As the number of confirmed COVID-19 cases accelerates around the world, 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.
Cynda Rushton is a professor at the Johns Hopkins School of Nursing and Berman Institute of Bioethics and an international leader in nursing ethics. Below she discusses the conditions and decisions nurses encounter every day while wrestling with the massive health care challenges posed by the new coronavirus.
How has nursing changed as we 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 redeploying to learn new skills and take new roles. 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 do nurses face?
For nurses, our ethical framework has focused on the well-being of individual patients. Historically, we made decisions based on a patient’s preferences and values. As the pandemic worsens, we will need to make these decisions using triage protocols. We have to rethink our ethical perspective to maximize the good for more people and minimize the harm, so 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 their usual level of care. 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, we have 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 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 we would admit under other circumstances. We have to make moment-to-moment decisions on how to use equipment, medications and resources when there aren’t enough for everyone.
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. We must continue to use our voices to advocate for systemic changes that the pandemic reveals and to stand together to find solutions that are aligned with our professional values.