Following the Great Recession in the US in 2007 and the knock-on effects across the world, numerous governments across Europe enforced austerity measures in the hope that a reduction in public spending and increased taxation would help to mitigate rising debt and prevent economic collapse [
62]. The focus of this paper is upon the effects of austerity on nurses through the lens of moral distress. In this section, we provide the data in which participants described a number of resource challenges that created and exacerbated the moral events they encountered and subsequent experiences of MD. Throughout this section, we highlight the ways in which these avoidable ethical challenges can be correlated to austerity measures.
Lack of Sufficient Staffing
Over the past two decades there has been a growing body of literature reporting the inability of nurses to provide care due to time and resource constraints—variously labelled as ‘unfinished care’, ‘implicit rationing’ ‘missed care’ [
28] and most commonly in the UK as ‘care left undone’ [
5,
6]. This research has sought to evidence the correlation between registered nurse to patient ratios, nurse education and patient mortality to emphasize the importance of safe staffing levels and nurse education for both mortality and nurse job satisfaction [
1‐
4,
59]. However, there has been limited research exploring the association between nurse staffing, the political context and the occurrence of moral challenges [
72]. It is widely believed that undergraduate and postgraduate nursing bursaries were cut because of austerity measures [
7] which had the (predictable) knock-on effect of decreasing the number of qualified nurses [
43] and causing nurses to leave the NHS due to unsatisfactory working conditions [
44,
52,
67]. The decrease in nursing numbers and subsequent increase in inadequate staffing levels have forced nurses to effectively ration care. Despite growing evidence, mandated safe staffing levels remain aspirational in England and as Lawless et al. [
32] argue, this seems to be largely due to the tension between safe staffing and funding constraints.
Our data supported this, for example in the passage below from Phoebe:
a lot of people had a really sad Christmas here because they were stretched beyond what they should be and there was a lot of anger on the unit… because they felt utterly and completely abandoned. There were no matrons… everyone else was sitting at home and one nurse, one of my team, was quoted as saying ‘how bad does it have to get for someone to come in and help us… I know there was a lot of anger because the staffing shouldn’t be that bad but I don’t know if I would call it moral distress because it’s more… I guess yeah because a lot of the nurses did say, ‘this isn’t safe’, you know? We’re having to keep patients sedated because we haven’t got enough staff to cover if they’re not sedated and that’s not right, so I guess if you dig a bit deeper it would be moral distress but I don’t think that’s the first thing that would come to people’s minds (Phoebe).
In Phoebe’s narrative, she describes how the nurses working in her unit were unable to fulfil their professional responsibilities to patients because of understaffing. This resulted in patients being sedated and ventilated for longer, and rehabilitation opportunities missed, both of which are important for decreasing mortality and reducing length of stay in the Intensive Care Unit (ICU) [
24,
42,
79]. A recent report from the Royal College of Nursing (RCN) provides evidence from nurses reporting similar experiences to Phoebe’s [
52]. However, the report does not highlight the ethical implications of these episodes of missed care. Phoebe is describing how lack of sufficient staffing thwarted the nurses’ ability to fulfil their ethical obligations to patients because they were constrained. The presence of moral-constraint distress is evidenced by Phoebe’s description of her resulting feelings of anger and frustration, which can be interpreted as causally related to being “utterly and completely abandoned” and thus forced to provide care that was not only suboptimal but also unsafe.
Indeed, it is well documented that insufficient staffing causes moral-constraint distress. Using the Moral Distress Scale and the Moral Distress Scale Revised in various countries, the item ‘Work with levels of nurse staffing that I consider unsafe’ has consistently been one of the top four items reported as causing the most frequent and intense moral-constraint distress [
12,
30,
48,
50,
60]. The emergence of this theme in our findings is therefore unsurprising. Peter and Liaschenko [
49] highlight the relational barriers that understaffing creates because of the emphasis on efficiency and increased workloads, both of which are constraints that prevent nurses from forming relationships with patients and inhibits their ability to provide holistic care.
Scott et al. [
56] argue that the ethical implications of missed care have been relatively unexplored and very rightly re-frame understaffing as a form of implicit rationing. They highlight how despite the reduction in nursing staff, nurses are still expected to fulfill patients’ needs fully [
56]. The UK is now one of the highest ranking countries in Europe to cut health expenditure (with a drop in growth behind only Greece, Ireland, Estonia and Slovak Republic) [
74] but there seems to be an expectation that quality should not be affected [
32]. In reality, the lack of funding in healthcare and insufficient staffing means that nurses must prioritise and ration their time which leads to increased incidences of missed care.
Indeed, England reported higher incidences of unfinished care than the European average, along with Ireland, Belgium, Germany and Greece (in ascending order) [
28].
