We are in unprecedented times—uncertainty and fear are ever present and nurses are being called to serve others in ways that challenge our appraisal of benefit to our patients and risk to our families’ health and well-being. Many of us are experiencing varying degrees of moral distress and moral outrage arising from the gaps between what we ought to be doing and what we are actually doing under these adverse conditions. It can feel as if it is impossible to do ‘the right thing.’
What can we do to remain whole in the midst of the COVID-19 crisis? How can we accept what seems unacceptable?
Instead of using precious energy in unproductive ways, we can focus on the things that are within our control for meeting the demands of the situation with integrity.
Recognize your moral distress.
It’s easy to get swept away with fear. When fear takes over, we can become paralyzed—unable to think clearly or to act in accordance with our values. One way to confront our fear is to recognize and name the source of the angst.
What is causing your distress? Notice tension anywhere in your body. Accept whatever it is you find. What are the conflicting obligations you are confronting? Try to name the conflict.
You may realize that your core value in the current situation is to not cause harm to your patients. You may say to yourself, I have an obligation to care for my patients, and I am worried that because there are no beds/equipment available, I may be causing more harm than good to my patients. Such concerns are justified and rational. But because of the conditions and limitations imposed by the pandemic, our individual and collective perspectives will need to shift and expand in ways we are unfamiliar with.
Shift your perspective.
It is possible to accept the reality of what has happened without abandoning what matters most. You know your patient needs more; you advocate on their behalf in order to meet their needs, but at the same time you expand your focus to encompass the needs of the larger population in need of medical and nursing care. Understandably, this shift in focus is a source of distress. It means letting go of the expectation that we can continue to operate as usual despite the shortages of resources.
Sacrifices have to be made with full awareness: we may find that we are being asked to enlarge our individual patient focus to a population focus to produce the greatest good for the greatest number of people. Such a reality may ignite feelings of anger, sadness, or despair.
But we are not being asked to abandon our values; rather, we are called to recalibrate our expectations, and perhaps to arrive at a new understanding of integrity within the current constraints. We may not be able to change the reality of the pandemic, but we can minimize harm and promote as much good as we can.
Stay focused on why you are a nurse.
It’s easy to get distracted by mounting issues related to the pandemic and the uncertainty about how it will unfold. It may help to reconnect to why you are doing this work. Such awareness can anchor us, motivate us, and remind us of our commitment to serve the health of others. Like us, patients and families are fearful and under stress.
Difficult choices will have to be made. Stay focused on your core work and what you can control—the patient in front of you is where your attention needs to be in this moment. You have an opportunity to bring calm and stability rather than bringing more fear and anxiety. Your calm presence, competence and caring, your critical reasoning, your empathy are needed now more than ever.
How you carry yourself resonates with others around you. Fear is contagious, but so is courage and compassion. Taking a deep breath before entering a patient’s room and recalling why you are doing this work can help to reset your nervous system so that whatever time is available can be used for the highest good. Notice the moments during the day when you are in sync with your values. Pause to honor your efforts and remind yourself that you are doing the best you can in a very difficult situation.
Remember you are not alone.
In the context of social distancing and expanded infection control measures, it’s easy to feel isolated and alone. You can bet that others are experiencing the same challenges and distress that you are. As nurses and human beings, we are “hardwired” for connection.
In response to social distancing, create new rituals connect with your colleagues, friends, and family. Schedule a virtual team huddle at intervals during the day that includes a pause to honor the work you are doing, notice the moments of compassion and grace that arise in the workday, and offer kindness and encouragement to each other.
Ask for support—this is not the time to be a martyr; it’s an all-hands-on-deck situation. Use resources such as chaplains, peer-to-peer support teams, or ethics consultants virtually or in person to help process the experiences that will inevitably arise.
Intensify connections with mentors, leaders, friends, and family you rely on when challenges arise. And join the national conversation about your experience as a nurse in this pandemic. (For example, a web-based platform has been created to provide a protected space for nurses to exchange ideas, emotions, and best practices with each other until the COVID-19 pandemic has passed: https://nurses.wikiwisdomforum.com/.)
‘Stewards of our own well-being and integrity.’
This is likely to not be a sprint but a marathon. It is a time when we must be exquisite stewards of all our resources, including our own well-being and integrity. This is not optional; it is a moral mandate of our profession. Remember that you are already resilient; you wouldn’t be a nurse if you weren’t—tap into the inner resources that have supported you in the past. There is no better profession than ours to manage this crisis. Through our wisdom and courage, we will stand together to serve. I offer you these phrases as a reflection to begin and end each day:
Strengthen me to see the wonder of my work through the eyes of those I serve.
Enable me to serve others with respect, compassion, courage, and love.
Let my work be a light to those in need and a beacon of hope for those who despair,Author Unknown
By Cynda Hylton Rushton, PhD, RN, FAAN, Anne and George L. Bunting Professor of Clinical Ethics, Nursing, and Pediatrics, Johns Hopkins University, Berman Institute of Bioethics and School of Nursing
A response from the author of this post: Evelyn Abudulai‘s comment points out many aspects of the current COVID-19 pandemic which predictably leave nurses feeling unsupported, unprotected and their lives expendable. The systemic failures of our government and healthcare systems to anticipate and prepare for this crisis are starkly evident. As she points out, this leaves nurses in the position to provide care under conditions that put them, their families and colleagues at significant risk. While it is true that nurses and other healthcare professionals are committed to serving under at times extreme circumstances, this does not mean that there are no limitations to those expectations or that they are absolute. The moral mandate created by our professional code of ethics (https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/ ), clearly outlines the duty of nurses to preserve their own well-being and integrity. Provision 5 of the ANA Code of Ethics states that nurses owe the same duties to self as to others including protecting their own health, safety and well-being so that their basic humanity is honored and they can provide the care needed by those we serve. Embedded in this, is the requirement to assess their own risks of providing care under extreme circumstances alongside their professional obligations. Each person will need to determine their own threshold for continuing to provide care. To amplify this point, the ANA recently developed guidance for nurses who are struggling to determine their balance of obligations.
