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jobs, but the one in which I was most significantly effected by ethical challenges was the time I spent working in the business office and customer service department of a large Health Management Organization (HMO). For reasons of anonymity and because I truly believe that my experiences may not have been universal for the entire organization, I prefer not to name the organization. In order to set the stage, I must explain at the time of my employment I was not in a position of significant responsibility, no one reported to me, and I was had a relative amount of freedom in the scheduling of my work, time lines and my basic comings and goings.
Perhaps because I was rather the low man on the totem pole, I tended to hear a lot of stories from coworkers, who liked to use me as a sounding board. I have never been comfortable engaging in any office gossip or politics, but there were many there who seem to find me a sympathetic listener and understood that the things they told me would go no further. The work environment, whether in the patient care areas or the business offices was eminently stressful for most of the people I knew. Some of it was due to the rapid changes in medical technology we were experiencing, including the first elements of computer applications to order entry and documentation and well as plain office work. This was stressful especially to those who were older, who had been with the organization for a considerable amount of time and knew the pattern that every 5 years or so, jobs were cut and departments switched around in another round of cost cutting and reorganization. The pressure to continue to provide quality health care, in a consumer driven market, along with the significant pressure to contain and control healthcare costs all caused a significant ethical dilemma for many co-workers. These problems were often confounded by strong work ethics, loyalty to the corporation, and societal and cultural values. I think the best example I can give is when there was a significant cut back in the HMO in the registered nursing staff and a significant increase in the nurse to patient staffing ratio.
At the time, the company was not losing money, but neither was it significantly competitive with other similar health care plans in the local area. The company had recently lost a large health care contract with a local aerospace manufacturer, and this loss of enrollment had really hurt the company both financially and in its reputation. The hospital service for the HMO was usually either farmed out to local community hospitals or else the patients were housed at the one hospital that was centrally located, with satellite clinics in the local suburbs of a medium sized American City. When enrollment dropped, it was decided to basically close the hospital that was specific to this HMO and hospitalize patients in contracted facilities. However, whenever possible it was encouraged to keep patient in "short stay" status, meaning that patients would have day surgery and then be kept for no longer than 24 hours and sometimes not even that long until they could be judged reasonable recovered from the surgery or illness which would have made them be admitted in the first place. This service was called the "short stay observation ward" and had a total of 12 beds, with two RNs assigned and a few LPNs, I am not exactly sure how many. The RN and LPN staff would usually work a twelve hour shift.
The problem came in that the providers were more willing to admit patients to the short stay, probably because the relative ease of admitting within the system, and the comfort that the HMO enrollees felt being placed in a facility that was wholly owned by their company. For this reason, for the first year or so that this program existed, there were often times many patients who were admitted to this short stay observation unit who would have been better served in a more comprehensive care setting with a greater staff to patient ratio. This was one of the rare times in history that nurse jobs were relatively hard to find, and many of the nurses who worked on the short stay unit were uncomfortable with the care and responsibility they were required to follow- but feeling glad for the job they were loath to say anything about it. It was also somewhat obvious that the powers that be -- in this situation -- really did not want to hear that there was anything going wrong there. This short stay unit was one of the first of its kind, and therefore somewhat of a benchmark to the industry. No one really wanted to hear what was going wrong, they wanted success stories. This conflict caused a significant amount of moral conflict and situational distress with the nurses. They carried this stress and conflict a long time without saying anything about it, but I can honestly say that their initial concern was that of the safety of the patients. This stress was especially present when the nurses had to deal with a particularly ill patient who had significant decompensation while in their care, and in some cases even died. The nurses felt uncomfortable voicing their distress and discomfort at what they saw was an inappropriate admission, and yet they were not empowered enough by management to raise their concerns to a higher level for almost a year. Ultimately, the degree of ethical distress the nurses experienced resulted in a 15% turnover in experienced nursing staff in the first year that the short stay unit was open, an increase in medication error rates by 6% and one nurse going on extended disability for stress related illness.
This is not a particularly unique story. There is a significant amount of research out there about perceptions of stress related to morally or ethically ambiguous behavior. The phenomenon is significant enough in the nursing and health care professions that many health care professionals chose to leave medicine rather than continue to work in a way they feel is morally unconscionable and not in the patients' best interests. One cannot put the health care corporations in the role of "evil employers" either. There seems to be an inherent disconnect between the planners of health care delivery and the "do-ers" of health care delivery which often results in the development of plans and models of service which are unworkable for patients and staff members alike. It is important to remember that each person on the business side of the house is held to his or her own ethical, moral and professional standards and responsibilities to the shareholders of the company as well as the patients who, in the case of most HMOs are attempting to obtain low cost and comprehensive medical care. It is sometime interesting to note that the healthcare planners are often times themselves former nurses and physicians who, ostensibly, have been in the practice environment and would be more sensitive to the needs of the staff when it comes to program planning. But above all, it is up to them to make the business viable, as it is up to the nurses and medical professionals to make the care comprehensive. It appears that when there is an essential disconnect or lack of two way communication between these two spheres that the greatest amount of moral and ethical distress occurs, which in turn contributes to increased employee sick days, increased turnover and lower patient satisfaction rates.
While some companies may put ethical issues in decision making strategies behind many other issues, there are some corporate types who still disregard them in making decisions. Take a look at Martha…[continue]
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