From Pheobe’s narrative, we see how resource rationing negatively impacts both patient care and nurse job satisfaction, because nurses are forced to compromise the quality of care they wish to provide. Over time, compromised or crushed ideals leads to disillusionment, ‘job hopping’ or a decision to leave the profession [
34] and negative perception of one’s ethical environment is also correlated to higher levels of moral-constraint distress and intention to leave [
13,
21]. In our study, half of the participants (
n = 11) reported either leaving, intending to leave their role or the profession. They cited several reasons but issues related to feeling over-worked, forced to provide suboptimal care, stressed and morally distressed made up part of their rationale:
You know, the NHS is the most affordable, best system ever and we’re having it pillaged under our noses and it’s like abandoning the sinking ship, isn’t it? You know. We’ve lost a couple of shiny new Band 5 s to go and work in the private system for forty-five grand a year doing like nine to five outpatient assessment stuff. Be f***ing mad not to, wouldn’t you, really?… It’s like well, yeah, but she’s probably not gonna be exhausted and she’s probably gonna get to spend weekends with her children when she has them and afford a house and stuff… they haven’t even got kids and whatever and you can see them burnt out, dropping like flies but then still doing bank shifts and things. Like I can’t do bank shifts. I, I’d have to do something else. I couldn’t do, um, be in there more than I have to be in there ‘cos it’s just so emotionally and physically exhausting, because of all those things like if it was smooth and managed properly and you weren’t, like, waiting for ever for, you know, it’s like, I’m thinking you know if you need like an ENT input and your hospital doesn’t have ENT, well then you’re gonna be waiting like, however long it’s gonna take, five days, ten days for ENT input from another hospital to come. It’s just…ridiculous things in the system. So I can’t separate the morality from the management I think. I think that’s where those strings are being pulled and that’s…but those pulling those strings aren’t ever accountable for the outcomes, it seems to me. It’s the doctor that fucks up at the bedside by accidentally putting some sort of anabolic intrathecally because he was like pulled in the night and didn’t sort of…stop and think what he was doing (Holly).
Lack of Sufficient Skill Mix
Participants perceived staffing problems as circular: junior nurses joined critical care but would feel unsupported in their new role due to lack of sufficient staffing and poor skill mix and end up leaving. Joyce, a senior nurse, discusses the challenges this created for her both personally and professionally. Personally, she felt fearful because she didn’t know who she would be working with from one day to the next, and professionally it was difficult to allocate junior nurses to patients they could care for safely and feel supported.
here turnover is so high, so many junior staff, so many people leave every week, like every two weeks there are new starters and we didn’t have an awful lot of senior staff and a lot of people who had the course done so even coming back it was just like who am I going to be working alongside, like how far are they down their training and sometimes the allocations… the person might only have been on the job a month in the side room and might not be able to give medications yet and you might not have a floater to go round and give support, that’s a bit challenging (Joyce).
Joyce seems to be describing three different problems: understaffing, lack of sufficient skill mix leading to difficulties allocating patients and thirdly, the effects of hospital design on resource allocation decisions. Joyce described feeling angry and frustrated because she felt the care she provided was being compromised as a result of external factors that constrained her ability to fulfil her ethical obligations—the very definition of moral-constraint distress.
As with lack of sufficient staffing, poor skill mix should, we argue, be seen as another form of rationing causing nurses to feel unable to provide not only holistic but
safe care. Despite an increasing and ageing population, the UK government have continued to enforce austerity measures by cutting health expenditure [
68]. These cuts have had a huge impact on the current nursing workforce and nurses are reporting working in high stress environments which are untenable and unsustainable [
52]. This seems to be both deterring people from entering the profession and causing them to leave resulting in a workforce gap [
43,
67]. Danielle discusses her perception that the nursing role is being increasingly extended and stretched, and therefore causing individuals to feel increasing stressed and dissatisfied:
…they’ve got to be looking at budgets and have we got too many agency staff on and… especially the nurse’s role, it’s been turned into so many other different things that it wasn’t initially that people’s resources and capabilities are stretched so thin that you’re being asked to do much more with less resources. And this has an impact on, on everything… (Danielle).
Numerous reports have echoed Danielle’s narrative and highlight poor working conditions, high levels of stress and pay restraint as factors causing nurses to leave the profession [
43,
52,
66,
67]. Recent statistics from the Nursing and Midwifery Council show that more nurses and midwives are leaving the profession than joining it, and two of the most cited reasons for leaving the register were working conditions—specifically poor staffing levels and high workloads—and disillusionment with the quality of care that nurses reported feeling able to provide [
44]. That nurses feel disillusioned highlights the potential for MD: they are providing suboptimal care which prevents them from fulfilling their moral responsibilities to patients. Similarly, other countries facing healthcare spending cuts because of austerity driven policies report staff demotivation, disillusionment and lower quality of care [
9,
29,
33,
78].
Danielle highlights the potential effects of spending cuts beyond nursing, describing her perception that consultants may be reluctant to make ethical decisions about whether to withdraw LST because of lack of time and lack of support.
if you had a consultant speaking to you they would say, ‘Well, you know, I couldn’t see that family for three hours because I was dealing with x, y and z’… maybe they feel that they are in charge and they’re looked on to make all these decisions and they can’t make the decisions because they haven’t got the support behind them. And that’s why they pass it onto somebody else. I mean that would make a lot of sense (Danielle).
