Key Words: nursing shortage, errors, ethics
Welcome to this issue of the Ethics Column of the Online Journal of Issues in Nursing (OJIN). This issue summarizes and highlights trends from the OJIN survey on "Errors, Shortage and Ethics" that 1,386 of you participated in from October 30, 2002 to December 10, 2002.
The survey had two major purposes: (a) first, to identify registered nurses’ (RNs) perceived experience with clinical errors or untoward clinical incidents over the past year, whether the errors/incidents were related to the current nursing shortage, and whether the nurses felt any resultant moral distress; and (b) second, to identify if RNs perceived that other nurses made clinical errors or experienced untoward clinical incidents over the past year, whether the errors/incidents of other nurses were perceived to be related to the current nursing shortage, and if the RN participants felt any resultant moral distress.
Clinical errors and untoward clinical incidents are shown in Table 2. Current nursing shortage meant that within the past year (2002) study participants had to sacrifice the quality of their care because of the lack of nurses. Moral distress meant that study participants experienced negative emotional feelings (e.g., anger) and/or symptoms (e.g., headaches) because the nursing shortage made it impossible for them to take the morally right course of action.
In the late 1990s, the nursing shortage was becoming more of a reality. In January 2001, OJIN featured an issue, The Nursing Shortage: Is This Cycle Different? In the Ethics Column for that issue we stated: "In times of crisis it is often that values and beliefs and, subsequently, our ethics are challenged" (Silva & Ludwick, 2001, para. 1). Based on that belief and the overwhelming readership and letters to the editors for that OJIN issue, we asked readers to write in and tell us how the shortage was impacting on everyday ethical issues in nursing practice. However, we did not receive enough letters to adequately analyze ethical issues. Therefore, we concluded that this anonymous exploratory survey might be a better method to gather online data about ethics and the shortage.
In 1999, the Institute of Medicine (IOM) released a report to the public on the incidence of medical errors and untoward patient outcomes, detailing that as many as 98,000 deaths annually could be attributed to medical errors (Kohn, Corrigan & Donaldson, 2000). In a groundbreaking article in the Journal of the American Medical Association (JAMA), Aiken, Clarke, Sloane, Sochalski, and Silber (2002) examined hospital data from 1998 to 1999 on over 200,000 surgical patients and found that inadequate nursing staffing levels significantly impacted patient mortality. Further, nurses in this study reported that with increased nurse to patient ratios they felt decreased job satisfaction and emotional fatigue.
Decreased job satisfaction and emotional fatigue have been related to moral distress. Corley, Elswick, Gorman and Clor (2001) developed and evaluated a 32-item Moral Distress Scale (MDS). According to them, items for the MDS "were developed from research on the moral problems that nurses confront in hospital practice" (p. 250). Their analysis of the overall mean item scores showed that nurses experienced moral distress at "moderately high levels" (p. 253). The highest level of moral distress was in response to this item: "Work in a situation where the number of staff is so low that care is inadequate" (p. 254). Furthermore, the authors noted that moral distress was a factor in 15% (N=32) of their study participants leaving a prior job. Thus, moral distress and decreased job satisfaction appear to be important variables for some nurses.
Research also has shown that moral distress is one type of emotional fatigue. Powell (1997), in her study of the "Lived Experiences of Moral Distress Among Staff Nurses," found when conflicts about the moral aspects of caring for end-of-life patients occurred among health team members, that the study nurses exhibited negative feelings such as frustration, resentment, anger, sadness and guilt. In addition, some staff nurses exhibited unresolved feelings related to moral distress long after the moral distress incident(s) occurred. Although the nursing shortage was not a factor in this study, emotional fatigue that took the form of moral distress was. The toll of fatigue on nurses and ways to combat fatigue, while beyond the scope of this study, are important areas for nursing research, given the current nursing shortage.
The 1,386 participants were RNs worldwide including but not limited to the United Kingdom, Puerto Rico, India, and Germany. RNs also responded from every state in the United States of America. The majority of the participants were staff nurses who worked in hospitals. Participants’ educational preparation varied, but most of them held a Baccalaureate Degree. (See Table 1.)
