Fighting the virus is not enough-Pandemics, social justice, and the role of nurses in Switzerland.

OVERVIEW

In Switzerland, as in other high‐income countries, Covid‐19 has had an unprecedented impact on the healthcare workforce in general, and the nursing workforce in particular (Merçay et al., 2021). In addition, the Swiss case demonstrates that not even wealthy countries are immune to the serious threats this pandemic has posed on societal functioning. How “well” Switzerland was prepared for the pandemic and has been coping with this unprecedented situation is still issue of debate. A major challenge consisted not only the intermingling of politics, science, economy, and the power of interest groups, but also the difficulty of making the voices of those groups heard who were particularly vulnerable and disproportionately burdened by the pandemic such as vulnerable patients, children, single parents, or residents of nursing homes as well as healthcare workers and other relevant professional groups (Balthasar et al., 2022). In this commentary, we trace how the public discourse on nursing during the pandemic potentially changed from an initial (over‐) heroization to a moral and political recognition of the nursing profession's critical role to the health system. In the light of the social inequalities that have been exacerbated during the pandemic, we conclude that further steps must follow in order to deploy the full potential of nursing for social justice and to assure both high‐quality and equitable nursing care.

THE SWISS HEALTHCARE SYSTEM DURING THE COVID‐19 PANDEMIC

Generally, Switzerland is recognized for its high‐quality healthcare system. Universal health coverage is not only anchored in the Swiss constitution, but also manifest in its health insurance law. Despite a balanced repartition of responsibilities between a variety of players including federal and cantonal governments, healthcare providers, health insurance companies and citizens, the OECD has highlighted a series of challenges inherent to the Swiss healthcare system (OECD, 2021). These include one of the highest health expenditures relative to national GDP among OECD countries as well as a comparatively low contribution from public funds to health. The high contributions by households and citizens lead to a considerable cost‐induced waiver of medically necessary care among those populations threatened or affected by poverty and / or vulnerability. These dynamics require social cushioning and protection mechanisms, which are not implemented equally well in all cantons and municipalities. Despite such social gradients in accessing care, the performance of the Swiss healthcare system is generally considered to be high (OECD, 2021).

Since February 2020, the pandemic has imposed a large, initially unpredictable, burden on the Swiss healthcare system. While the direct impact of the pandemic in terms of morbidity and mortality has been considerable (Balthasar et al., 2022), public health measures of infection containment have also constituted a significant burden on populations that are vulnerable in terms of age, health, wealth, residency status, or (health) literacy. The latter has made known gradients in access to healthcare visible again and led to an exacerbation of preexisting inequalities (Balthasar et al., 2022; NCS‐TF, 2022). Furthermore, the burden on the healthcare workforce in general, and on nurses and nursing students in particular, has been considerable in terms of physical health, mental health, perceived moral distress, workplace dissatisfaction as well as intention to leave the profession (Merçay et al., 2021; NCS‐TF, 2020; Ramelet et al., 2022).

PREVENTING THE PANDEMIC AS ‘GREAT LEVELER’

How do we make sense of these phenomena? In his egregious study on inequality, Harvard Professor Walter Scheidel draws an analogy between the four Apocalyptic Horsemen (the biblical heralds of the imminent end of time) and four “horsemen of leveling,” that is, ruptures that violently (but only transiently) can flatten societal inequalities: warfare, revolution, state failure, and pandemics (Scheidel, 2017). The metaphor of the pandemics as ‘great leveler’ in particular is powerful in trying to understand the abovementioned phenomena for three reasons:

First, it may elucidate complex dynamics of (however transient) redistribution of wealth at play in post‐pandemic societies.

Second, it may explain how even politically stable high‐income countries like Switzerland with comparably good health infrastructure can be severely challenged by public health crises attributable to the pandemic spread of a novel pathogen.

Third, it may give reasons for states trying to do ‘anything’ including prolonged lockdowns to preserve, avert or at least mitigate the occurrence of worst cases and concomitant human suffering.

Thus, the metaphor of the ‘great leveler’ may explain the threatful equality of outcomes of a pandemic all states need to prevent—and the respective challenges faced also by high‐income countries with expensive healthcare systems like Switzerland. However, this metaphor is not able to explain a crucial difference: High‐income countries can mobilize much more resources than low‐ or middle‐income countries to alleviate or delay leveling effects and to protect social, economic, and cultural life. Consequently, projected outcomes of a pandemic may be “equal” for each country in terms of leveling effects that eventually cannot be influenced because they also depend on the nature of the pathogen itself (Scheidel, 2017). In contrast, the identified impact of measures on individuals and populations to prevent this outcome is unequal, that is, highly dependent on preexisting social gradients in accessing healthcare. This fatal mechanism tragically confirms the so‐called inverse care law in asserting that the more populations are underserved and show increased healthcare needs, the less healthcare they receive in comparison to privileged populations (Riou et al., 2021). The validity of this mechanism has also been confirmed by a large study of Covid‐19‐related surveillance data in Switzerland, whose results have been labeled as “pandemic of inequality” by the authors (Riou et al., 2021, p. e690).

