A Johns Hopkins Ethics Nurse Discusses Difficult Decisions, Challenges and Moral Distress: "We know you are overworked, understaffed, possibly heartbroken and anxious, but always courageous"
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As the number of confirmed COVID-19 cases accelerates in the United States, nurses on the front lines of the health care response have found themselves in unprecedented positions, making high-stakes decisions for patients and their own personal lives.
"We in uncharted territory in response to the magnitude of the pandemic," says Cynda Rushton, a professor at the Johns Hopkins School of Nursing and Berman Institute of Bioethics known as an international leader in nursing ethics. "It's a time of great stress and uncertainty, and nurses are rising to the challenge."
Two weeks ago, Rushton — author and editor of Moral Resilience: Transforming Moral Suffering in Healthcare (Oxford University Press, 2018) — helped create the Frontline Nurses Wikiwisdom Forum, a virtual safe space where nurses can share their challenges and experiences during COVID-19.
"We know that nurses are the backbone of American health care, and often its heart and soul," the site says. "The COVID-19 pandemic is testing all of us, but nurses are on the front lines. This space will be available 24/7 until America exits this crisis. Join us. Share your knowledge, experience, and challenges about working on the front lines of a pandemic. We know you are overworked, understaffed, possibly heartbroken and anxious, but always courageous. Feeling part of a community, even a virtual one, can help."
Rushton recently spoke with the Hub about the conditions and decisions encountered daily by nurses who are wrestling with the massive health care challenges posed by COVID-19.
How has nursing changed as the U.S. begins to confront the COVID-19 pandemic?
Nurses' roles are now more important than ever. Nurses are often the last thread of compassion for patients. They're the ones doing the screenings, taking care of the critically ill, implementing triage protocols, communicating to families, and attending to the dying. Nurses in every role are impacted. They're being asked to work in areas of the hospital that aren't their normal specialty. They're providing telehealth consultations. They're being redeployed to learn new skills and take new roles — as safety officers, and taking care of critically ill patients. They're making triage plans operational. We've had to reallocate our resources in profound ways, and nurses are innovating and leading in the midst of the crisis.
From an ethical standpoint, what new challenges are nurses facing?
For nurses, our ethical framework has focused on the well-being of individual patients. Historically, decisions were made based on the autonomy of patient's preferences and values. As the pandemic worsens, these decisions will be made using triage protocols. We have to enlarge our ethical perspective to more fully integrate a public health framework that maximizes the good for more people and minimizes the harm, so that people most likely to benefit from scarce resources receive them.
That shift leaves nurses feeling like they're abandoning their individual patients. They're not able to provide the level of care they're used to. The gap between what they can do and what they believe they should do creates moral distress, a sense that they're compromising their integrity.
In the midst of this crisis, it's necessary to reconsider what fairness and justice means, and to recalibrate our ethical obligations in response to the severe conditions.
What exactly are those obligations?
They're very complex. Nurses always have obligations to the patient in front of them, but the pandemic imposes so many limitations. We can't say, "Whatever you prefer is available," but we can say, "Here's how I'm able to help you with the resources we have." It might be that I can offer my knowledge and skills to relieve your symptoms and help you make decisions, or provide options for palliative care or spiritual support, or simply listen to your fears and concerns.
At the same time, nurses have to consider how we can benefit more people. This often means making room for sicker patients by discharging patients who would under other circumstances be admitted. Moment-to-moment decisions are required on how to use equipment, medications, and resources when there aren't enough for everyone.
And what obligations do nurses have to themselves and their own families?
We always begin with patients as our first priority in our professional ethical framework. That doesn't mean we don't have obligations to our own well-being and families. Nurses are grappling with questions like, "Am I potentially causing harm to my family by coming home from work every day?" and "How do I balance the needs of my loved ones with the endless needs of patients?"
The stakes are very high, and unfortunately there are no good answers. Part of being able to find integrity here is accepting the reality of our current situation and living with uncertainty—acknowledging we're making decisions under constrained and difficult circumstances. However, the American Nurses Association Code of Ethics is clear: Nurses have the same obligations to self as to others. Investment in one's well-being is not optional; it's a moral mandate.
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