Leveraging the Code of Ethics to Practically Promote Ethics During COVID-19.

The COVID-19 pandemic has surfaced many ethical challenges for nurse leaders who need the courage, ability, and support to make the right decisions. This paper discusses 3 ethical challenges: workforce shortages, staff assignments, and moral distress. It also offers strategies to leverage our code of ethics to navigate these situations. 2021 by Elsevier Inc. All rights reserved.

Nurse leaders are facing an unprecedented amount of highly charged ethical issues.

Nurse leaders have a moral obligation to know and uphold the values of the nursing profession.

Nursing values can be leveraged to help navigate ethical challenges during the COVID-19 pandemic.

The COVID-19 pandemic has created an exorbitant number of ethical challenges for nurse leaders. We are living in and experiencing one of the greatest health care tragedies of all time. The capability and tenacity required by nurse leaders to make the right decision at the right time can be daunting.

The literature provides insight into the many settings and conditions where the professional registered nurse must make ethical determinations about the care he/she provides.1, 2, 3 However, we are lacking a comprehensive analysis or guide on how nurse leaders can prepare and respond to these types of ethical challenges.

Ethical Principles

The year 2020 marked the 30th anniversary for the American Nurses Association’s Center for Ethics and Human Rights. That year, the center received a host of concerns from nurses about ethics in practice during the public health crisis. In fact, the Code of Ethics With Interpretive Statements , was viewed over 300,000 times last year, a 9% increase over the prior year. This demonstrates the level of heightened awareness and the crucial role ethical principles and considerations play in nurses’ decision-making.

The American Organization for Nursing Leadership (AONL) maintains the practice of ethical behavior as a core competency of the nurse manager. This includes upholding professional nursing values and standards in all scopes of nurse manager practice. Many nurse leaders today are feeling overwhelmed. They are attempting to promote and sustain ethics while facing incredible clinical challenges and supporting a workforce that is fragmented, understaffed, and burned out. Despite this devastating and unrelenting environment, our roles as nurse leaders afford us the opportunity to influence the sustainment of a caring culture. Our professional position prompts a moral obligation to recognize and address ethical issues that affect both the patients and teams we serve alongside. Striving to uphold that commitment in today’s practice environment is morally distressing and may be one of the contributing factors to why nearly 4 out of 10 nurse leaders are reporting they are not emotionally healthy.

Nurse leaders should consider the use of a Reflexive Principlist Decision-Making approach as a framework in steering ethical deliberation (Figure 1 ). This framework will guide the leader through an ethical challenge with intentional reflection on the principles found within the Code of Ethics for nurses, and apply them to make a decision or take action to ensure an optimal outcome. Nurse leaders’ obligations are not to know every detail of and be able to fully apply every moral theory or model. Rather, the ethical obligation resides in abiding by the profession's Code of Ethics and principles therein. If nurse leaders reflect on the relations between their profession’s ethical obligations and the challenging situations COVID-19 has created, they are performing their role in an ethically supportable manner.

Figure 1

Reflexive Principlist Decision-Making Framework

Following are some of the current challenges facing the nursing profession, specifically from a workforce vantage point, with potential strategies to leverage the Code of Ethics for Nurses in navigating these challenges. In concert with the Reflexive Principlist Decision-Making framework, the literature provides insight into additional resources11, 12, 13 that may also prove beneficial to the nurse leader in piloting ethical outcomes.

Staffing

Assignments

Many nurse leaders can chronicle multiple ethical challenges that have emerged while making staffing assignments related to COVID-19 patients. Should we spread the COVID-19 patient population to different nurses to mitigate burnout? Should we cohort patients and staff to reduce the risk of COVID-19 exposure and spread? Should we make special considerations for pregnant or high-risk health care workers?

The struggle and toil of being fair to our team and of exposing them to the least physical and emotional harm possible are real. When weighing decisions about staff allocation and assignments, each plan must reflect the fundamental priority of patients’ interests. Indisputably, the safety and well-being of our staff is important and factors into ethical decision-making around staffing assignments. Nurse leaders are struggling to balance the well-being of the patients and team, all the while recognizing that staffs’ well-being directly impacts the care they provide. Something we as nurse leaders can do amid that seemingly impossible struggle is take small, basic actions that place the interests of patients at the forefront.

When determining assignments, consider the individual patient needs, the diversity of the nursing staff, and their unique skill levels, qualifications, and expertise. Sometimes focusing on smaller choices and actions can assist a leader to provide the best, safest care possible for patients while also benefiting the interests of nursing staff who need to feel appreciated and valued. This could be accomplished with a simple, yet intentional switching of a patient to a different nurse.

Nursing staff expect their leaders to be fair and do the least amount of harm as possible in making staffing assignments. Amid a health care crisis, risk of harm is not always possible to prevent. Nurse leaders should consider the ethical principles of respectfulness and transparency and work toward an integrity-preserving compromise. Nurse leaders should continue to hold honest discussions about the resources available and the potential options, striving to make assignments based on collaborative planning. After all options have been explored and staffing decisions are made, it is important for nurse leaders to be intentionally transparent and veracious about how and why these decisions were made. Articulating one’s decision-making process helps members of the team have confidence in their leader, understand the complexity of the situation, and have peace of mind that all decisions were made with the best of intentions.

