Reply to Discussion Post 3-2




Competing Needs: Experience with Canada’s Healthcare System

          Kelly and Porr(2018) discuss competing needs in their experience with Canada’s healthcare system. They write that Medicare, Canada’s national health program, came under intense scrutiny in the 1990s. Back then, provincial health system reviews highlighted Medicare service costs as too high and unsustainable. The Canadian government directed each province to improve the quality and efficiency of healthcare services through managerial reform and using limited resources more effectively. Provinces responded by closing and merging hospitals, reducing bed numbers, and cutting staffing levels. Hospitals also employed new ways of managing patient flow and clinical treatment decisions. Due to healthcare reform in Canada emphasizing efficiency and cost outcomes, healthcare organizations shifted from a “treat-heal-care” model to a more corporate or business paradigm, the business model of healthcare delivery. 

The Impact of the Business Model of Healthcare on RNs

         According to Kelly and Porr (2018), the business model significantly impacts the ability of RNs to function as autonomous professionals in keeping with their professional knowledge, ideals, values, and scope of practice. They state that RNs working within this business model of healthcare have to learn to adapt and practice under the auspices of a care delivery model that is against philosophical principles learned in nursing school, including patient-centeredness and holism. An example they give is how Canadian hospitals use care pathways to standardize clinical practice and direct crucial interventions to occur at certain intervals throughout patients’ hospitalization.  However, the standardized care pathway does not adjust to the individual and complex needs of patients. Kelly and Porr (2018) state that the use of standardized, cost-effective care routinely trumps the professional and ethical mandate of RNs to provide individualized patient-centered care. 

         Moreover, they state that the business model of healthcare silences and prevents RNs from voicing what is the right or best way to care for patients; it also unconsciously supports a culture of acceptance and suppresses nursing knowledge. The silence of RNs leads many to experience tension and frustration. Canadian RNs routinely experience subordination and displacement of their professional nursing judgment and knowledge by healthcare organizations despite knowing what is needed for the patients for whom they care.  Kelly and Porr (2018) state that the business model of healthcare routinely undermines the professional knowledge of RNs and their ethical mandate to provide individualized patient-centered care, often causing tension, strain, and ethical conflict. They state that the business model of healthcare requires a reductionist, standardized approach to care delivery accompanied by often inflexible organizational policies, regulations, and operating procedures. There is little room for tailoring healthcare to accommodate unique or holistic patient needs, offering a harsh and constraining reality for RNs. RNs find themselves providing routinized nursing care against the ideals learned in nursing school. 

          Organizational policies causing tension and frustration in nurses is directly related to the healthcare issue I identified, which is nurse turnover. Perkins (2021) lists problems that nurses encounter in their work environment: increased demand, lack of support, inadequate autonomy, strained work relationships, lack of fairness, incivility, and respect. She states that working in difficult environments leads to an increased likelihood of nurse turnover, further impacting staffing issues and increasing the difficulty of the work environment.


What Nurse Leaders Can Do

          Nurse leaders should address competing needs through crafting and supporting organizational policies that allow nurses to fulfill their ethical and professional roles. Leaders can create and sustain the right balance between organizational policies and nurses’ professional values. Xing et al. (2020) write that nurse managers must create empowering environments where staff are engaged and given access to pertinent opportunities,  information,  support,  and resources. They write that access to organizational resources not only helps staff eliminate barriers but also lets them feel engaged, which contributes to establishing a positive work atmosphere. 

          Xing et al. (2020) also states that in the challenge to achieve high-quality service, leaders must nurture a  culture in which the primary objective is pursuing secure, efficient, patient-centered care. They state that only an organization where the culture is based on dignity, mutual respect, and equality can achieve every aspect of good care, improving quality, productivity, and patient satisfaction; fostering compassion; ensuring effectiveness; and inspiring innovation.

          Moreover, Sejelmo et al. (2020) state that leaders should make an effort to facilitate a good work environment with an optimal balance between job demands and job resources, as this, in turn, might have a positive influence on patient safety culture.

          Milliken (2018) suggests that nurse leaders can create opportunities for individual nurses to develop moral agency and resilience at the unit and organizational levels. These opportunities may include unit-based ethics rounds; in-services; formal and informal ethics training; and participation in interprofessional education. Nurse leaders can also model and contribute to shifting values toward an organizational culture that supports ethical awareness and ethical practice. Also, according to Wolters Kluwer (2018), nurse leaders should be at the forefront of efforts to increase ethical thinking and discourse within the workplace.  Wolters Kluwer (2018) suggests that nurse leaders can implement an ethics program to promote better decision-making and collaboration for the good of each patient. They state that failure to do so may result in increased rates of moral distress, which occurs when nurses carry out actions that do not meet their ethical standards. When moral distress increases, staff turnover and a loss of job satisfaction also increase (Wolters Kluwer, 2018). 

          Nurse leaders can lead the way for nurses through organizational policies supporting ethical awareness. Hoskins et al. (2018) state that leaders in the nursing profession have an obligation to prepare nurses for the ethical challenges of clinical practice, equipping them with the ability to recognize morally relevant issues and a skill set to address ethical concerns and navigate stressors across the healthcare system. As Milliken (2018) states, developing and fostering ethical awareness fundamentally requires recognition that ethics is in everything that nurses do. Encouraging nurses to develop ethical awareness is one way to empower nurses to act as moral agents to provide patients with safe and ethical care.


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