Nurse Shortage: Metropolitan Community Hospital METROPOLITAN COMMUNITY HOSPITAL (MCH) was in trouble. The nurse shortage, a problem throughout the country, had reached epidemic proportions at MCH. While all four of the other hospitals in town were experiencing nurse shortages as well, none of the competing hospitals was facing the crisis that confronted MCH. For the first time in her 12-year tenure at MCH, Jane MacArthur, MCH's chief nursing officer, was beginning to feel a little insecure about her position. In fact, she was updating her resume and had begun to consider new opportunities. MCH is a 250-bed, privately owned, not-for-profit hospital located in the heart of a midsize city on the East Coast. The four other hospitals in town range from 200 to 400 beds and include an investor-owned hospital (part of a national chain), a county hospital, a Catholic hospital (part of a regional network), and another privately owned community hospital. All of these facilities had been aggressively competing for the limited number of nurses in the geographic area, and no matter what strategies it employed or how many resources it committed to the task, MCH was clearly losing to the competition. In the past two years, the five area hospitals had engaged in a bidding war in terms of salaries, sign-on bonuses, and benefits such as relocation expenses, tuition reimbursement, and domestic partner healthcare coverage. MCH simply could not match the deep pockets of some of its competitors. The nurse turnover rate at MCH had reached 25 percent as nurses left MCH to take more lucrative positions at competing hospitals. MCH's geographic location was an additional recruiting obstacle. Its urban neighborhood was believed to be a high-crime area, and although statistics disproved this notion, the perception remained among the predominantly young female nurse population. Jane was aware of this perception, but because it was not supported in fact, she dismissed it as not needing her attention. As more and more foreign-born nurses were recruited to MCH and as an increasingly higher percentage of agency staff were used, the budget overrun for nurse staffing had reached record proportions. The board had become impatient with Jane's attempts at justifying this cost overrun. The board chairman declared, "We can no longer tolerate explanations for the problem. We need solutions." The problem had become more significant than just cost overruns. The nurse­ to-patient ratio on the medical/surgical units at MCH was 1 to 12, an unacceptable level by any standard for both patient safety and quality of care. Patient and family complaints had increased dramatically over the past year. Adverse events had also increased, and John Fairfield, the hospital's legal counsel, who had never been one of Jane's supporters, was quick to remind the CEO and the MCH board that the source of these potential litigations was failure to remedy the nurse shortage. Two years earlier, when Eugene Wellborn was hired as CEO at MCH, the nurse shortage was identified as a problem but did not rank high on the board's list of priorities for Eugene to tackle. In fact, the board chairman had assured Eugene that Jane was unquestionably competent and could be relied on to resolve the issue satisfactorily. The message was clear that nursing took care of itself and that Jane had the board's full confidence. In retrospect, Eugene wished he had not hesitated in dealing with the issue. The nurse shortage occupied a huge proportion of his daily schedule and usurped time and energy he could be spending on the hospital's other pressing agenda items. Hardly a day passed that Eugene did not have to deal with an irate patient, family member, or physician. The nurse shortage at MCH had been the primary topic of discussion at last month's general medical staff meeting and had been accompanied by threats of diverting patient admissions to competing hospitals if the situation did not improve immediately. Jane was quick to point out that physicians were a major part of the problem and one of the reasons she was having difficulty recruiting and retaining nurses. The medical staff enjoyed strong political clout and expected others to defer to them on questions of authority, facility planning, and patient care. Past administrations had abdicated many of their responsibilities related to patient care and seemed indifferent to issues other than the financial viability of the institution and its public image in the community. Attracting physicians had been a priority in the recent past, and Eugene's predecessor had spent every Wednesday afternoon on the golf course with prominent members of the executive medical staff committee. Eugene left this kind of relationship building to Carter Sims, MCH's young, ambitious chief operating officer. For his part, Eugene believed his role and responsibility as CEO was to focus on the external environment. He needed to develop collaborative relationships and coalitions throughout the community if MCH were to survive into the future. This was his strong belief and the mandate he had received from the board. Nevertheless, Eugene was troubled by the powerful position of the medical staff and agreed with Jane that the behavior of some of the physicians contributed to the exodus of nurses. He had been reluctant to confront the medical staff leadership on this issue, believing that he needed to develop a stronger relationship with the physicians before taking on such an adversarial role. To the nursing staff at MCH, this administrative posture suggested that nurses were not valued and were only supposed to follow the physicians' orders. In this environment, the physicians had become accustomed to behaving in an autocratic and sometimes disrespectful manner toward the nurses. The hospital's legal counsel John Fairfield had on more than one occasion cautioned Eugene about the legal implications of actions that he believed bordered on harassment. These incidents had fueled hostile outbursts between Jane and the chief of the medical staff, who she believed turned a blind eye to the physicians' inappropriate behavior. In some ways, Jane's management style mirrored the autocratic, disrespectful approach to the nursing staff favored by some physicians. Jane, on the other hand, saw herself as a benevolent dictator, always ready to do battle in defense of her team. The nursing staff resented both of these higher authorities. Behind Jane's back, they referred to her as "the general," and they had even more derogatory nicknames for some of the physicians. The nurses believed that they did all of the work and received none of the rewards. They had no authority or control over their work and no participation in the decision making about patient care. They received no recognition or respect for the physically and emotionally stressful work they were expected to perform without regard to personal or professional preferences. Their work schedules were frequently modified, overtime was often required, and they were arbitrarily pulled from their work units to float in an unfamiliar, understaffed area of the hospital. The informal leaders among the nursing staff had begun to talk about organizing. Some of them had complained to Carter Sims, the COO, but it seemed that the administration's answer to the nurses' complaints was to throw money at the problem. In fact, Carter Sims was overheard to say, "If we pay them enough, they'll be happy." That did seem to be the case with the foreign-born nurses that MCH recruited. They seemed willing to tolerate the unpleasant working conditions if the pay was good. This difference of opinion created resentment among the US-born nurses, who believed the foreign-born nurses were encouraging unfair treatment by allowing themselves to be exploited. This resentment spawned a lack of cooperation and tension among the nurses that patients observed. Eugene knew it was just a matter of time before news of the disruptive environment at MCH reached the community and he heard about it at the Rotary Club. The only patient care units in MCH that were peaceful and operated efficiently were the emergency room, the operating room, and the intensive care unit. The physician-nursing coalitions in those patient care units made them untouchable. Both Jane and the attending physicians knew better than to antagonize the skilled, experienced, and confident nurses whom the medical directors of those units considered irreplaceable. Indeed, the nurses were considered more competent and more valuable than some of the attending physicians whose patients were treated there. As Eugene pondered the situation at MCH, he knew he must take action, and he knew it was not going to be pleasant.

Question: In the above case study, a health care executive is faced with an ethical problem. a). Explain the executive's issue. b) Proposed a solution to the issue.