbell, 2006). Hospitals also employed new ways of managing patient flow and clinical treatment decisions (Grinspun, 2000; Rankin & Campbell, 2006).

Product-line management, originating from the manufacturing industry was viewed as an approach that could provide the necessary tools and structures to meet the demands of reduced funding. Cost-contained healthcare thinking traces its roots back to the work of American engineer W. Edwards Deming, who worked with Japanese industry leaders to rebuild their economy in the post-World War II era (Mann, 1989). Deming’s message was a focus on quality and continuous improvement to improve productivity, reduce costs and improve business success. This approach to healthcare was introduced in Canada as “patient-centered care” (Grinspun, 2000, p. 31). However, institutional focus on cost-saving measures has resulted in neglect and a lack of health promotion for patients and families (Campbell & Rankin, 2016; Grinspun, 2000; Rankin, 2014).

...RNs are the health professionals who gain understanding of unique patient needs that are so critical to health, healing, and recovery. RNs working within this business model of healthcare must learn to adapt and practice under the auspices of a care delivery model that is antithetical to philosophical principles learned in nursing school, including patient-centeredness and holism. Through daily contact with their patients, RNs are the health professionals who gain understanding of unique patient needs that are so critical to health, healing, and recovery. Besides Carper’s (1978) well documented empirical, aesthetic, personal, and ethical ways of knowing, RNs use embodied knowledge (i.e., what they know and learn from being with and caring for patients and their families), often referred to as knowledge in-action, that is partly explicit and often difficult to describe (Blackler, 1995). RNs use their specialized body of professional knowledge to attend to and care for people’s physical bodies and mental health (Cameron, 2006; Rankin & Campbell, 2009).

The business model requires a reductionist, standardized approach to care delivery... The business model requires a reductionist, standardized approach to care delivery accompanied by often inflexible organizational policies, regulations, and operating procedures. There is little room for tailoring healthcare to accommodate unique or holistic patient needs, offering a harsh and constraining reality for RNs, and ultimately, their practice norm. Through a process of socialization within the organizational culture, RNs find themselves providing routinized nursing care, all the while practicing in juxtaposition with the ideals learned in nursing school. Anecdotal accounts and empirical studies increasingly attest to the growing tension, strain, and ethical conflicts experienced by RNs today.

Tensions, Strains, and Ethical Conflicts

Chafing occurs especially when RNs know what is the best care for their patients, yet their professional knowledge about how to meet unique and holistic patient needs is subjugated by organizational policies and processes... The Canadian Nurses Association (CNA) (2013) asserts that “the nurse’s role as a direct service provider is to be uniquely connected with patients and families in all health and illness-related events throughout the lifespan” (p.3). It seems as though healthcare reform has perpetuated a disconnect amongst the vision, mandate, and values of the nursing profession and everyday RN practice. RNs have shared that their nursing care “chafes” (Rankin & Campbell, 2009, p.15) or rubs up against institutional cost-containment objectives. Everyday work life evokes feelings that some have disclosed as “feels like hell” (p.10). Chafing occurs especially when RNs know what is the best care for their patients, yet their professional knowledge about how to meet unique and holistic patient needs is subjugated by organizational policies and processes (i.e., implementation of standardized clinical care pathways).

Rankin and Campbell (2009) studied how patient care is compromised with the use of such standardized approaches to care. Clinical care pathways direct discharge plans that frequently result in premature discharge for patients, who often still have significant needs. RNs in Rankin and Campbell’s study attempted to provide makeshift temporary plans and teach patients about self-care and medication administration and side effects under hurried circumstances. We suggest that individualized expert nursing care is being chipped away at by the use of these standardized clinical pathways. Why are RNs not speaking up to voice the concerns they have regarding patient care?

The Silence is Deafening

The CNA Code of Ethics for Nurses (2017; hereafter referred to as Code of Ethics) serves as a foundation for ethical nursing practice. It is designed to assist RNs to practice ethically and work through ethical challenges that surface in practice with individuals, families, communities, and public health systems. This code also serves as an ethical basis from which RNs can advocate for delivery of safe, compassionate, competent, and ethical care, and promote the health and well-being of individuals for whom they care. However, it is vital for a code of ethics to influence behaviors without organizational and policy barriers (Anand, Ashforth & Joshi, 2005).