Workforce Scarcity

Staffing and workforce scarcity is one of the most pressing challenges facing our nurse leaders today. Staffing challenges were prevalent prior to the pandemic, but staffing shortages have compounded over the last 18 months. Nurses are currently needed in estimates as high as 11 million. Turnover is higher than ever as nurses leave their permanent positions because their families are relocated to different areas for employment or to offset their personal financial pressures. Many nurses are leaving the profession altogether due to the immense stress and strain. Additionally, new nurses are graduating with less hands-on clinical experience due to pandemic student restrictions, which is causing delays in getting additional nurses independently caring for patients.

The workforce scarcity poses an ethical challenge for nurse leaders trying to determine whether the quality of care is being sacrificed. Furthermore, are there acceptable concessions in care that can be forfeited in an ethically justifiable manner during a current crisis? Standardized staffing models and ratios have been researched and measured. These studies demonstrate that RN-to-patient ratios correlate with improved patient outcomes, fewer safety incidences, and lower mortality. Unfortunately, these models were designed for use under normal conditions and offer no guidance for crisis staffing. The exact tipping point where quality slips in a patient assignment is unknown. Yet, nurse leaders today are being forced to make choices which result in rationing staff and potentially risking quality outcomes.

These situations have caused nurse leaders to be confronted with difficult questions. What measures should be taken to maximize staffing resources? Should contract labor be explored even though it may exacerbate the local and national staffing shortage? How will adding temporary premium pay workers impact my team that has been committed and dedicated? Should alternative care models that leverage licensed practical nurses, student nurses, or even new graduate nurses not out of orientation be explored? Do we jeopardize the contributions nurses make in alternative roles and pull them back into direct patient care roles?

As nursing professionals who must act according to the nursing Code of Ethics, we have an ethical obligation to place the interests of our patients first. In times of crisis, the goal is to maximize and leverage every resource available to provide the safest level of care possible. We are morally obligated to think creatively and differently than we do in normal times for the primary purpose of maintaining the best care possible for patients. All options should be explored in a collaborative manner, and all decisions should be clearly linked to patients’ interests and be made transparent to all affected parties.

During the present staffing shortages, we should act with heightened awareness that our actions may unintentionally further jeopardize the quality of care we can provide patients. Practically, we may be unable to adequately address staffing shortages and provide the normal standards of care during a current crisis.

Addressing Moral Distress and Promoting Resiliency

Preventing burnout and promoting resilience are buzz words we are hearing in conversations all around the country. The very essence of being resilient is having the ability to withstand and quickly recover from a difficult situation. The reality of COVID-19 is that this “situation” has been relentless, making it challenging for nurses to keep showing up day after day.

We have all heard about the stress and burnout that the pandemic has exacerbated for the health care industry. What we have not acknowledged is the moral component of this stress. Nurse leaders and nursing staff all want to do the right thing, but the current health care crisis presents a conundrum. There are too many constraints, limitations, and adversity, and we lack the team members and medical supplies to actualize what feels right.

Daily, nurses are confronted with situations in which they feel the care they are providing is futile. Continuously coding patients, draining an exorbitant amount of resources for a single patient, and taking drastic efforts to save a patient with a poor prognosis are all examples of situations that cause moral distress and lead to burnout. Balancing the role of the professional nurse with personal values make it difficult to keep showing up and handling all these ethically charged situations day after day.

This is not just stress. This is moral distress, and the exhaustion, anger, and anguish impact nurses’ ability to care for patients and the work climate on the unit. Moral distress not only harms the individuals experiencing it, it impacts our ability to hold true to our values and mission. It compromises the whole system.

Nurse leaders are encouraged to utilize the clinical ethics resources available to help prevent and mitigate moral distress. They must feel empowered to call on ethics experts to help gain the expertise they need to lead through these morally distressing situations. Even nurse leaders who are untrained in ethics and have little access to ethics resources can mitigate moral distress and promote resiliency within their teams. Nurses’ own interests and self-worth are values that must be upheld.

As nurse leaders, we can refocus our teams by reminding them daily of our values and the social good we are carrying out. Regularly and clearly articulating the specific values we are attempting to uphold re-emphasizes that the entire team is safeguarding their obligations with integrity and doing what is morally right. Although this may not change the realities leaders and teams are facing, it can remind them that the context is not a moral failing if we embrace our professional values and are doing our best to uphold them.

Conclusion

The current, incessant health crisis both highlights and produces ethical challenges that we as nurse leaders must face. Nurse leaders should face these challenges by focusing on the values of the nursing profession found in the nursing Code of Ethics. There are often multiple morally acceptable options in challenging situations, but striving to be aware of and uphold these values in every situation is a moral obligation. Even nurse leaders with limited ethics knowledge and resources can take practical actions to align themselves and their team with these values.