Procedures and Survey
To capture attention of potential participants, we posted the link to the survey on the home page of OJIN. Prior to responding to the 72-item survey online, readers were informed about the purpose of the survey, time involved, guaranteed anonymity, voluntary nature of the study, contact information, and that only RNs were being solicited for participation. Participants were not only given directions for completing the survey but also the definitions of current nursing shortage and of moral distress.
The survey contained 11 categories of clinical errors or untoward clinical incidents. (See Table 2.) Ten categories involved patient errors/incidents and one category involved nurse injury on the job. Participants were asked about whether they: a) had experienced the errors/incidents (yes or no), b) if the errors/incidents were related to the current nursing shortage (not, somewhat, strongly), and c) if the errors/incidents caused them moral distress (no, some, strong). Because many nurses work closely and intensely with other nurses by virtue of their jobs, parallel questions were asked to determine if: a) study participants were aware of other nurses who had experienced any of the 11 categories of errors/incidents (yes or no), b) the errors/incidents of the other nurses were related to the current nursing shortage (not, somewhat, strongly), and c) the errors/incidents of the other nurses caused the study participants to experience moral distress (no, some, strong).
In analysis of the results, the responses related to the current nursing shortage and moral distress were collapsed from three choices to two choices: not related and somewhat/strongly related. (See Table 2). Then results were calculated by both frequency counts and by percentages across all 11 categories of errors/incidents as reported by participants for both themselves and for other nurses. For example, using Table 2, you can see that 78% of study RNs indicated that they did not give a medication or gave a medication at the wrong time; 69% believed that this error was somewhat/strongly related to the shortage; and 73% reported that they felt some/strong moral distress as a result.
Table 2. Clinical Errors/Untoward Clinical Incidents Reported by RN Study Participants for Themselves and for Other Nurses
Trends and Discussion
The following suggested trends from the data are in need of further study:
- Overall, RN participants perceived that both they and other nurses made clinical errors related to not giving medications and/or treatments and/or giving them at the wrong times; in addition, overall, the RN participants perceived that both they and other nurses experienced untoward clinical incidents related to patient falls, pressure ulcers, unplanned patient readmissions, restraint use, and nurse injury.
- Overall, RN participants perceived that the clinical errors/untoward clinical incidents that they and other nurses experienced occurred largely as a result of the nursing shortage.
- Overall, RN participants perceived that the clinical errors/untoward clinical incidents related to the nursing shortage that they and other nurses experienced resulted in moral distress.
- Consistently RN participants perceived that other nurses made clinical errors and/or experienced untoward clinical incidents related to the nursing shortage more frequently than the RN participants.
Regarding trends 1 and 2, three points need mentioning. First, RNs attributed most but not all of the errors/incidents to the nursing shortage. Therefore, factors that contribute to nursing errors/incidents with a nursing shortage and without a shortage should be explored. Second, although the study did not examine how nurses viewed the current shortage as contributing to the errors/incidents, it would be insightful to examine real life examples from nurses on how the shortage has contributed to errors. Third, creative and systematic ways to reduce errors/incidents should be a priority whether the errors are related to a nursing shortage or not. Errors, whether they result in adverse consequences for patients or not, are seen by the public as a breach in duty and are not easily excusable.
Regarding trend 3, the increased occurrence of moral distress was perceived to be a result of the errors/incidents related to the current nursing shortage. As apparent in Table 2, not all nurses who reported errors/incidents perceived that these were due to the nursing shortage. Powell’s (1997) study discussed earlier is also an example of this phenomenon. We can only surmise then that factors other than the current nursing shortage can contribute to moral distress among hospital nurses.
In the present study, RNs reported experiencing moral distress related to the nursing shortage across all 11 categories of errors/incidents. Systematic reviews of clinical errors or untoward clinical incidents should focus not only on the errors/incidents but also must give consideration to whether nurses are experiencing moral distress and, if so, what factors are contributing to the moral distress and how to decrease or alleviate the distress.
