Nurses bring a wealth of experience and expertise to resource allocation decision making in many different arenas in and outside of health care. This article, grounded in the utilitarianism theory of justice, will examine macroallocation and microallocation of scarce resources in health care, including participation of nurses in macroallocation and microallocation of these resources, and types of allocation challenges within health care. Macroallocation in specific branches of the United States government and integrating resource allocation content into the educational curriculum are also discussed. The authors make the case that nurses can most effectively meet patient needs by active engagement in decisions that involve macroallocation and microallocation of resources.
Key words: health resource allocation, ethics theory, decision making, public policy, nursing administration, budgets, scarce resources, microallocation, macroallocation
Nurses bring a wealth of experience and expertise to both macroallocation and microallocation resource decision making in a multitude of arenas in and outside of health care. Macroallocation decisions take place at the highest levels of administration and policy. In contrast, microallocation decisions are those most familiar to nurses at the bedside with patients and their families.
Resource-allocation decision making is impacted by ethical considerations; yet ethicists offer different perspectives, approaches, and theories as they justify how to most fairly allocate resources. Although this article will be grounded in the utilitarian theory, other nurses may choose to operate from a different theoretical perspective. What is important is that nurses incorporate an ethical perspective in making decisions related to scarce resource allocation.
This article, grounded in the utilitarianism theory of justice, will examine macroallocation and microallocation of scarce resources in health care, participation of nurses in macroallocation and microallocation of these resources, and types of allocation challenges within health care. Macroallocation in specific branches of the United States (U.S.) government and integrating resource allocation content into the educational curriculum are also discussed. As authors we make the case, based on our diverse experiences and observations working in hospitals, private and public corporations, non-profits, and government agencies, and including experiences in bedside nursing, administration, education, and policy, that nurses can most effectively meet patient needs by active engagement in decisions that involve macroallocation and microallocation of resources.
Utilitarianism: A Theory of Justice
Theories of justice speak to how society morally justifies distribution of benefits and burdens (Beauchamp & Childress, 2001). According to moral and ethical theorists, utilitarians strive to provide the greatest good for the greatest numbers (Darr, 2005). By way of example, consider the challenges of maximizing health and wellness by providing immunizations. At the highest levels, vaccination programs and policies provide protection against disease not only for the individual vaccinated but also for large populations across the range of socioeconomic groups and cultures. Vaccination programs are designed to provide the greatest good for the greatest number. However, some potential recipients of vaccinations and other preventive measures will choose not to be vaccinated. Although programs and policies are established to protect the greater good, micro-level concerns, such as the fear of vaccination side effects, will prevent some individuals from obtaining vaccinations, thus potentially endangering other members of society. The ethical principle of autonomy gives these individuals the freedom to make the decision against personal vaccination, while allowing a broad-based vaccination program to move forward.
Macroallocation versus Microallocation of Scarce Resources
With ongoing cuts to domestic spending in the current economic and policy climate, our nation faces significant challenges to fair and ethical allocation, allotment, and distribution of tax dollars and available resources. To ensure distributive justice or the “fair, equitable and appropriate” (Beauchamp & Childress, 2001, p. 226) distribution of resources, it is essential to base decisions on input from knowledgeable professionals, including nurses. This involves “macro” allocation decisions or determining what funds to expend, goods to make available, and methods of distribution (Beauchamp & Childress, 2001) and “micro” allocation decisions which focus on deciding who will be the recipient of scarce resources (Beauchamp & Childress, 2001).
Nurses and Microallocation of Scarce Resources in the Care of Patients
...there appears to be minimal attention paid to staff nurse involvement in macro-level challenges related to ethical allocation of scarce resources. Historically, nurses have been most actively involved in microallocation decisions that directly affect patients. Nursing education, nurse socialization, and the tasks of the typical nurse’s workday, for the largest percentage of nurses, provide ongoing exposure to critical issues affecting direct patient care. A review of nursing textbooks and journal articles on the topic shows a preponderance of discussion on micro-level ethical issues (Bandman & Bandman, 2002; Butts & Rich, 2005; Tschudin, 2003). Though nursing leadership textbooks speak to higher-level issues, there appears to be minimal attention paid to staff nurse involvement in macro-level challenges related to ethical allocation of scarce resources. Nurses are educated to always put patient needs first. They are routinely involved in helping to make decisions that directly touch patients and families, like helping to determine whether additional time and resources (material and financial) should be expended keeping a terminal patient alive, or helping to make the decision regarding which patient is the best candidate for the one available donor organ.
One vivid example of allocating scarce resources is illustrated in a true story from the bedside. As two nurses mistakenly contaminated a catheter, one nurse retreated to a supply closet to obtain a new catheter. Supplies were low and only a catheter kit including both a sterile field and catheter were available. One of the nurses suggested opening the kit with the intention of using just the catheter, while disposing of the sterile field.“Don’t worry about opening a full kit, instead of just the catheter,” she suggested to the other nurse who was concerned with conserving precious resources, adding “Insurance coverage will pay for the kit.” Imagine how many similar micro-level decisions are made nationally, on an annual basis, contributing to a significant increase in the cost of health care. Microallocation decision making and macroallocation decision making are connected. They do not exist in isolation.
