Jun 26, 2020
By Kristin Zelyck

Nursing ethics provides guidance during the pandemic crisis

cna-aiic.ca / Code of Ethics 2017Nearly every part of our nursing practice has ethical implications. We are making ethical decisions when prioritizing care and resources among patients and practising our clinical skills with competence.

The COVID-19 pandemic has created new and complicated moral dilemmas for many nurses. The author addresses some of the ethical issues that nurses are facing, and offers guidance on how to deal with them.

Takeaway messages:

  • Nursing ethics can support common goals: to provide safe, compassionate, competent, and patient-centred care.
  • Specific ethical values and responsibilities are required of nurses during the pandemic crisis.
  • Ethical awareness can prevent moral distress and promote resiliency.

The current pandemic crisis has drawn significant attention to front-line health-care workers, where nurses hold a significant majority. Coincidentally, the World Health Organization has also declared 2020 to be the International Year of the Nurse and the Midwife. As nurses, we are currently on centre stage.

At a time when our professional and ethical conduct is gaining attention, what do ethical guidelines and codes of ethics have to offer nurses? Could increased ethical awareness strengthen and guide our practice and decision-making skills?

As a profession and discipline, nursing espouses certain ethical values and guidelines that aim to provide a moral compass for our practice and professional conduct. These include principles of ethics (respect for autonomy, beneficence, non-maleficence and justice), certain ethical virtues, and the Canadian Nursing Association (CNA) Code of Ethics for Registered Nurses (2017).

In this discussion I will aim to address some of the significant ethical issues that nurses have brought forward during the COVID-19 pandemic — such as safety, increased workloads, and increased exposure to patient mortality, all of which can lead to moral distress and burnout. I will also try to demonstrate how our nursing ethics can support our nursing practice and professional conduct in this uncertain and transient health-care climate.

CNA Code of Ethics

Nearly every part of our nursing practice has ethical implications. We are making ethical decisions when prioritizing care and resources among patients and practising our clinical skills with competence.

Additionally, ethics informs our decisions to provide patients with education and information, advocate for patients, and work collaboratively with our patients and the interdisciplinary health-care team toward common goals. Therefore, we require strong ethical decision-making skills to promote safe, compassionate, competent, and patient-centred care.

The CNA Code provides guidelines that articulate specific ethical values and responsibilities to advise nursing practice. Although nurses may be aware of the Code, they may not be familiar with specific values and responsibilities defined in it.

The CNA Code outlines seven nursing values that overlap and are related to certain ethical principles such as “respect for autonomy, beneficence, non-maleficence and justice” (CNA, 2017, p. 31). To guide our practice, the Code also emphasizes key ethical virtues such as compassion, empathy, and trust. These key nursing values provide a framework to guide nurses in ethical decision-making, practice, and overall professional conduct. Furthermore, the Code promotes a reflective practice among nurses to promote growth, health, and well-being.

We require strong ethical decision-making skills to promote safe, compassionate, competent, and patient-centred care.

Values, responsibilities, and concerns

Certain ethical values and responsibilities may be more relevant and necessary during the current crisis. These include safe work environments; resource allocation; mitigating harms; practising with compassion, empathy, and trust; honouring patient dignity; maintaining privacy and confidentiality; and preserving professional conduct.

Throughout this pandemic, nurses have raised valid concerns about safety, increased workloads, and increased patient mortality, all of which can lead to moral distress and burnout. Nurses have also shared their pandemic experiences openly using various media platforms. Increasing ethical concerns, coupled with growing public attention, mandate a heightened ethical awareness among nurses.

In my own practice setting, nurses have raised concerns about patient and personal safety. One of the main concerns is the need for and lack of appropriate personal protective equipment (PPE) (Harris, 2020). The CNA Code speaks directly to this issue: “During a natural … disaster, including a communicable disease outbreak, nurses provide care using appropriate safety precautions in accordance with legislation, regulations and guidelines provided by government, regulatory bodies, employers, unions and professional associations” (CNA, 2017, p. 9). The Code further encourages nurses to “question, intervene, report and address unsafe, non-compassionate, unethical or incompetent practice or conditions that interfere with their ability to provide safe, compassionate, competent and ethical care” (p. 8).

These ethical guidelines extend beyond PPE concerns to nursing workloads and the resources required to provide competent care while maintaining our best practice standards even during a crisis.

Public attention and trust

Nurses are also using various media platforms, including social media, to share their personal experiences as front-line workers during the pandemic. I believe this represents our need to debrief and make sense of our experiences. Inevitably, these reflections draw the attention of the public and reflect on the whole nursing profession.

