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Leadership beyond the pandemic and care delivery innovations is supported by an unrestricted grant from the Johnson and Johnson foundation in partnership with the Johnson and Johnson center for health worker innovation.  

Bill Klaproth (Host): It is without doubt, we are living and experiencing one of the greatest healthcare tragedies of all time. Ethical tensions abound at the forefront of healthcare and nurse leaders are often caught in the cross hairs of navigating multiple issues at the front lines of care. The literature provides insight into the many facets of nursing where the professional registered nurse must make ethical determinations and decisions about the care he or she provides to the patient.

Although these ethical tensions abound, not much evidence abounds surrounding the ethical concerns and considerations that nurse leaders face as they lead their teams from day to day. Not withstanding, an all inclusive list of these concerns, our guest today, Dr. Stuart Downs will focus on three of the most relevant and most pressing concerns facing nurse leaders as they navigate the pandemic and beyond; staffing, patient family centered care and moral distress. As we discuss Ethical Tension: Nursing and High Stakes Care with Dr. Stuart Downs.

this is leadership beyond the pandemic care delivery innovations. I'm bill clapper, auth. Dr. Downs. It is always great to talk with you. Thank you so much for your time on such an important topic. So as we consider the ethical tensions facing nurses, and for the sake of this podcast, nurse leaders.

You maintain that staffing is one of the most pressing concerns facing nurse leaders. Can you tell us more?

Dr. Stuart Downs (Guest): Thanks again for having me today. This is part two for us. Let me say at the outset, my intent over the next few minutes in our time together today is just to get nurse leaders sort of thinking about the ethical tensions that you just mentioned, and certainly staffing is one of those. It's obviously no secret that the country's in the midst of a severe staffing shortage right now and as a result of the COVID pandemic primarily. Our staffing challenges were clearly prevalent prior to the pandemic, but our staff concerns have certainly heightened over the last 12 months. Any nurse leader could probably list for you several ethical issues that have arisen in their minds and in their daily activities and daily work related to staffing.

But one of the first that comes to my mind is a scenario that I know many nurse leaders were confronted with in the beginning of the pandemic and even now probably, ongoing. I recently had a nurse leader approach me with a challenge he was struggling with about sharing the risks brought about by our staffing conundrums and as a nurse leader, we certainly have the responsibility of making decisions about who gets those patient assignments, if you will. But this particular leader was struggling with attention of being fair to his team on assignments, but also being cognizant of the fact that he didn't want to expose all of his staff to COVID positive patients or what we call persons under investigation, those patients, as that would increase the risk to more staff and potentially even increase the number of staff who would not be able to come to work because they tested COVID positive. So, he was confronted with the challenges of and I would probably categorize these into three buckets. One, do all COVID positive patients or those awaiting a tests go to the same group of nurses or do I split those assignments? Ethically, do certain nurses get the same patient assignment every time they come to work? That's certainly very daunting and very hard for any nurse to be in that line of duty day in and day out. And then I would also say do I spread the COVID patient population to different nurses so as to make a feeble attempt if you will, to mitigate burnout and exhaustion of my team? There's clearly an ethical tension there, in making what I would call these risks or risk sharing decisions on behalf of the nurse leader, as our intent as nurse leaders is to be just and equitable in making patient assignments, but at the same time balancing burnout and team member morale.

Host: Yeah, that makes sense. And it's easy to see the dilemma there. So, let me ask you this. When it comes to staffing concerns and assignments as you were just talking about, how do contract RNs factor into all of these equations?