FROM (OVER‐) HEROIZATION TO A MORAL AND POLITICAL RECOGNITION OF NURSES' WORK

Nurses were also in Switzerland at the frontline of public health responses to the pandemic threat, not only witnessing the dynamics of the so‐called inverse care law on vulnerable populations, but also discovering their own vulnerability in terms of exposure to risk, physical, psychological, moral distress, and moral injury (Merçay et al., 2021; NCS‐TF, 2020). Like in other countries in the first wave of the pandemic, they were publicly acclaimed, applauded and celebrated as a systemically relevant professional group, although the acclaim and applause did not always filter through to Covid wards, ICUs, nursing homes, and other healthcare settings affected by the Covid‐19 pandemic and nurses reported that they did not have the feeling of actually receiving the due recognition for their work.

Whereas such (over‐) heroization of nursing seemed to ebb quickly, the prolonged duration of the pandemic and the long‐lasting period of challenging working conditions and high workload for nurses reached public attention and increased media coverage. It focused predominantly on individual nurses in the first two waves, but successively broadened its focus to the status quo of the nursing profession in general. Special attention was paid to the exacerbation of nursing shortage due to quarantine, phenomena of physical, psychological, and moral distress including moral injury, and securing the quality of nursing care in situations, which could take the characteristics of humanitarian crises like, for example,

the exposure to care settings unable to guarantee minimum staffing and equipment requirements for safe care

the explicit implementation of triage decisions on ICUs

the covert or silent triage of people due to age or place of care (e.g., nursing homes) to increase reserve capacities in hospitals (NCS‐TF, 2022)

the failure to provide effective palliative care

the impossibility to meet psycho‐social and spiritual needs of patients suffering from social deprivation due to visiting restrictions

the management of exceptions to visiting bans and the question of distributive justice

the provision of end‐of‐life care without family presence and under working conditions that implied use of personal protective equipment

In light of the continuing pandemic, the pertinent question of how to secure the future of nursing in Switzerland entered the public debate and with it, explicit questions relating to occupational and mental health (Merçay et al., 2021; NCS‐TF, 2020). Interestingly, the discourse related to the “pandemics of inequality” (Riou et al., 2021, p. e690) seemed to play a rather marginal role within the nursing discourse. Transcending the initial (over‐) heroization of nurses, many political stakeholders expressed the moral recognition as well as the systemic relevance of nurses for the health and wellbeing of society. Led by the Swiss Nurses' Association and with support of many allies, the moral recognition subsequently induced a political recognition by the Swiss population. After a popular vote in November 2021, the so‐called “nursing initiative” has been adopted (www.pflegeinitiative.ch) that resulted in an amendment of the Swiss Constitution guaranteeing the provision of sufficiently staffed, high‐quality nursing care to all citizens, including adequate education, good working conditions and professional autonomy. Unsurprisingly and given the breadth of these amendments, the political debate on its implementation has been ongoing.

NURSES AS AGENTS OF SOCIAL JUSTICE

During the Covid‐19 pandemic, the discourse on nursing has led to a better recognition of the value of nursing care in Switzerland. Nevertheless, the challenge of a high‐income country with the promise of universal health coverage but bearing symptoms of a pandemics of inequality (Riou et al., 2021, p. e690) persists. Even if there is a hope that the coronavirus may be better controllable in its endemic form, other variants as well as other public health challenges can follow anytime and pose novel threats to the equitable provision of care which exacerbate preexisting inequalities. To counter and prepare for such challenges, any healthcare system seems well advised to develop a high‐quality nursing workforce with a strong commitment and capacity for promoting social justice and realizing human rights, a core element of the nursing profession according to the ICN's Code of Ethics for Nurses (ICN, 2021).

STRENGTHENING THE NURSING WORKFORCE IN SWITZERLAND: FOR THE PANDEMIC AND BEYOND

As to facilitate such progress in Switzerland, the fundamental role of nursing in contributing to social justice needs to be recognized both in terms of fighting “the virus” and the structural injustices it threatens to reinforce. We see two crucial steps towards that goal. First, the political visibility of the nursing profession and perspective needs to be increased as to secure effective conditions for state‐of the‐art nursing practice. Establishing a Chief Nursing Officer on a national and cantonal level seems a timely and necessary step in the right direction. Second, and most importantly, the clear and unambiguous approval of the “nursing initiative” by the Swiss electorate does not allow for political procrastination if we are to address the critical areas of education, working conditions and professional autonomy.