Like many of you reading this, I have a range of emotions and feelings as the pandemic of COVID19 grows in the USA: anxiety, fear, and anger. Today (and for the last several days), I am angry about the lack of Personal Protective Equipment (PPE) available for nurses who are being called to care for those who are most ill and the most contagious. The following is my attempt to express my personal concerns and align them with nursing’s guiding ethical principles.
There may be flaws in my thinking and I am open to respectful dialog about these issues. I understand that emotions are running high and that we may not agree, but we can and should have civil discussions and dialogs.
Lack of Personal Protective Equipment. On February 7, 2020, the World Health Organization warned of a shortage of Personal Protective Equipment in China and beyond. As that was 6 weeks ago, there has been time to ramp up the production of PPE. Meanwhile, state’s governors from Maine to Wisconsin to Florida and Washingon are asking to access the federal stockpiles for access to PPE:
Nurses Quitting: A few days ago, one of my Facebook friends quit her job because she was no longer being provided the proper PPE, She was not directly caring for COVID19 patients, but she needs proper PPE to keep herself and her patients safe during the provision of care, and her quitting her job got me thinking, considering ethical issues, advocacy, the role of the nurse, and so on. I respect her decision, and I hope this post makes it clear that during these frightening and murky times, the decisions we make as nurses are going to be hard ones.
I want to say, from an ethical perspective, it is perfectly acceptable for nurses to quit their jobs and/or refuse to work without proper PPE. Refer to my previous post of the ANA calling for the CDC to provide evidence when they make guidelines, and consider the recent use of bandanas and reuse of face masks protocol from the CDC: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html. This flies in the face of everything we know about the transmission of viruses.
Ethical Principles: The overarching ethical principles at play here that help to guide nurses’ decision making are beneficence (doing the good thing, moral obligation to do the right thing, what is best for the patient) and nonmaleficence (do no harm to patients). When we work without proper PPE, there is a very real risk that not only might we harm ourselves, we potentially spread pathogens to patients. When we don’t have proper PPE, our stress, fear, and anxiety can be magnified and potentially may harm patients.
Additionally, The code of ethics for nurses (https://www.nursingworld.org/coe-view-only) requires a lot of us. To begin with, we must be deeply familiar with The code and how it guides our decision-making processes. The following are some excerpts from The code that guide our decision making at this time:
The code: 3.5 Protection of Patient Health and Safety by Acting on Questionable Practice
This concept is all about the reporting of inappropriate and questionable practices. We may become stymied when even our boards of nurses are aware of dangerous and non-evidence-based practices, but they may see no way around them. We can report the issues, but when the governing bodies we report to are not holding up our own ethical standards, the field is put at greater risk for collapse (from infection spreading and/ or providers quitting).
Even as standards are relaxed, entities such as the Oregon Board of Nursing should be taking more responsible action and not placing nurses and patients at risk. The following is a statement by the Oregon Board of Nursing that states that nurses cannot refuse assignments because of sub-par PPE that does not align with CDC or WHO regulations. In other words, in this case, the BON is either not considering the greater harm for both patients and nurses by not recognizing the greater ethical concerns and personal risks nurses are being asked to take, or they simply see no other solutions. The paragraphs about the social contract and evidence-based approaches contradict the highlighted area regarding changes in PPE approaches and the right to refuse assignments.
Regardless of what our boards of nursing state, Provision 4 makes it clear that we are ultimately responsible for our own practice: “The nurse has authority, accountability, and responsibility for nursing practice; makes decisions, and takes action consistent with the obligation to promote health and to provide optimal care”. Specifically, Provision 4.1 states that “Nurses bear primary responsibility for the nursing care that their patients and clients receive” and “Nurses must always comply with and adhere to state nurse practice acts, regulations, standards of care, and ANA’s Code…”. This does lead to interesting paradoxical issues with the Oregon Board of Nursing, as one could view this as a regulation, but it contradicts further statements in The code, including:
Provision 4.3: “Nurses are always accountable for their judgment, decisions, and actions: however in some circumstances, responsibility may be borne by both the nurse and the institution. Nurses accept or reject specific role demands and assignments based on their education, knowledge, competence, and experience, as well as their assessment of the level of risk for patient safety. Nurses in administration, education, policy, and research also have obligations to the recipients of nursing care” and “Nurses must bring forward difficult issues related to patient care and/or institutional constraints upon ethical practice for discussion and review”.
Most importantly, The code calls for us to take good care of ourselves so that we can take care of others. We see this shown in Provision 5, particularly:
Provision 5.2 Promotion of Personal Health, Safety, and Well-Being
“…nurses have a duty to take the same care for their own health and safety. Nurses should model the same health maintenance and health promotion that they teach and research, obtain health care when needed, and avoid taking unnecessary risks to health or safety in the course of their professional and personal activities.” The sticking point here is arguing whether or not the risks of not wearing proper PPE, which include risks of death for oneself or other patients who have not yet been exposed, is necessary or not. From my perspective, I can see where working without proper PPE could be too large of a risk to oneself and the communities served.