Participants discussed their perception that consultant decision-making was already highly variable and with added resource pressures decisions would be increasingly delayed. Variability in consultant decision-making has been labelled the ‘roster lottery’ by Wilkinson and Truog [
77] and we suggest that resource constraints add an additional avoidable compounding factor which complicates end-of-life decision-making and increases inequity for patients. This causes moral-constraint distress for nurses who are then witness to these increased inequities and feel powerless to effect change.
The third issue raised by Joyce is hospital design, in particular the move to single patient rooms or side rooms [
56]. Charge nurses are responsible for allocating care across their nursing units and some hospitals are now developing units that consist only of single-bed rooms. These present a substantial workforce planning challenge in ICU and charge nurses are responsible for making allocation decisions which have important moral implications. As Scott et al. [
56], highlight, nurses are expected to make these decisions from their single perspective without an explicit and agreed decision-making framework in which care priorities are agreed.
Side rooms are seen as positive for patients because they provide increased privacy, reduced noise levels and a reduction in the transmission of hospital acquired infections [
10,
73]. Although the connections between austerity and hospital design are not clearly reported, the development of single-bed only hospitals is another efficiency move that has been conducted with little attention to the effect on nursing staff. Participants reported being left in side rooms with critically ill patients for prolonged periods of time without assistance or support, leaving them feeling isolated and “trapped”. Participants described how this forced continued proximity seemed to magnify the emotions they experienced during moral events and increased their feelings of powerlessness and frustration associated with MD:
I just wanted to cry with the daughter and be like no I think you’re right but also I felt really trapped because physically I was in that side room and I couldn’t have anyone to be like ‘look come and look at him he’s dying; let’s stop this now…’ (Jenna).
This efficiency move, combined with staffing shortages, seemed to compound and exacerbate ethical challenges. In the previous quotation, Jenna discusses feeling trapped in the side room and unable to speak to colleagues about a patient who seemed to be dying. Jenna described experiencing moral-constraint distress because the team had decided to proceed with a time-limited trial of LST to see if the patient would improve. Jenna is describing the moment the patient’s daughter had realised these treatments were failing but Jenna was unable to escalate to the Consultant because she couldn’t leave the side room for assistance. Indeed, previous research exploring the effect of single-bed hospital design found that nursing staff felt teamwork was hindered and they had reduced ability to provide high-quality care [
17,
35].
Lack of Acute Care Beds
Participants discussed the broader ethical challenges that cuts in healthcare spending raised. In the following quotation, Rachel considers the fair distribution of resources and questions whether, as a society, we should be prioritising acute care and individuals who have lived a healthy lifestyle:
That’s five wards worth of patients who are waiting, they’re elderly - we know there’s a growing population of elderly- and nothing has been put in place to cope… that’s why the wards are full, that’s why the hospital’s chocker, that’s why we can’t get people in because they’re full of people waiting for social care and because it’s under a different umbrella… it’s obviously our tax money but it’s not NHS money, it’s social money… It’s just a big political mess and that’s why I think rather than spending money on people who are not prepared to look after themselves, why aren’t we looking after those people who have looked after themselves all the time and give them a decent end to their life… (Rachel).
Rachel raises important societal questions about public health considerations which need to be balanced with issues of social justice because of health inequalities. Nonetheless, it is interesting that Rachel has made this point. She seemed to express moral-uncertainty distress though frustration and anger as she questioned who was more deserving of her limited time. The increasing focus on spending inevitably raises biases that we all hold and which have the potential to impact care quality. In an ideal world, HCPs could be protected from the effects of extreme governmental policies so they can concentrate on providing equal and unbiased care.
Lawless et al. [
32] highlight the government response to the Francis Inquiry, an inquiry into huge failings at Mid Staffordshire Hospital in which patients received suboptimal care. Many patients died due to a focus on cost savings above safety and a toxic culture:
This was a systemic failure of the most shocking kind, and a betrayal of the core values of the health service as set out in the NHS Constitution. We must never allow this to happen again…We will foster a climate of openness, where staff are supported to do the right thing and where we put people first at all times (pp. 5–6) [
15].
Despite growing evidence that cuts to health and social care are causing increased mortality [
76], increased staff dissatisfaction and loss of morale, the government are still failing to invest sufficiently in these areas thus mirroring the failings discovered in the Francis Report [
20].
The lack of acute care beds also impacts the care nurses are able to provide. In the following quotation, Olivia articulates feelings of frustration and anger (moral-constraint distress) because she is forced to create new beds in areas that are not routinely staffed:
…they did a private patient and they wanted private patient heart valves done. There were no beds and I said if you want it done then you need to take out one of our delayed discharges that’s the only way we can create a bed, you know, and I said ‘no that’s the only way’ and they were, ‘well we’ll do them’ and I said ‘no, there are no beds’; ‘well we can open Recovery’; ‘no we can’t keep…, there are no nurses to keep opening these extra beds’. We put out to agencies, they don’t get filled, its unsafe, it’s not nice, I wouldn’t want my relative to be nursed in Recovery because there’s no Critical Care bed, they should be where they should be (Olivia).