Healthcare organizations are not always designed to support the Code of Ethics; the business model of healthcare encourages RNs to act in ways that accommodate and advance institutional cost savings, accept organizational norms, and maintain status quo (Johns & Saks, 2014; Rankin & Campbell, 2006). What is preventing RNs from advocating for patients and making their concerns known regarding their inability to provide optimal nursing care?

Critical to the success of lean implementation is the trust, support, cooperation, and input of everyone in the organization... The Toyota Production System (TPS), or more generically “lean manufacturing,” is based on the concept of standardized work (i.e., an assembly line with everyone doing the same job exactly the same way) with a constant focus on continuous improvement (Mann, 1989). Critical to the success of lean implementation is the trust, support, cooperation, and input of everyone in the organization, especially those doing the job, the frontline assembly workers (Martin, 2012). Early discussions of applying lean principles in healthcare settings were started by Dr. Dennis Berwick (1989). Berwick called on the field to adopt a focus on continuous improvement by empowering frontline healthcare workers and called for understanding and revision of processes rather than placing blame on an individual.

Disengaged RNs distance themselves from their own expert nursing knowledge and judgment in order to perform in keeping with organizational mandates. Employee silence exists when there is widespread reluctance to speak up about critical issues of concern, such as those experienced by RNs within healthcare institutions. Some keep quiet out of fear of punishment and in the interest of maintaining group consensus and cohesiveness. Other RNs feel pressure to silence their concerns due to organizational or professional factors that support the status quo (Mitchell & Ferguson-Pare, 2002) and therefore become disengaged (Hartrick Doane & Varcoe, 2015). Disengaged RNs distance themselves from their own expert nursing knowledge and judgment in order to perform in keeping with organizational mandates. Other RNs may fear negative labels or believe organizations will fail to listen to their concerns (Morrison & Milliken, 2003). Sinclair (2000) cited a judge who was amazed by how physicians and managers “ignored pertinent information that was brought to their attention by RNs” (p. 485). Similarly, Sibbald (1997) described how knowledgeable and expert RNs voiced serious concerns about patient safety in a pediatric cardiac program, but were routinely silenced by the organization and physicians.

Employee status within organizations also influences their decision to remain silent. Newton et al. (2012) illustrated how RNs had to “accept unsafe conditions;” learn to “suck it up;” “just accept this is the way it is;” and felt like they were being “blown off” when they encountered situations deemed unsafe or unethical (p.97). If employees repeatedly witness situations where their voices have no impact on outcomes, they become disenchanted, discouraged, and frustrated (Ashford, Sutcliffe & Christianson, 2009).

Suffering in Silence

Milliken, Morrison, and Hewlin (2003) described how employee silence can create stress, frustration, dissatisfaction, cynicism, and disengagement. These outcomes have serious long-term consequences for employees and for their relationship within the organization. Newton et al. (2012) supported this assertion, reporting that the RNs in their study felt “beaten down” (p.97) and predicted that they would choose to remain silent if they encountered a similar situation in the future.

A constant state of frustration, tension and “chafing” builds and can be displayed as displaced aggression... RNs who experience ethical tensions and contradictions between institutional policies and what they believe is the “correct” thing to do often encounter ethical distress, which can interfere with their ability to provide safe, ethical nursing care (Rodney, Hartrick Doane, Storch, & Varcoe, 2006). The quality of the practice environment is an ethical issue because of its important effect on the quality of patient care (Aiken, Clarke, Sloane, Lake, & Cheney, 2008; CNA, 2017; CNA, 2008; Kramer & Schmalenberg, 2008). It also affects RNs’ sense of health and well-being in the workplace (Peter, Macfarlane & O’Brien-Pallas, 2004). For example, Hanna (2004) described how RNs were physically impacted by unresolved ethical issues. They spoke of sleeplessness, nausea, migraine headaches, gastrointestinal upset, tearfulness, and a sense of isolation.

