Resource allocation in health and nursing care raises a number of important political, social and ethical issues. As populations increase, population demographics change and/or demand for health and nursing care outstrips supply, this moves us either to make a decision to increase investment in health care, redistribute resources from lower priority services to those of higher priority, or limit access to the services that exist – the latter is called rationing of health care.

Decisions regarding resource allocation and rationing in health care, though potentially highly emotive, are important political and social decisions and thus should receive careful attention, analysis and consideration. This chapter aims to explore issues of resource allocation and rationing, within the context of nursing practice and the provision of nursing care.

Health care resource-related discussions, which reach the public domain, often focus on headline grabbing issues such as whether a particular life-saving treatment should be provided by the relevant national health system (NHS in the UK or the HSE in Ireland) regardless of cost, organ transplants and shortage of organs, or whether particular groups in society, such as smokers, the obese and the elderly, should receive the same access to health care as those who exercise, look after their health or are young, tax-paying adults with caring responsibilities.

To date, the topic of resource allocation in nursing has not generated extensive, public discussion. However recent inquiries such as the Francis Inquiry in England (Francis 2010, 2013), the Vale of Leven Inquiry in Scotland (Vale of Leven 2014), and the Tallaght Hospital, Halapanaver and Portlaoise Hospital inquiries in Ireland (HIQA 2012, 2013, 2015) all have important things to say about the nursing resource and its impact on patient care.

Similarly, since the early years of this century, the work of Linda Aiken and her team, across a variety of health systems and countries (in the USA, UK and Europe) is suggesting a clear pattern in terms of the correlation between nurse staffing, nurse education levels and the outcomes for patients in acute surgical wards (Aiken et al. 2002, 2003, 2014; Rafftery et al. 2007).

All of the above would seem to suggest that it is timely to explore issues of resource allocation and rationing and its relevance for nursing and the provision of nursing care. This is particularly the case as we know that in a number of countries, including Ireland, the impact of the recent recession and the imposition of austerity measures across the public sector has had a direct impact on front line staffing in the health service. For example the Irish health system has experienced the loss of 5,000 nursing and midwifery posts from the sector between the years 2009 and 2014. Currently there are three thousand fewer front line nursing and midwifery staff in the Irish health system than was the case in 2007 (WIN 2016). This reduction in staffing has happened at a time when the general population continues to increase, with significant pressures emerging across both acute hospital and community services.

A couple of years ago you would come on duty, sit down and consider how you would best allocate staff across the Emergency Department (ED) in order to get through the work, care for our patients and make the best use of the staff and skill set you had. Now its “what do we need to do to survive the shift” (Nurse Manager, busy Dublin ED, Summer 2016).

Resource allocation refers to the allocation of resources to a service, department or project.

It is important, at the outset, to differentiate between resource allocation and rationing. These are related but nonetheless distinct notions. In allocating resources we are making decisions regarding how to distribute the available resources. There is an implicit assumption that, broadly speaking, there is enough of the resources in question to go around. In situations of rationing, by definition, we are starting from a position that there is not enough of the particular resource to satisfy the needs of all those requiring it.

Focusing on the medical context, Caplan (1992, p. 322) defines rationing as follows:

In the health care setting, rationing can be defined as a conscious, reasoned decision by a health care provider faced with irremediable scarcity to deny access to life-extending medical interventions or to interventions that can help restore or ameliorate serious dysfunction for some patients or for a group of patients. Rationing presumes that the health care interventions are both desired and known to be effective.

This is a much narrower definition of rationing than one may meet in the economics and ethics literature, where the notion of rationing may be used to cover any allocation decision. However Caplan argues for a narrower, more focused definition and continues:

… in health care, rationing refers to a very well-defined subset of allocation policies – those which require a conscious decision or the adoption of an explicit policy wherein certain persons of known medical need are excluded from treatment that might save, prolong, or significantly enhance the quality of their lives.