Dr. Downs: That's a great question because I would tell you that the utilization of contract RNs even in my own organization, has been extreme over the last several months. So, it is definitely a second related concern as we continue to discuss staffing challenges. It's very clear that incentives for contract nurses are greater than those of the employed RN. They make a higher hourly wage. They receive in many times, completion bonuses and other incentives. And sometimes they do get all the COVID positive patients, the hardest and most acutely patient assignments because they are quote unquote the agency nurse. So, in essence I would say many times they get dumped on. And while these nurses may expect it because they signed up for this, I would ask the question, is it right? Is it ethical? Often the nurse leader is the person who's left to make this clinical decision. And a sense of injustice sort of arises in my mind and probably in the minds of many nurse leaders, as they utilize contract nurses to ensure the provision of care on a daily basis. So, ethically should I as a nurse, should I give the agency nurse the worst assignment? Should I give them more patients than they employed nurse? All of the COVID positive patients, just because they make more money? After all they too are what I would say vital constituents of the nursing profession that I would argue without whom, we cannot survive and would not have survived thus far in navigating the pandemic. So, as I say all of this to you, I stop and pause for a moment.

And I think how do I as a nurse leader process all of this? If there was ever an ethical tension with which nurse leaders are faced today, it is certainly related to staffing. One other item that I would like to point out Bill if I could around staffing is the fact that many professional nurses for reasons that are all too familiar, have also left their permanent posts to work for agencies because the financial tensions that are prevalent across the country today. Many are working full-time and overtime hours to compensate maybe for the financial losses related to a spouse or a significant other. Many RNs have transitioned to agency and contract work because their spouse or significant other was temporarily relocated to a different area of the country. The list goes on and on. The fact is, we are in the midst of a recession. Nurses may be migrating to contract work just because they need the money. So, how am I as a nurse leader, fair and equitable in mixing agency nurses with my permanent team, when I'm forced to use contract labor to meet the staffing demands? I'd also ask the question, are we sacrificing quality care with the high utilization of contract labor? Very fair and very valid questions to ask ourselves as nurse leaders. If the contract nurse has all of the most highly acute patients who suffers? At what point is too many patients? Standardized staffing models had been in place and measured and there are mounds of research around safe staffing, all of which provide rich evidence around RN to patient ratios. But these staffing models were designed for use under normal conditions. And we all know that things are just not quite normal right now.

So, again as I would attempt to summarize this, the ethical tension that the nurse leader has to balance you know, really is the number and acuity of the patients assigned versus quality outcomes. And while this tension comes into play especially with regards to our contract workers, we're at the point where it is also impacting employee team members. We don't know the exact tipping point if you will, or quality slips in a patient assignment or maybe we do. But the stakes are clearly high when patient outcomes weigh in the balance as to the decisions that the nurse leader is forced to make on a daily basis. There's also a safety element that I've just discussed over the last little bit related to the nurse leader in balancing staffing assignments based on the quality of care they would provide versus the way that is just, fair and equitable to the nursing staff. Clearly an ethical tension that rests on the shoulders of the nurse leader.

Host: Yeah. There's certainly is a lot to discuss when it comes to this. And you certainly laid out all of the issues for us, Dr. Downs. One of the other most pressing concerns, which you note facing nurse leaders, is patient family centered care. Now we certainly have seen in the pandemic, how the lack of visitation has negatively affected the patient and the family. So, let's talk about visiting hours and patient family centered care and how that is a pressing concern for nurse leaders. Tell us about that.

Dr. Downs: Yeah, that's another great question you know, because that's been clearly a topic of focus and a hardship for many, not only nurse leaders, but patients and their families. Visiting hours have long been a phenomenon of research and Dr. Susan Grant has been a front runner when it comes to patient family centered care models. There's evidence out there that supports open visitation on critical care units. Patient family centered care models also support open visitation in other service lines as well, not just in the ICU space. There's a lot of evidence related to fall reduction and geriatric care support from the presence of family members as participants in that patient's care. Again, all in the quest of optimizing the safety of that patient and an optimal outcome. I can go on and on there. But the lack of visitation during the pandemic has had and I would argue will have untold effects on patient care outcomes probably for years to come. The lack of hospital visitation and even visitation in other care settings has definitely exacerbated the inequalities that already existed pre-pandemic.

