Nursing ethics in a time of pandemic
When 14 nurses from across Canada gather online as the incoming Summer 2020 MSN cohort during the global COVID-19 pandemic, matters of ethics are foremost on our minds. Together we identified five pressing ethical issues, through a nursing lens, that have transformed from theoretical concepts to everyday realities during these last weeks.
1. Duty-to-care. According to the Canadian Nurses Association Code of Ethics, nurses (as other healthcare professionals also) are professionally obliged to provide safe, competent, compassionate, and ethical care during a pandemic, even when providing care puts their own health and life at risk. As nurses at the point of care, we have seen barriers to such care, when, for example, protocols advise against touch that is not absolutely necessary, and when patients are kept isolated. We have also worried about our own safety, and asked the question, where is the line of “unreasonable burden” when a nurse steps back from providing care? Does this principle apply to nurses who are pregnant? Nurses who are older? In situations when employers do not provide sufficient personal protective equipment? If a nurse says “no” to additional shifts, might they be treated punitively by their employer? If nurses are rushed or deployed into roles they are not prepared for, are they able to enact their duty-to-care? As these questions accumulate, nurses inevitably experience moral distress.
2. End-of-Life Care. As nurses, we hold the ethical values (among others) of promoting well-being, providing compassionate care, promoting informed decision-making and honouring dignity. We are seeing firsthand during COVID-19, that people are dying without their loved ones with them, and without the rituals that would be important to them and their families. Sometimes we step into the role of “family member”, offering presence during a stranger’s last breath. As nurses, we may bear the brunt of families’ frustration of not being able to be involved. How do we support families in their grieving, when they cannot be together as would be valued in their traditions? Depending on the pressure for critical care beds, nurses and healthcare teams are facing resource allocation decisions. How do nurses guide patients and families in earlier advance care planning conversations? How do nurses support the principles of a palliative approach, even in the face of fast-changing, acute illness?
3. Concern for privacy and confidentiality. We appreciate public health strategies to contain the spread of the virus and advocate that this is done with minimal invasion of people’s privacy. We are concerned about the potential of blaming the person who has been infected, and breach of confidentiality in the immediate. As technologies are proposed to assist with contact tracing and alert people to possible exposure, we are concerned for the security of personal data. We see the tension between protecting individual privacy and fostering a greater good (i.e., prevention of spread of the virus). We pose questions such as: For how long, and what methods will patient information be stored in a way that will protect the patient and their privacy? Who is authorized to access this information, and what will be the recourse for unauthorized access?
4. Equity for people who are structurally vulnerable. Structural vulnerabilities are amplified during a pandemic. Those people already facing structural vulnerabilities—such as crowded conditions that make physical distancing difficult, or lack of access to healthcare services—are all the more susceptible to the corona virus. At a national level, we have seen this reality reflected in virus outbreaks in prisons, long-term care facilities, and remote Indigenous communities. Globally, we see the devastation of this pandemic in low and mid-resource countries, where hospitals cannot accommodate the numbers of people needing acute and critical care services, and where public health systems may not be equipped for the necessary screening and tracing. As nurses who hold to the values of equity and justice, we advocate in the immediate for targeted services and interventions for populations most at risk. In the longer term, we advocate for health and social systems that support all people to live with dignity and safety. Equity will require cooperation and awareness at local and global levels. The pandemic is showing us that our society is only as strong as those who are weakest amongst us
5. Organizational, workplace ethics. Nurses are well aware of the importance of quality practice environments to support the delivery of safe, compassionate, competent, and ethical care. Organizations are obliged to provide a safe work environment and ensure sufficient resources, such as PPE, to allow safe practice. During this pandemic, leaders set the tone by being transparent and involved, for example, in discussing PPE procedures for donning and offing officers, all day use of a single facemask, and new recycle programs for N95 respirators. We have seen some healthcare leaders assist at the point-of-care as a compassionate way to connect during times of uncertainty. The pandemic is causing nurses to face new ethical issues such as redeployment; we are acutely aware of workload issues, as we work short and work in areas unfamiliar to us. We especially recognize the challenges faced by novice nurses, and therefore they require additional support during transition into practice.
At a minimum, the pandemic has upended routines around the world. More crucially, nurses are concerned about the difficulties that have arisen as the pandemic spreads. Specifically, nurses have questions about how to adequately provide care to severely isolated and sick patients while also trying to ensure their own safety from this novel virus. Furthermore, our patients are dying without their loved ones with them, and nurses are seeking to support them and their grieving families. We recognize the need to track and trace individuals so we can continue to care for their wellbeing, and follow the spread of the virus and prevent future outbreaks. At the same time, it is necessary that we uphold patient privacy and confidentiality, to not place blame on any one person, who is in fact a victim of the virus. Structural vulnerabilities during this time of pandemic are seen not only on a personal level, but on national and global levels as well. Finally, nurses are concerned with how their places of work support healthcare workers to provide safe, ethical care in spite of the various challenges that this pandemic brings. Providing safe, competent and ethical care involves the actions of our political leaders, communities, healthcare leaders, and all healthcare providers.
Co-Authored by: Ellena Benacchio, Rupi Bhangu Escobar, Meghann Buyco, Laura Cranna, Caitlin Friesen, Michelle Hilton, Tamara Irwin, Esther Kempling, Sarah Pahl, Victoria Radley, Michelle Remedios, Primrose Sotocinal, Debbie Thiessen, Jessica Verseveldt
Course: NURS 510 Foundations of Nursing Knowledge, with Dr. Sheryl Reimer-Kirkham
RESOURCES
Canadian Nurses Association (2017). Code of ethics for Registered Nurses. Accessed from: https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/code-of-ethics-2017-edition-secure-interactive
Canadian Nurses Association (2020). Nurses’ ethical considerations during a pandemic. Accessed from: https://cna-aiic.ca/-/media/cna/covid-19/nurses-ethical-considerations-during-a-pandemic_e.pdf