The stakes are high where rationing in health care is concerned. Thus the overriding moral imperative with respect to rationing in the health care system is not to determine what criteria or rules are fair. It is to make sure that, in the face of apparent scarcity, there is no distributional policy which is a viable alternative to rationing. (p. 322)

The point being made here is that although rationing may occur at the level of both general and specific allocation decisions, not all allocation decisions are rationing decisions. That is, not all allocation decisions contain the conscious choice to give some patients significantly less than optimal care and/or let some patients die, while other patients will receive optimal care/the care that they need to continue living.

However Teutsch and Rechel (2012, p. 2) suggest that

At some level, all resources are scarce and that is certainly true for health care. In the face of scarcity, resources are either explicitly or implicitly rationed. Rationing of health care limits access to beneficial health care services. The central question, then is not whether health care is rationed, but how, by whom and to what degree. The ethical dilemma is how to balance the precepts of autonomy, beneficence and distributive justice.

Maria Schubert, a Swiss scholar who has published some of the first work in Europe exploring rationing in nursing, defines rationing of nursing care as:

… the withholding or failure to carry out necessary nursing tasks due to inadequate time, staffing level and skill mix (Schubert et al. 2008, p. 228)

In a development of Schubert’s position a recent successful COST Action¹ grant application defined rationing in nursing care as follows:

Rationing of nursing care occurs when resources are not sufficient to provide necessary care to all patients. The reason for this phenomenon include staff reductions, increased demands for care due to the technological advancements, more treatment options, more informed service users, all requiring more time and attention from care professionals. Rationing of nursing care may also occur due to particular approaches of nurses’ clinical judgement and knowledge in allocating the resources and the wider value basis of society on care. As a result, fundamental patient needs may not be fulfilled and human rights linked to discrimination may be affected. RANCARE (2016, Technical Annex, Overview Summary p. 3)

Consideration of the different positions, presented in the above definitions, seems important for a number of reasons. For example it does seem that Caplan is correct to draw a distinction between resource allocation and rationing. In resource allocation we allocate the resources we have, one’s salary for example, to do particular things – pay our mortgage, buy food, clothes, entertainment, and so forth. In an ideal world we may wish we had slightly more resource to allocate. However generally there is enough to go around and no one loses out significantly in the allocation. Allocating family budget for a holiday might be an example here. If Family A had €10,000 to spend they might chooses to go on a 10-day cruise on the Mediterranean. However because they actually only have €5,000 to allocate towards a holiday, they choose a very pleasant two week holiday on Lake Garda. While a cruise on the Mediterranean is still a dream to be worked towards, the family are happy.

In the nursing context let us imagine that there are 12 staff on Medical Ward B – this is, in general, an adequate number of nurses to provide the required patient care, assuming staff work at a reasonable pace and there are no more than the normal admissions, discharges and activity demands. Staff are allocated according to the model of care being used and the normal patient care is given during the nursing shift. However, if one morning the nurse in charge comes on duty and the normal 12 members of staff is reduced to 8, as a result of illness or other reasons, then she may well have to consider how to ration care to some patients in order to ensure that others get the care they require. This should involve explicit discussion, agreement and direction at the nursing hand-over and reporting period at the commencement of and throughout the particular shift – in order to try to ensure some degree of transparency, fairness and peer review of the rationing decisions. The nurse in-charge will also alert the central nursing office in order to try to get additional help for this particular shift, so that the depleted nursing resource can be augmented, by agency nurses or nurses “on loan” from a quieter part of the hospital – to try to maintain the normal, good standard of care provided to the patients on Ward B.

In the context of reduced staffing, or perceived inadequate staffing, it is relevant to explore some implications of not making the staffing resource issues explicit. Let us return briefly to Alice whom we met in Chap. 8 (please see p. 102 above). Alice seems to have very little nursing resource allocated to her. This gives rise to a number of questions such as “Why has Alice received little nursing care/nursing resource?”; “Who has made the decision that Alice will not have nursing care and on what basis?”; “Who is aware of the decision to ration the nursing care that Alice is to receive?” “Has this been discussed with Alice, her parents, her medical team?” Nursing care is a social resource. Alice is in hospital because her doctor has decided that she needs medical and nursing care. Given the description in her case study it could be argued that Alice is not getting what she needs from nursing staff – what is due to her as a patient.

