A clinical situation in which an ethical decision had to be made was related to me by a nurse manager colleague. Three unit managers were tasks with developing options to deal with a budget resource planning shortfall which had been complicated by a new corporate requirement to ensure that all software licenses were current. The budget shortfall affected three different patient divisions which fell under one unit. There was a nurse manager for each unit, and each had been told to contribute to the solution to the problem.
There was general agreement among the nurse managers with regard to the problem of software licenses, but less agreement with regard to potential solutions to the budget shortfall. The two issues had become tied together, but in fact the resource shortfall was with regard to regular clinical operations, and it required reducing the costs of regular expenditures including human resources and supplies. The nurse managers had been tasked with making recommendations with regard to managing the shortfall, which was a percentage reduction in the regular budget which had been applied to all budgets across the healthcare context. The memo requesting the recommendations had also included the request with regard to reporting back with regard to the results of the software license audit in their unit and incorporating any compliance requirements in a plan. The ethical decision to be made was therefore interpreted as how to reduce the existing budget in addition to including a new one-time cost for the necessary software licenses.
The process that was used by the nurse managers included meetings between the managers of the involved areas and in some cases with more senior management. These were for the purpose of determining and exchanging the various interests involved. There was no formal ethics committee at this level to be included in the decision making. My nurse manager colleague described that these discussions were often derailed by the problem of the software licenses, and it appeared that none of the office software used on any of the computers in the units had up to date software licenses. Both issues were seen as financial issues, but clearly ethics was a component.
Ethical decision-making principles which came into play included: the ethics of reducing nursing hours; potential impacts on patient care and the ability to comply with processes and the breach of the software licenses and hospital policy regarding the need for current licenses for all software.
Ethical principles manifested in various ways. Nurses had autonomy to determine those line items that were recommended for reduction, but this was limited by the fact that the reductions, which would have a negative impact on nursing objectives, would have to be made. Beneficence and nonmaleficence were therefore factors as the nursing managers saw no possibility of making a decision that would not have a negative impact. It could be argued that there was paternalism in demanding the budget reduction rather than asking whether such an objective could be achieved while ensuring compliance with patient health outcome objectives and standards of care. Fidelity and confidentiality were not principles primarily involved in the making of this decision. Utility and justice were served at the expense of veracity, given that the resulting decision was one that the nursing managers did not intend to comply with.
In the end the nurses outlined in their report the options alongside the breaches of policy or other problems that each option would create. The option chosen, as expected, was to reduce the nursing hours. My colleague described this as a paper exercise, where managers agreed to schedule fewer hours, however in practice this could not occur. The result was a shortfall to the budget, as this represented the most ethical possible choice.
The impact of the various codes of ethics on the decision was not as great as the impact that it had on the decision making and consultation process. The American Nurses Association (ANA) Code of Ethics was a point of reference in early and informal meetings, leading to various discussion points based on the different interests involved. While all agreed on the primacy of the ANA code, it did not often relate to various conflicting interests or provide a way to determine which interests were paramount.
With regard to the software license, this was resolved as the costs were paid from a centralized information technology budget. This was frustrating as much of the discussion had revolved around this aspect, wasting precious nurse manager time. My colleague informed me that she had chosen that situation because it revealed the greatest problem with ethical issues in healthcare services, that being that the ethics were determined on multiple levels, and often the threat to ethics came from superiors on the management chain as their objectives were often a threat to the ethical principles of nursing and the provision of quality care to patients.