And I get concerned when nurses seem to think it’s only about them be willing to take on the personal risk for themselves, forgetting about how they may also become the vector.
One last ethical issue, we have to do our own self-care during these challenging times. As nurses, we are required to take care of ourselves. Provision 5.2 continues: “Fatigue and compassion fatigue affect a nurse’s professional performance and personal life. To mitigate these effects, nurses should eat a healthy diet, exercise, get sufficient rest, maintain family and personal relationships, engage in adequate leisure and recreational activities, and attend to spiritual or religious needs…it is the responsibility of nurses leaders to foster this balance within organizations”
Now onto a round-up of current COVID19 issues for nurses as I am seeing on social media:
Masks: Some nurses are being told to store their 1 daily mask in a paper bag and remove/ doff between patients, and replace/don the old mask for new patients. Of course, the bag and the mask would all be potentially contaminated; the bag actually creates a source of contamination and risks for greater transmission. I also heard rumors on social media of nurses being told to share masks, and I am hoping this is simply just false information, as I couldn’t verify that claim. I did hear that eye shields were being shared. I have confirmed that nurses who are normally required to wear masks because they have not been vaccinated for the flu are now being told to not wear masks because there is a shortage of masks. I have also confirmed that having a doctor’s note regarding why one must wear a mask (verification that they are immunocompromised) may work in some settings to either ensure masks are available to the person or excuse them from work.
We are vulnerable: Nurses are humans and many of us are vulnerable, whether that means we have chronic health conditions and co-morbidities, or we are at risk because of age.
- The average of RN’s in the USA is 50, perhaps increasing risks related to the virus (https://alliedstaffingnetwork.com/americas-nurses-are-aging/ ),
- Indeed it has been documented that healthcare workers may fair worse when they contract COVID19, which in part may be related to stress or multiple exposures to the virus. The healthcare system was already strained before the pandemic started, and as nurses also become ill, the system will become even more strained (https://www.businessinsider.com/nurses-are-understaffed-and-frustrated-as-they-battle-coronavirus-2020-3 ).
- We are already feeling the “psychic” shock of this pandemic, and showing signs of potential PTSD ( https://www.washingtonpost.com/outlook/2020/03/18/doctors-nurses-are-already-feeling-psychic-shock-treating-coronavirus/?fbclid=IwAR3yUXxn6VrwckM1p3FX1pAeBMARQ8hlxCMaUm_kr81b2xZB6aHLr2UBV9k ). I am seeing growing division of nurses on social media pages regarding many of these topics.
- I heard rumors that as many as 1/2 of the positive COVID19 cases in the state of Pennslyvania were healthcare providers. I couldn’t verify this fully, though there are positive healthcare providers (https://6abc.com/6026148/), and on this date, at least 10 of the 44 cases recently identified in PA are healthcare providers (https://patch.com/pennsylvania/chestnuthill/20-44-coronavirus-cases-philadelphia-are-healthcare-workers?fbclid=IwAR1o0fR0kLQA4aat1-qr1LU0UyxrWz3Gy_nVecEB3_QXgXc9c0cMghZCnAs ).
- We, of course, know that healthcare providers are at greater risk, and likely more so with poor PPE (https://www.washingtonpost.com/health/covid-19-hits-doctors-nurses-emts-threatening-health-system/2020/03/17/f21147e8-67aa-11ea-b313-df458622c2cc_story.html ).
- We are worried about our families, and this may mean distancing ourselves from them (https://www.advisory.com/daily-briefing/2020/03/18/doctor-fears) or choosing to protect the frail in our family instead of working. I have heard of nurses and doctors renting airb-n-b rooms to be away from their families in order to protect them from contamination.
- We are being denied sick leave after exposure or told to use PTO or go without pay. Or we are being told to work post-exposure, or work with flu and cold-like symptoms if no fever is present.
- For nurses who are willing and able to work, many believe they should be getting hazard pay for the risks they are willing to take.
Nurses are also fighting amongst themselves about whether it is okay to quit the workplace now. We have to recognize that these are complex decisions; nurses are real people who have their own health issues. Getting angry about people not willing to take the risk is not productive in both the short and long term.
It’s okay to choose your life and your well-being over the “duty” or social contract to work. It’s okay to make those tough decisions, like quitting your job, and, for some folks, they may be willing to risk their license by refusing assignments where they can’t keep themselves or their patients safe, even if their board of nursing disagrees.
Many nurses will carry on, work hard, provide excellent care, and do their best.
It’s also okay to feel vulnerable and scared in these uncertain times and to question your decisions and the decisions of administrators, regulators, and leaders.
It’s okay to organize and advocate for our needs, whatever that looks like.
Always remember, you have ethics on your side.
NurseManifest 
It’s time for a national nurses’ strike. Stark as this may sound, 4 hours of strike—or a rolling work action—will bring attention to the value of nurses and our unwillingness to be martyred by our compassion.
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That might help, but I am already worried about the government requiring medical personnel to work. If this was going to happen, it would need to happen soon, like this weekend,
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Carey
As always, your post is brilliant, thought-provoking, and timely.