https://www.nursingworld.org/~495c6c/globalassets/practiceandpolicy/work-environment/health–safety/coronavirus/nurses-ethics-and-the-response-to-the-covid-19-pandemic.pdf
In the broader context we must use our voices in constructive and respectful dialogue to bring the systemic gaps in our national, state and local healthcare systems into stark focus. This will require all of us to leverage our moral outrage and anger to create constructive and sustainable solutions. In the moment, we must stand in solidarity to support each nurse, regardless of their decisions in the current situation. Respecting each other’s choices will allow us to arrive at the other side of this epidemic with workforce able to meet the challenges ahead.
Dr. Rushton et al, inspirational words granted but not realistic and certainly errorneously situates nurses as superhuman. Beyond any doubt, nurses chose to voluntarily invest in acquiring the knowledge and skills they have with the sole purpose of advancing the cause of our common humanity. Their caring and compassionate nature should not render them expendable. Currently, thousands of nurses go to work scared each day, scared for their lives and by extension the lives of their family. Their fear has nothing to do with the prospect of providing care to Covid-19 patients (for afterall from nursing’s inception, nurses have been providing care to patients with all manner of contagions) but has everything to do with being expected to provide care with little or no protection! And by the way, as an instinctive mammalian survival mechanism, fear can lead to paralysis yes (especially if it borders on panic), but it can also galvanize people into action. You write about ‘integrity,’ ‘resilience’, being “hardwired”, nurses’ non-optional ‘moral mandate’! Their code of ethics does not require them to be self-sacrificial lambs (pun not intended during Easter) especially given the inexcusable lack of preparedness and gross betrayal by governments and health care systems in toto despite years of alarm bells sounding, and most recently warnings that this pandemic was imminent. If that was not enough, the evolving situation in Wuhan should have been instructional. We live in a global village, viruses know no borders. As is typical of most governments and healthcare systems which tend to be reactive rather than proactive, these warnings were not heeded. Now we must scramble to battle and transcend this unprecedented global existential crisis with little or no ammunition. In the midst of it, instead of anticipating and acting proactively in the best possible way to stem transmission, we are still reacting and grounding infection control guidelines on rapidly evolving information and daily developments. Consequently, the measures/precautions we are taking each day should have been measures taken yesterday or a week ago. So the virus stays one step ahead of its host. In a pandemic, at whatever cost, we err on the side of caution to save the most lives.
To compound it all HCPs are expected to shoulder the brunt of this unprecedented (certainly in contemporary times) herculean crisis and sacrifice their lives. ‘Duty to care’ can only be upheld when one is accorded the appropriate tools, PPEs inclusive with which to undertake one’s work safely (for the sakes of both HCPs and care recipients) efficiently and effectively to achieve the best outcomes. Morally and ethically, nurses have a duty of life first to themselves. For all the compassion, empathy, caring, integrity and whatever else we can pile on, nurses and other HCPs are no good to anyone if they are sick or deceased. While nursing continues to liken itself to the military through the use of metaphorical terms such as ‘frontline’ and ‘trenches’, the fact of the matter is they are not the military owing unquestionable allegiance. They are professional knowledge workers with the ability and obligation to critically appraise situations and processes that directly impact their ability to perform their work and to interrogate them whenever necessary. But, assuming that analogy holds, what nation sends its army to battle without arms or artillery? Nurses did not sign on any dotted line to walk in a field of landmines. Nurses are human beings with the same fundamental basic human rights and common human aspirations. They are mothers, fathers, sons, daughters, wives, husbands, etc. and have families who depend on them. This notwithstanding, true to their unwavering passion and sense of dedication (emanating from free will, not ‘ordered’) nurses go out daily to care for their patients and to look out for their best interests. While they are doing that, who is looking out for their best interests? Nurses do not need glorification, they need protection and the same value accorded to all human lives. That will be reward enough.
Let us not write pieces and cite quotations that insensitively fail to acknowledge the justified fears nurses have and should have, that inadvertently evoke guilt feelings, or shame them into working without adequate protection. Instead let us use the power of our pens and raised voices to raise consciousness about the enormity of the task ahead and the absolute paramount need for our HCPs to be well-equipped, supported and protected if humankind is to win this war. If we can acknowledge the fears of people who do not have to expose themselves to equivalent risks, how can we cavalierly dismiss or belittle the fears nurses have? Are they lesser human beings? Yes, at the core of nursing practice are the emancipatory principles of respect, empathy, compassion, commitment to social justice and equity. Nurses are not immune to or precluded from the benefits of these principles and values. They are a part of the human race. I respectfully invite you to move out of the sanctuary and safety of your offices or shelter to the bedside. Walk a day in the shoes of these nurses who despite their grave fears, commit themselves, and work tirelessly day in and out to provide direct care in these dangerous times. Guaranteed, it will be insightful. When we emerge out of this darkness, nurses will do well to become more than ever and with earnest, politically active and engaged. Occupying more seats at the policy table is the only way nurses can influence policy decision-making that impacts their work environment and ensure political and beaureucratic accountability from the powers that be.
so very well said. The times are so challenging, and yet we must rise to the occasion. Peace and Blessings to all of my fellow nurses.