If an organization fails to support ethical practice, RNs may become apathetic or disengaged to the point of being unkind, non-compassionate, or even cruel to other healthcare workers and to persons receiving care (CNA, 2008; Rodney et al., 2002; Rodney et al., 2006; Storch et al., 2009). Such counterproductive behaviors are often expressed with lateral violence, incivility, or bullying and are considered a result of RNs’ inadequate interprofessional skills, for which they blame themselves (Rankin & Campbell, 2009).

Displaced aggression generally occurs when a person is constrained from reacting to the source of the frustration. A constant state of frustration, tension and “chafing” builds and can be displayed as displaced aggression as outlined by Bushman, Bonacci, Pedersen, Vasquez, & Miller (2005). Displaced aggression generally occurs when a person is constrained from reacting to the source of the frustration. In the case of the RN reacting to the chipped cup, her feelings of powerlessness and inability to remedy such situations, coupled with her status within the healthcare hierarchy, could have triggered behaviors of aggression and incivility toward colleagues (Hartrick Doane & Varcoe, 2015).

Time to Speak Up and Out!

Functioning within healthcare organizations where the main goals are cost containment, efficiencies, and effective care significantly impacts the ability of RNs to function as autonomous professionals in keeping with their professional knowledge, ideals, values and scope of practice. RNs can clearly articulate the deep gaps amongst what constitutes good patient care; what actually transpires; and how care is constrained by barriers such as organizational policies, resources, and staffing ratios (Hartrick Doane & Varcoe, 2015). RNs, however, believe their conversations are simply “blowing off steam” in the coffee room and often end up blaming each other and/or interpreting their emotional turmoil as a personal limitation (Hartrick Doane & Varcoe, 2015).

Although RNs have much to say, they may not make their views known as individuals or professional nursing associations. RN silence and hesitancy to voice professional opinions related to healthcare provision contributes to the notion of acceptance, and that RNs have nothing to offer about such matters (Perron, 2013). Buresh and Gordon (2006) contended that RNs are inclined to assume no one will listen or take their concerns seriously. Continued silence by RNs inadvertently sustains adverse conditions detrimental to patients and families, and themselves. This culture of silence has unknowingly created a culture of acceptance, and continues to supress nursing professional knowledge. Unfortunately for many, such conditions result in sickness, fatigue, stress, workplace bullying, and some RNs decide to leave the profession.

Springer and Clinton (2017) attribute such silence to the lack of parrhesiastic nursing leaders. Parrhesiastic is a term coined by the late French philosopher Michel Foucault (2001) to describe “one who speaks the truth: (p. 11) and "is sincere and says what is his opinion” (p.12) and does so through courage and commitment in opposition to dominant discourses (Springer & Clinton, 2017). Although professional bodies do address work environment concerns, this support also can be strengthened and nurses may be unaware of association level support resources. This silence has created a culture of acceptance and maintenance of the status quo. Nursing leaders (i.e., nurse managers, nursing directors, professional nursing associations, union heads) tend not to take strong, consistent stands on issues related to work environment. How often do we hear our nursing leaders speak out in support of RNs and the ethical issues they face every day in the institutions in which they work?

To advance the profession, all RNs must lead by example. Some institutional nursing leaders over identify with the healthcare organization commitment at the expense of RNs who work and care for patients and their families (Springer & Clinton, 2017). To advance the profession, all RNs must lead by example. They must mentor and support parrhesiastic nursing leaders who speak out and reveal the realities in which RNs work if the profession is going to be recognized as a significant contributor to the health and well-being of individuals, families, and communities (R.A. Springer, personal communication, August 8, 2017).

Recommendations and Conclusion

As medical and organizational dominance continues to prevail, nursing knowledge and concerns are not always considered equally important. RNs will likely continue to react and display examples of displaced aggression over trivial occurrences such as a chipped cup, unless more critical research is performed to uncover the impact of organizational structures on the relationship amongst ethical climate, moral distress, and the use of voice (Newton et al., 2013). Healthcare organizations must also recognize the value of RNs as legitimate contributors to patient care. Promoting and maintaining quality work environments is central to the ability of RNs to provide ethical care.