I have been thinking a lot about this very issue and I offer this small consideration. Having been an actuary I tend to think of the value of resources over time. As an actuary that was always the value of a dollar paid at different points in time, which would be arrived at by assuming an interest rate and discounting future payments to the present moment.
But it doesn’t have to be dollars. We can think of it as nurses as well. So, one of the problems is how many nurses might we have to serve patients in say 3 weeks, if we put all the nurses we have into current patient care? If we do that with no protections at all, we should expect that most will be infected in a short period of time. About 80% of those nurses will recover, having had relatively mild symptoms, and they may return to service in say three weeks and they may not even need protective gear for themselves, though they would still need some gear to protect patients.
About 5% of those nurses are likely to require intensive care and 1% will die. I have a hunch that none of that 5% are likely to return to nursing because they will either be physically or emotionally traumatized. Some of these nurses will have developed antibodies, and may even be immune, but the trauma will likely be severe and they are likely to have to deal with the deaths of friends, relatives, and colleagues as will all of us.
About 15% will have severe enough symptoms, that they will need some hospital-based care, and or oxygen and again here I suspect many will not be able to return, let’s say half of this group return within 3 weeks.
So early on we lose as much as 12.5% of an unprotected workforce.
Now I know almost all my colleagues were already on mandatory overtime schedules before Covid-19, and they were barely able to meet the needs of their patients then. Now, there are more patients coming in, and some are much sicker. But the next few weeks are just the ripples of a pond when you drop a pebble in it. So my friends are running in place, working more than ever, and theirs is a natural response to a short term emergency situation. Their adrenaline is pumping, they are working longer hours, trying to get even with where they feel they need to be now.
But they are fast wearing themselves out, and we haven’t seen the first tsunami wave yet. Another few days of working at their current pace, will leave them worn out, their immune systems already beginning to fail, and then the first tsunami is going to hit, and then a few weeks later the next tsunami is going to hit, and then the third tsunami is going to hit.
As nurses, we also need to think about which patients are we going to be available to serve? If we lose many nurses before the first tsunami hits, we won’t be able to meet the needs of the patients during the first tsunami. If we lose nurses serving the needs of patients from the first tsunami we will be in worse shape to meet the needs of the second tsunami patients…
People can/must make sound ethical choices to be available to patients from some, but probably not all of the different time periods, as it is unlikely that any of us will be able to meet the needs of patients for all the time periods.
People who sit out the first wave, maybe even the first tsunami, when PPEs are in short supply, may actually be making a reasonable ethical choice to maybe be available to the cohorts of patients in the first, second, or subsequent tsunamis when PPEs will hopefully be available. No matter what we nurses do, we cannot make up for the systematic crippling of the health care system we did not design and do not control. Other people have created the current catastrophe – nurses are just pawns on a chessboard and the Boards of Nursing that should have protected nurses has failed us every bit as much as the accounting and finance departments
In such situations I am always guided by a sage old piece of advice:
“More than any time in history {wo}mankind faces a crossroads. One path leads to despair and utter hopelessness, the other to total extinction. Let us pray that we have the wisdom to choose correctly.”
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I did hear that the virus mutates (of course) and that you can get reinfected. So the idea of sort of building herd immunity may not work well. Also, because of the average age of nurses being 50, I worry about a lot of these same things around stress resilience and higher risks with the virus. I’ve been thinking the military needs to be brought in and trained to do the work we do; obviously, that’s complex and perhaps unrealistic and nobody can replace nurses.
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Hagten and Carey,
A work action might not be a bad idea because as I suggest – the problem is going to get worse and an early job action might just save a lot of lives down the road, including our own.
Clearly, worst potus ever is going to need a stick of dynamite to get moving.
I think at a start, 15 minutes would likely be a better time frame though. Just enough time to get some attention, not enough to lose many, if any patients. At some point though it may just be necessary to walk out completely in order to save future patients.
We will be replaced. Our replacements will be nursing students who didn’t finish their programs and haven’t taken the NCLEX, by teachers with no training, by family members of ill people, and eventually by anyone who can be conscripted.
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Pingback: Nurses’ Concerns COVID19: Update March 29, 2020 | NurseManifest
I feel the need, once again, to point out that while there is much talk of a “third wave”, and it would be easy to take credit for having suggested multiple tsunamis, this is neither a third wave, nor a real tsunami. They are still ahead.
We never got control of this virus because of an abysmal failure at the Federal level, the promotion of bogus cures, the failure to produce PPEs, failures in testing, failures in contact tracing…
We are still in our first wave, and the first tsunami is on its way as we enter flu season, rather than leaving flu season, with a exponential case growth in many previously virtually unaffected states as a result of large scale political rallies, motorcycle rallies, and the ever present Morons Without Masks 2020.
Here in Gainesville, the local college football team has 19 infected players, three infected coaches and the head coach wanted to pack the 90,000 seat stadium on Saturday with screaming fans. Sadly, this is the university I earned my BSN at… The long term consequences of the worst cheating I have seen at any college or university is taking its toll…
Fortunately, wiser heads prevailed and the game has been postponed to protect the other team and its fans.
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