In Alice’s case it seems pertinent to ask who determined that there is not enough nursing time/care to go around? Who is responsible for the decision to ration nursing care, if it is perceived that there is not enough nursing care to go around? Who is accountable for the decision to ration nursing care? What is the basis for the decision? Who knows about the decision? Are the nurses on Alice’s ward aware, as a collective staff group, that Alice is receiving little or no nursing care – or has Alice somehow become “invisible” to nursing staff; is she being actively discriminated against for whatever reason? Is the decision to ration nursing care explicit or implicit – and does this matter? How is the rationing of care monitored? Who maintains oversight of care rationing and is accountable for the impact on patient care? Are there any other factors that can help with more effective allocation of the nursing resource available and thus potentially reduce or remove the need to ration nursing care in certain contexts and circumstances? It would seem that implicit rationing decisions are particularly problematic as, by definition, these decisions are unlikely to be transparent, or open to review. Implicit rationing decisions therefore also do not provide the stimulus or opportunity to consider alternative ways of allocating the available nursing resource, which may remove the need to ration nursing care in the first place.

Nurse and midwifery staffing in the Irish acute hospital sector, like many similar national systems, is largely historical. Little, if any, attempt has been made to adjust this historical nursing staff compliment in recognition of increasing population, changing demographic, increased acuity and dependency of patients or the increased patient turnover that has resulted from decreased length of hospital stay (Scott et al. 2013). It seems reasonable to expect that these changing pattern of demand would have some impact on the numbers of nursing staff required to organise and provide care.

The first national survey of nurses working in medical and surgical wards across the Irish acute hospital sector was carried out in 2009/2010 (Scott et al. 2013). Findings from this national survey provide insight into both the level and type of nursing work reported as “left undone” due to time constraints. The study also provides data on the levels of non-nursing work reported to be engaged in frequently by nurses across the acute hospital sector. Ball et al. (2013) in the UK and Ausserhofer et al. (2014) in a Europe-wide study provide similar information on the types of nursing care activities that nurses report as regularly left undone due to time pressures/shortages of nursing staff. What the findings of each of these three studies suggest is that nurses are either implicitly or explicitly rationing care to patients because, from the nurses’ perspective, there is not enough time to provide the amount of nursing care required. These findings suggest that we need to engage in discussion about resource allocation and rationing in nursing.

However there is also growing evidence to suggest that there is a need to recognise the impact of factors such as the working environment, nurse characteristics and leadership on the quality of nursing care provided to patients. Aiken et al. (2011) suggests that some of the more detrimental effects of nurse staffing shortages can be ameliorated, to some extent, by a positive work environment, inclusive of supportive nursing leadership. Aiken et al. (2014) suggest that staffing wards with nurses who have degree-level education, or above, can have an impact on 30-day mortality rates of surgical patients. Papastavrou et al. (2012) argue that both team working and nursing leadership impacts on the covert/implicit rationing of nursing care; increasing the effectiveness of team working reduces implicit rationing of nursing care, as does increasing nursing leadership.

These studies appear to provide support for Caplan’s demand that instead of focusing on devising fair rules for rationing as our starting point, we should begin by identifying when we are making implicit or explicit decisions to ration and make sure that there is no alternative – no better way of distributing our limited resources – that would avoid or minimise rationing. The potential impact of enhanced team working, nurse education levels and nursing leadership on the effective use of the nursing resource, seem important issues to explore in enhancing patient care and avoiding what may be unrecognised, unmonitored, implicit rationing of nursing care. This is also an important reason to argue for explicit rather than implicit rationing of nursing care.

Decisions regarding the allocation of resources for and within health care are broadly seen to be taken at three different, often interacting, levels. I argue below that nurses should recognize the possibility of contributing to discussions at each of these three levels because they have a civic, moral, and professional responsibility to make this contribution.