Raising awareness of the disconnect that exists between organizational agendas and the ethical obligation of nurses to provide a certain standard of care may be the first step to improve understanding... Buresh and Gordon (2006) proposed that RNs are silent because they lack the necessary skills to use their voice effectively. Educating and supporting RNs in techniques that cultivate effective and respectful communication during challenging and difficult conversations is warranted. Resources such as those from VitalSmarts (2017) offer training programs related to use of essential and effective communication skills in complex work environments. Healthcare organizations must promote an atmosphere (regardless of one’s status) of speaking up and voicing concerns in a style that maintains professionalism and accountability. We have found documents written by the Registered Nurses of Ontario (Heathy Work Environments Best Practice Guidelines, 2007) and the American Association of Critical Care Nurses (AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence, 2016) that offer excellent guidelines to promote and support positive workplace environments.

Nursing scholars need to build partnerships with RNs working at the point of care. These fundamental relationships will assist nursing scholars to complete vital research in these areas and, more importantly, translate that knowledge in an easily accessible and understandable way for RNs working at the point of care. In other words, dissemination of research findings involves moving beyond simple dissemination of knowledge into actual use of knowledge. The majority of reputable nursing journals provide excellent and detailed research that outlines implications for RNs at all levels of healthcare, including practice issues, patient care topics, healthcare professionals and policy makers. However, few are written in formats easily understood and accessible to RNs at the point of care.

Many RNs in clinical areas may not be familiar with research methodologies. Moreover, if RNs are busy, overworked, and fatigued from rotating shifts, they may not have the time or energy to read and synthesize such vital material. It is therefore up to nursing scholars to make this valuable knowledge readily available and user-friendly for clinicians to use in practice. Nurse scholars could translate research findings at nursing in-services, nursing research conferences, nursing forums, or local nursing unit journal clubs to highlight the relevance of these studies to practice environments.

Nurse scholars should also disseminate research findings to those RNs who participated in their studies by preparing a short synopsis detailing the study findings. This provides RNs with opportunities to convey nursing research reports to colleagues and invites RNs at the point of care to voice ethical concerns by providing empirical support related to the issues. For example, in a study conducted on a nursing unit that explored ethical nursing practice, Hartrick Doane and colleagues (2009) developed positive working partnerships with participants. This resulted in motivation for RNs to proactively voice concerns regarding difficulties routinely faced while attempting to provide ethical care in complex environments.

Increasing awareness about what is actually happening within healthcare organizations might help RNs understand how they may be subconsciously contributing to the subordination of their knowledge. Instead of feeling powerless, this consciousness-raising could transform RNs from disembodied, docile, practitioners to ones active in developing ways to bring about organizational change focused on health improvement and well-being of patients and families.

...RNs can move from a culture of silence and acceptance to one that encourages speaking up in a respectful and professional manner. Raising awareness of the disconnect that exists between organizational agendas and the ethical obligation of nurses to provide a certain standard of care may be the first step to improve understanding by RNs about what is actually happening within healthcare organizations. With this new awareness, and education, RNs can move from a culture of silence and acceptance to one that encourages speaking up in a respectful and professional manner. Collaboration among all healthcare providers, with consideration of the voice of RNs. will foster positive work settings and ethical nursing care in cost contained environments.

Acknowledgement: The first author would like to acknowledge Mr. Aubrey Dawe and Mr. Bill Stirling for their edit suggestions during the development of this manuscript.

Authors

Paula Kelly, MScN, BScN, RN
Email: paulak@mun.ca

Paula is a lecturer at Memorial University of Newfoundland School of Nursing and is a PhD (Nursing) candidate. She has a rich nursing career in women's health and obstetrical care. Her program of research focuses on the social organization of healthcare, nursing knowledge, and nurses’ work. This paper draws on her recent work related to organizational behavior and the healthcare system.

Caroline Porr, PhD, MN, RN
Email: cporr@mun.ca

Caroline is an associate professor at Memorial University of Newfoundland School of Nursing who teaches in the undergraduate and graduate level nursing programs. This year she is honored to be presented with the 2017 President’s Award for Outstanding Teaching.