Regarding trend 4, it is initially important to address possible reasons why the study RNs reported higher errors/incidents among other nurses than among themselves. First, the RN participants may have underreported their own errors and experiences with untoward clinical incidents as a face-saving strategy. Second, each study participant represented one RN, whereas the "other nurses" could have been many other types of nurses over the past year.
RN participants consistently reported that other nurses had higher numbers of errors/incidents associated with the current nursing shortage as compared to their self-reports. RN participants reported moral distress for themselves when they were reporting their perceptions of other nurses’ experiences with errors/incidents. If the RN participants are experiencing moral distress because errors/incidents related to the nursing shortage made it impossible for them to take the morally right course of action then the impact of errors is much wider than we may know. Did nurses feel they should have reported the errors of other nurses, assisted the other nurses in some way, or perhaps spoken out about unsafe practice? Further research is needed regarding: a) whether nurses experience moral distress when other nurses make errors or have untoward clinical incidents and b) if nurses do experience moral distress when another nurse makes an error or has an untoward clinical incident, what are the implications for morale.
Finally, regarding the study in general, it is vital to find out how the shortage may contribute to errors. It is not helpful to use the shortage as a general scapegoat for errors and unsafe incidents. More study is needed to understand the impact of the shortage for daily nursing practice. Since the shortage is expected to become worse, it is important to examine how to help nurses in practice now and protect nurses in the future.
Several limitations are acknowledged in this study. First, we recognize that the study participants were self-selected so that no claim is made to the generalization of the findings from this study. We know, for example, that diploma educated nurses were underrepresented in this study. (See Table 1.)
Second, we note that this is an exploratory study, and the results reported here are limited to frequency counts and percentages. We make no statistical assumptions about association and causal relationships among errors/incidents, nursing shortage and moral distress. We believe this study raises questions for further research about these concepts.
Third, while we asked parallel questions of RN participants about other nurses’ experiences with errors/incidents, we believe this approach can be viewed as a limitation. However, because many nurses work closely and intensely with other nurses by virtue of their jobs, we wanted to explore if work of other nurses impacted on errors, shortage and moral distress as perceived by the study participants.
Fourth, study participants were guaranteed anonymity; therefore, there is no way to assure participants were RNs. We heard from one Licensed Practical Nurse who questioned our decision to limit the study to RNs.
The authors thank the 1,386 RNs who took the time to participate in this study; the number exceeded our greatest expectations. We also thank the nurses who took the time to e-mail us with comments and questions about the survey and who shared experiences with us about the nursing shortage. Your insights were helpful.
We also extend our gratitude to the American Nurses Association and OJIN for providing the mechanism by which this study could be implemented online. We also thank Dr. Rich Zeller, Professor of Nursing, at Kent State University, College of Nursing for his assistance with methods and statistics in developing the survey and organizing and tabulating the data.
Finally, we thank The Institute for Quality Healthcare, Comparative Occurrence Reporting Service (CORS) at the University of Iowa, Iowa City, Iowa for permission to use and adapt part of their measures for our survey instrument.
Aiken, L., Clarke, S., Sloane, D., Sochalski, J., & Silber, J., (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association (JAMA), 288 (16), 1987-1993.
Corley, M. C., Elswick, R. K., Gorman, M., & Clor, T. (2001). Development and evaluation of a moral distress scale. Journal of Advanced Nursing, 33(2), 250- 256.
Kohn, T., Corrigan, J., & Donaldson, M. (2000). To err is human: Building a safer health system. Washington, D.C.: National Academy Press. Retrieved March 18, 2003 from http://books.nap.edu/books/0309068371/html/R1.html#pagetop
Powell, R. C. (1997). Lived experiences of moral distress among staff nurses. Dissertation Abstracts International, 58(09), 219. (University Microfilms No. AAT 9810373).
Silva, M. C., & Ludwick, R. (August 13, 2001). The nursing shortage and ethics: Up Front and personal. Online Journal of Issues in Nursing. Retrieved March 18, 2003 from www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Columns/Ethics/NursingShortageandEthics.aspx