What does ethics have to do with recruitment and retention?

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of high quality health care staff is an ongoing challenge for hospitals in Canada, especially when it comes to nurses.  A 2008 study by the Canadian Nurses Association predicated that Canada would face a shortfall of 113,000 nurses by the year 2016.  A more recent study cited a mean nursing turnover rate in Canadian hospitals of just under 20%.  As a result hospitals have turned their attention to various strategies to help recruit and retain quality nurses (among other positions).  These strategies include attention to issues like workplace safety and the introduction of staff wellness programs.  But would you believe if I told you that devoting attention to ethics in a health care organization can help with recruitment and retention, particularly when it comes to nurses?

Allow me to explain by posing another question.  Have you ever encountered a situation as a front line worker or administrator in which you felt like you had no choice but to go along with something you believed was morally wrong?  Perhaps it was a situation in which you felt forced to do something that conflicted with your professional values or code of ethics?  Usually when I ask that question in a room full of health care workers I’m met with a sea of raised hands.  That kind of experience is so common in health care that I would be concerned if someone didn’t raise a hand.  What impact did that situation have on you?  Stress?  Lost sleep?  Frustration?  Did you feel reluctant to return to work?  That is called moral distress, and it is a well-documented phenomenon in health care.  It is a specific type of work related stress associated with encountering the kinds of situations described above.

There is a lot of research on the topic of moral distress but unfortunately it has remained largely hidden in nursing ethics journals that few health care professionals read.  A few years ago a colleague and I published a paper on the topic in the nursing administration journal, JONA’s Healthcare Law, Ethics, and Regulation (Bell J and Breslin JM. “Healthcare provider moral distress as a leadership challenge,” 10 (4); 2008: 94-97).  What the research shows is that moral distress is quite prevalent amongst , especially nurses.  This is most likely due to the fact that nurses spend the most time with patients and their families but also have limited authority to impact the care plans of their patients.  Research also shows that there is a direct link between moral distress and emotional exhaustion, burnout, and turnover.  So to put this all together: (1) many health care providers experience moral distress in their work; (2) some of those health care providers do leave their positions, and in some cases their professions altogether, in response to unresolved moral distress; and (3) many of those who stay in their jobs report high levels of stress, disengagement, and emotional withdrawal.  Although much of the literature focuses on nurses, similar experiences have been reported in studies of physicians, social workers, pharmacists, and respiratory therapists.  It doesn’t require too much of a stretch to hypothesize that moral distress is a potentially significant contributing factor to sick time and turnover rates amongst health care providers in Canadian hospitals.

Since moral distress is a particular type of stress associated with encountering morally difficult situations, existing efforts to improve retention and manage turnover will have limited impact on the prevalence and effect of moral distress.  What is required is a willingness on the part of hospital administrators to implement interventions specifically tailored to the moral component of moral distress.  Such interventions include the development and revision of policies addressing recurring ethical issues, the existence of a functioning ethics committee and a process for resolving ethical issues, ethics education, and ethical decision making tools.  A more specific type of intervention that I have used with success in organizations is what I call an “ethics debriefing”, which combines the beneficial aspects of a stress debriefing with ethics case analysis.  These interventions are all components of what Accreditation Canada calls an ethics framework, and they require someone with the appropriate expertise (like an ethicist or ethics consultant).  They also require hospital leaders who recognize the link between ethics and staff satisfaction, recruitment, and retention.