NUR 651 Module 8 Ethics Paper Example

When There Are Not Enough Nurses: An Executive Decision to Suspend Rural Births and the Moral Distress It Creates

[Student Name]

Southern New Hampshire University

NUR 651: Advanced Concepts for Nurse Executive Leaders

Module Eight Ethics Paper

[Instructor Name]

[Date]

When There Are Not Enough Nurses: An Executive Decision to Suspend Rural Births and the Moral Distress It Creates

Most discussions of moral distress in nursing focus on bedside nurses who cannot provide the care they believe patients need. Nurse executives face their own version: decisions about resources in which every available option harms someone, made under constraints they did not choose. Riverside Community Hospital, the smallest of Northfield Health System's four composite hospitals, delivers about 300 babies a year. Its labor and delivery unit has lost four of nine registered nurses in eight months, recruitment has failed and on several nights one nurse has covered two laboring patients and a newborn. The chief nursing officer must recommend to the executive team whether to suspend births temporarily and direct patients to the tertiary center 45 minutes away. This paper analyzes the decision ethically, proposes a process for making it and addresses the moral distress it creates. It argues that a transparent, principled decision that protects patients from unsafe care, paired with serious efforts to reduce the harm to access and to support affected staff, is the most defensible course.

Moral Distress and the Executive

Jameton (1984) gave the name moral distress to a particular kind of pain: a clinician is clear about what ought to happen, yet the setting blocks that action almost completely. The concept has since been broadened to include situations in which a person participates in, or is responsible for, an outcome they believe is wrong. The chief nursing officer is in exactly this position. Keeping the unit open with unsafe staffing violates her obligation to protect patients and nurses. Closing it violates her commitment to the rural community her system serves, where pregnant women will face longer travel and, for some, a risk of delivering before arriving. The constraint is real: there are not enough qualified nurses to staff the unit safely, and the solutions that could change that take months or years.

The Professional Obligation

Provision 6 of the Code of Ethics for Nurses states that the nurse, through individual and collective effort, establishes, maintains and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care (American Nurses Association, 2015). For an executive, this provision is not optional. It makes the chief nursing officer responsible for the conditions under which nurses work, and it implies that knowingly allowing an unsafe staffing pattern to continue fails that duty. At the same time, the Code's wider commitments, to community health and to fairness in who receives care, mean that the decision cannot be made only on the basis of internal safety; its effects on access for a vulnerable rural population must be weighed and mitigated.

Weighing the Options

Three options were considered. Keeping the unit open with current staffing and agency support where available risks harm from one nurse caring for multiple high-acuity patients, a violation of nonmaleficence that the executive cannot justify once she knows of it. Suspending births permanently would resolve the safety problem but would abandon the community's access to local obstetric care, raising a serious concern of justice for a population that already has poorer access to prenatal care. Suspending births temporarily, with a defined plan to restore services, protects patients from unsafe care now while committing the system to the community. It still harms access in the short term, and that harm must be reduced. On balance, a temporary suspension with strong mitigation best respects both nonmaleficence and justice. Mitigation would include keeping prenatal and postpartum clinics open locally, maintaining emergency department capacity for precipitous births with a trained nurse on every shift, arranging transport and lodging support for patients near term and publishing a recruitment and training plan with a date for review.

A Fair Process

How the decision is made matters as much as what is decided. The executive team will make the decision in an open meeting with the hospital's medical staff and nursing leaders, explain the staffing data, the options considered and the reasons for the choice and publish that explanation to the community. Community representatives, including a local family physician and a representative of the county health department, will be consulted before the final decision. The decision will be reviewed every ninety days against specific criteria for reopening, such as a minimum number of trained nurses on staff, so that the community can see it is genuinely temporary. Nurses on the unit will be told first, in person, and offered positions at other hospitals in the system or in Riverside's emergency department and clinics with no loss of pay.

Moral Distress Among Staff and Leaders

The decision will cause distress among nurses who chose rural obstetrics as a calling, physicians who will lose their local practice and community members. It will also affect the leaders who make it. Hamric et al. (2012) developed and tested a revised instrument that measures how often and how intensely clinicians experience morally distressing situations, including those involving staffing and institutional constraints, and found that higher moral distress was associated with clinicians considering leaving their positions. Northfield will use this measure with Riverside staff before and six months after the decision, and will offer facilitated debriefing sessions in which nurses can express grief and disagreement.

Rushton (2016) describes moral resilience as the capacity to sustain or restore integrity in response to moral adversity. She argues that it is supported both by individual practices, such as reflection and clarity about one's values, and by organizational conditions, such as ethics resources and cultures that allow people to speak up. For the chief nursing officer, this means acknowledging her own distress, seeking support from the ethics committee and peers and holding herself accountable for the mitigation plan. For the organization, it means treating distress as information about where the system is failing rather than as weakness.

Conclusion

The decision to suspend births at Riverside has no option free of harm. Keeping the unit open with unsafe staffing fails the duty to protect patients and nurses; closing it permanently fails the community. A temporary suspension, made through a transparent process with community consultation, specific mitigation and criteria for reopening, best balances nonmaleficence and justice. Acknowledging and responding to the moral distress the decision creates, for staff and for the executive, is part of making it ethically.

References

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association.

Hamric, A. B., Borchers, C. T., & Epstein, E. G. (2012). Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Research, 3(2), 1-9. https://doi.org/10.1080/21507716.2011.652337

Jameton, A. (1984). Nursing practice: The ethical issues. Prentice-Hall.

Rushton, C. H. (2016). Moral resilience: A capacity for navigating moral distress in critical care. AACN Advanced Critical Care, 27(1), 111-119. https://doi.org/10.4037/aacnacc2016275