Nurses and Macroallocation of Resources
It is our contention that patients, families, nurses, and health systems would be better served if nurses were schooled to be equally involved in microallocation and macroallocation issues that affect patient care.It is our contention that patients, families, nurses, and health systems would be better served if nurses were schooled to be equally involved in microallocation and macroallocation issues that affect patient care. Macroallocation challenges are encountered at all levels, in health systems, policy arenas, and academia. They involve decisions that impact large numbers of people, either directly or indirectly. By providing students and new nurses with education, tools, and on-the-job exposure to macro-level decision making early in their careers, nurses would develop the skills to make great contributions to such decision making throughout their working years. By dual level involvement in both microallocation and macroallocation of resources, at the bedside and beyond, nurses will help to maximize utility by supporting ethical decisions for a greater number of patients. All decisions should be made with the health policy considerations of quality, cost, and access in mind.
Types of Allocation Challenges
Macroallocation and microallocation decisions can be described in the context of four distinct types of allocation challenges: (a) partitioning the comprehensive social budget; (b) allocating within the health budget; (c) allocating within the health care budget; (d) allocating scarce resources for patients (Daniels, 1996). Each will be discussed in turn.
Partitioning the Comprehensive Social Budget
...[representatives]must strike a balance between meeting the needs of their constituents and all people needing the nation’s resources.Macroallocation decisions are made in government and policy arenas to allocate resources among competing needs such as education, foreign affairs, transportation, and health. Decision makers, at the highest levels, influence the percentage of resources spent on one societal or organizational need versus others. They are faced with deciding whether to spend more money on educating children, seeking new sources of energy, providing health insurance for vulnerable populations, or allocating resources to other critical but less visible challenges facing society. Currently three nurses, Carolyn McCarthy, Lois Capps, and Eddie Bernice Johnson, serve in leadership positions in the U.S. House of Representatives. These representatives are faced with making resource allocation decisions daily; they must strike a balance between meeting the needs of their constituents and all people needing the nation’s resources. In negotiations on a recent budget reconciliation bill to reduce the federal deficit ("Deficit Reduction Act," 2006), Senators and Representatives were faced with decisions regarding whether to cut health care or other areas of the budget. They were challenged with deciding whether to cut Medicaid funds that impact low-income families or Medicare which primarily funds health care for the aged. Which groups are most entitled to health care coverage? The consequences of decisions made at upper levels cascade to lower levels. If nurses are involved at the highest levels, they are well positioned to impact the total funds that flow to health care. They also help influence the direction of the flow, or the programs that will benefit from the allocated resources.
Allocating within the Health Budget
At the next lowest level of allocation, decisions are made regarding health resources, above and beyond health care. Often, health needs are intertwined with seemingly non-health-oriented issues. For instance, the Occupational Safety and Health Administration (OSHA) is part of the U.S. Department of Labor, not the Department of Health and Human Services. Yet, OSHA is focused on issues that significantly impact health and safety within the work environment. Is it more important to develop programs to provide on-the-job safety training for young employees, or write new guidelines and best practices for dangerous equipment found in unsafe work environments? These are tough choices, yet very real dilemmas. Imagine the possibility of a nurse with economic, labor, and health expertise, as the head of the Department of Labor, to help ensure that the available dollars are prioritized based on evidence and health care understanding.
Another example occurred after Hurricane Katrina when state officials nationwide faced difficult ethical decisions. They needed to decide, for instance, whether state governments should take funds earmarked for children’s low-income nutrition programs or other such programs and reassign them to meeting emergency preparedness needs for people of all ages? To many, emergency preparedness seems more critical. To a hungry child, food is essential.
Allocating within the Health Care Budget
Health care budget decisions identify which health care need is more important. Nurse administrators within health care systems must determine whether to spend greater resources on health promotion or medical treatment. Ask yourself the question, is it more critical to expend resources on health promotion programs to address obesity and other chronic-illness challenges, such as diabetes and heart problems, or should we use resources to vaccinate to prevent the spread of mumps? Within academia, the dean of a college of nursing participates on committees that determine how a university spends total resources. Within a college that houses multiple nursing and allied health programs, the dean, with assistance from faculty and staff, needs to determine whether to grow: (a) baccalaureate programs to educate new nurses, (b) masters or doctoral-level registered nurse programs to develop nurse educators and leaders, or (c) programs that educate more social workers or other health providers. If the health and allied health programs fall under the purview of two deans, negotiation may take place to determine how best to ethically allocate resources to meet the mission of the university and the respective programs.