When we identify ourselves as nurses, we need to be mindful of our values and ethical responsibilities. Our conduct should maintain and nurture public trust in the nursing profession and promote our common nursing goals: to “provide safe, compassionate, competent and ethical care” (CNA, 2017, p. 8).

Some questions to ask ourselves before sharing our nursing experiences publicly may include: How does this story represent the nursing profession? Does the story compromise patient or co-worker confidentiality? Does it honour the dignity of the patients I care for? Am I reflecting the common goals of nursing and health care?

Reflection and self-awareness

Our need to reflect and debrief is supported by the CNA Code, which encourages nurses to nurture a reflective practice and a sense of self-awareness. We can use reflection to learn from our experiences, gain wisdom and understanding, and ultimately, move our practice forward.

Throughout this pandemic, nurses have raised valid concerns about safety, increased workloads, and increased patient mortality.

Reflection may also increase our ethical awareness: our ability to recognize ethical issues as they arise, and respond appropriately (Milliken, 2018). Therefore, the sharing of these pandemic experiences is necessary for our personal growth, yet it also reflects on our nursing profession collectively.

Frequently, these shared experiences reflect conflict and distress, even fear of providing nursing care during the pandemic. When we are unable to attain our goal of providing safe, ethical, and competent care, the potential for moral distress increases.

Moral distress

Most nurses will experience some level of moral distress during their careers. Moral distress occurs when nurses know what they should do, but circumstances make it difficult to take the appropriate course of action (CNA, 2017). Causes of moral distress include excessive workloads and challenges with end-of-life decision-making (Burston & Tuckett, 2013).

Since the pandemic outbreak, nurses have experienced increasing workloads and responsibilities, increased patient mortality, safety issues, and scarce resources. Therefore, we are more likely to experience moral distress during this crisis. Moral distress contributes to burnout, lack of empathy, and increased job dissatisfaction. It also directly affects patient care by resulting in a reduced quality of care and negatively affecting patient outcomes (Burston & Tuckett, 2013; Rodney, 2017).

Ultimately, moral distress counteracts our nursing goals to provide safe, competent, and compassionate care. However, identifying and addressing moral distress and ethical issues can also motivate us to reflect and be innovative, resulting in resilience and increased ethical awareness (CNA, 2017). Therefore, it is better to acknowledge these feelings and stressors within our profession so that they can be addressed collectively and not only harboured individually.

Challenges ahead

As nurses, we are now being faced with significant challenges that include protection of our profession, duty to our patients, and maintaining our own health and safety. Being aware of our ethical guidelines and common values can give us courage and provide direction to address the ethical issues we encounter in this crisis.

I do not wish to leave you feeling discouraged. Instead, my intent is to encourage an increase in ethical awareness among nurses. As an intensive care nurse with an interest in ethics, I have found that ethical awareness has enriched and clarified the goals of my own nursing practice. Health care is extremely value laden, especially now, and I sincerely believe that upholding our ethical guidelines is paramount during the pandemic — for the public whom we serve, and for our profession as a whole.

Hopefully, at the end of this, we will be able to reflect and learn from our experiences. We will inevitably learn things about ourselves personally and professionally, and about our abilities to respond to a worldwide crisis. If we do our best to preserve our common goals to provide safe, compassionate, competent, and ethical care, we will come out stronger as a nursing profession.

Our ethical guidelines and values can assist us, not burden us, during this crisis. A heightened sense of ethical awareness is required to identify ethical issues so that we can prevent moral distress and instead, promote resilience among nurses.

Even though the current health-care climate is challenging and uncertain, our nursing ethics remains steadfast to guide our practice through this pandemic.

References

Burston, A. S., & Tuckett, A. G. (2013). Moral distress in nursing: Contributing factors, outcomes and interventions. Nursing Ethics, 20(3): 312–324.

Canadian Nurses Association (CNA). (2017). Code of ethics for registered nurses.

Harris, K. (2020, April 7). Doctors, nurses demand government fill “unacceptable” gaps in protective gear on front lines. CBC News.

Milliken, A. (2018). Ethical awareness: What it is and why it matters. The Online Journal of Issues in Nursing, 23(1).

Rodney, P. (2017). What we know about moral distress. American Journal of Nursing, 117(2): S7–S10. doi:10.1097/01.NAJ.0000512204.85973.04

Kristin Zelyck, BScN, RN, M Bioethics, has been a registered nurse for 18 years with most of her clinical experience in intensive care. Recently, she completed her Masters in Bioethics. Additionally, she works as a sessional instructor for the Faculty of Nursing at the University of Alberta. One of her primary interests includes promoting ethical awareness among nurses and nursing students to enrich and strengthen nursing practice.

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