Allocating Scarce Resources for Patients
With an increase in the size of the population, the length of life, the number of treatment options available, and overall health care costs, society faces increasing challenges regarding who should receive the limited supply of scarce resources. In the simplest form, if a family has only $1000 available for health care, should they allocate the funds to care for the children or care for the primary breadwinner? At the state level, Oregon implemented a rationing program by establishing a priority list of services with the goal of serving as many eligible citizens as possible (Beauchamp & Childress, 2001). Under any circumstances, decisions are not easy and there is no one right answer. Nurses must be prepared to serve on task forces and committees, as practitioners and leaders, with confidence that their input will help facilitate quality-oriented, equitable, decision making.
Macroallocation in Branches of Government
By holding leadership positions and taking part in macroallocation decision making...nurses have the opportunity to provide quality health care to a greater number of individuals. Macroallocation decision making takes place throughout government. Nurses involved in policy, at the highest levels of the executive, legislative, and judicial branches, impact favorable development of laws and policy, quality-oriented regulations, and judicial rulings that facilitate quality health. A nurse who works on a U.S. Senator’s staff helps to write an array of health-related legislation that impacts everything from health professions education to quality of care. Additionally, a nurse who writes the regulations to oversee Medicare implementation, within the executive branch, impacts allocation, as does a nurse-attorney involved with making judicial rulings related to an individual’s right to choose, or not to choose, to end their life. By holding leadership positions and taking part in macroallocation decision making within health care systems, academia, policy, and other arenas, nurses have the opportunity to provide quality health care to a greater number of individuals. Bedside nursing remains the heart and soul of a large percentage of today’s nurse workforce, and quality microallocation decisions at the bedside are fundamental to fair and equitable patient care. Nonetheless, if nurses are to experience their full power as a profession, they need to learn early in their education and career to take on responsibility, move to higher level positions with confidence, and be part of decision-making teams that impact macroallocation of resources in an ethical manner. Such opportunities may feel far removed from the patient. Yet, providing this leadership is just as critical to quality patient care as providing hands-on patient care.
Allocation Considerations in the Undergraduate and Graduate Curriculum
Educators are encouraged to integrate
macroallocation resource and microallocation resource discussions into existing curriculum. Educators are encouraged to integrate macroallocation resource and microallocation resource discussions into existing curriculum. A multitude of examples can be utilized for both undergraduate and graduate students. For example, in discussing organ donation, students easily relate both to micro-level issues related to individual patients, and to macro-level policies that impact rationing of the limited supply of organs. Educators are encouraged to use allocation case studies such as these in undergraduate programs, where the study of ethics is often threaded throughout the curriculum. At the same time, students who are already graduate nurses can envision or have encountered circumstances where a very important person is seeking special consideration to be moved to the top of the donor recipient list. These students are eager to discuss the ethical implications of granting such requests. For doctoral students, course work and study must embrace macroallocation decision making that is so critical to success as an academic, policy, or research leader. To bring attention to the challenges associated with allocation of resources in communities, students can participate in performing community assessments. By understanding gaps in coverage and inequity in care encountered by segments of the community, students are better prepared to address challenges and offer solutions in their roles as nurses. In follow-up, we encourage educators to share what they have learned about the successful integration of these components into course work at all levels of education.
In conclusion, it is our contention that nurses should be taught, in schools and on-the job, how to most effectively make decisions related to ethical microallocation and macroallocation of resources. If given the tools, nurses will be positioned to take on decision-making responsibility at all levels of the organization. Nurses who are prepared to address all levels of resource allocation in influential administrative and policy positions, beyond the bedside, will strengthen health care. Nurses with a voice in macroallocation, and microallocation of scarce resources will help organizations balance benefits and drawbacks of various decisions and provide quality care to a greater number of patients in a way that is ethically justifiable (Institute of Medicine, 1995).
Nancy L. Falk, PhD(c), MBA, BSN
Nancy L. Falk is a doctoral candidate, College of Health and Human Services, George Mason University, Fairfax, Virginia. Her primary research interests focus on aging and older workers, aging nurse faculty, and employed caregivers. She was the 2004-2005 John Heinz Aging Policy Fellow in the U.S. Senate and was instrumental in drafting S1575, the Nurse Faculty Education Act of 2005, introduced in the U.S. Senate in July 2005.
Elizabeth S. Chong, PhD, MSN, BSN
Elizabeth S. Chong is an Associate Professor in the College of Health and Human Services at George Mason University. She is a member of the Human Subjects Review Board in the Office of Research Subject Protections. Her background is in parent-child health and women's health nursing. In her research, she is interested in cultural comparisons of mother-infant interactions. Dr. Chong received a Ten Outstanding Young Women of America Award in 1986, was a White House Fellowship Regional Finalist in 1988, and a Fulbright Research Scholar to Seoul National University in 1988-1989.
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Article published February 14, 2008
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