But here's where the ethical tension arises for that nurse leader, when it comes to supporting patient family centered care models. We've declared over the course of this pandemic that to mitigate the spread of the virus, visitation must cease for the safety of the visitor, for the safety of the patient, for the safety of the team members providing care to that patient. At best in some scenarios we've limited visitation but still allowed it on case by case basis. But nurse leaders have been faced with multiple requests to make exceptions to the pandemic visitation rules. And the fact is quote unquote we know people who know people and the nurse leader is asked to temporarily ignore that policy that's been put in place from a safety perspective and bend the rules. So, I'd ask the question, is that right? It the right thing to do? Let me give you a scenario, Bill if I could that kind of puts this into perspective. The nurse leader receives a call from administration asking for an exception so that a VIP in the community could come visit with a loved one who's been hospitalized in the intensive care unit. The nurse leader would probably say hey administrator, is the patient at end of life? And they probably already know the answer to that question but they're hoping that is going to evoke a weak hand to dissuade the request. So, the response acknowledges the patient. The response to the nurse leader, maybe acknowledges that the patient is not at end of life and that they're probably maybe even stable in the ICU but the request for an exception still remains. So, who's caught in the middle? The nurse leader. So, the nurse leader feels that the tension is high because I gotta make a decision that one, I know is not right, two, I know it's not the right thing to do because I'm going to get probably criticized by my staff. They're going to ask lots of questions about this. But under pressure, I feel the need to concede to this request. How is this now going to be perceived by my staff? What are my other colleagues going to think of me because I made this exception or was forced to make this exception and in the heart and mind of that nurse leader, what is his or her perception of administration now given that this leader was put in this particular predicament. Often things that we have to consider, but these are real life stories and real life scenarios. On a broader scale, strict visitation policies were put into place because we support the science that declares open visitation and the congregating of groups will probably potentially maybe even have a negative direct impact on the spread of the virus both to our staff but also to our broader community.

So, these strict visitation policies now have an enormous impact on patient care outcomes and the team members caring for these patients. Patient family centered care models, family members and friends are often solicited to help ensure the safety of patients and be an active participant in their care. IT's a partnership between the caregiver and the family member and or their friends. Care across this country has occurred in a familial environment for years now only to be restricted to mitigate the spread of the virus. Consider an intensive care unit for example. A colleague of mine in my system recently wrote and I'd like to quote it for you because it has such a big impact. it made a big impact on me Bill. He said as the greatest tragedy of our time is unfolding before our eyes, in the ICU we see another tragic consequence of the pandemic and that is the separation of families. This separation exacts a toll on both parties. In nearly two decades of being an intensivist, the realization of the critical importance of this personal touch in the healing process was never more evident to me. While Skyping with families is crucial in creating confidence and trust, there's no substitute for personal touch. Lastly, he goes on to say that for some families, the last true moment of togetherness with the patient may well have been just before the patient is taken to the hospital. The brief moment before a permanent separation doesn't count as he has been told by many mourning family members. Yet our staff members, the true heroes of this tragedy, do step in attempting to fill this void. And in the process, often transfer another emotional burden to their already laydened shoulders, even as they see an unrelenting illness sap the life out of someone who they previously would have seen routinely survive such an illness. It's pretty powerful. We use iPads for Skype, for FaceTime but I'm going to tell you Bill it's not the same especially at the end of life. So, still this tension is at place in the hearts and minds of that nurse leader, as they have to make decisions in balancing safety of the team and the care needs of the patient. Oftentimes this tension puts the nurse leader in a confrontational role. For example, does one only one person at a time visit? Is there only one visitor per day? And does that have to be the same person? So, these are real life things that we as nurse leaders have had to deal with. And we're left to manage this tension related to the policies of the organization and doing what we know is the right thing to do for the patient but also ensuring an optimal patient care outcome. We, as nurse leaders are committed to our values. But how do we balance them in the face of patient family centered care? Pretty tough.

Host: It is tough. Yeah. And you have articulated great insight into these important areas that are clearly high stakes when it comes to tensions that nurse leaders must navigate on a daily basis as you say, it's not easy at all. And there is a great amount of tension and pressure. So, what effects does having to navigate these high stakes challenges every single day have on nurse leaders?

Dr. Downs: Another great question. I'd say, as I think about this, we've all heard about the stress and burnout that the pandemic has exacerbated for the healthcare industry. What we haven't really done though, is look at the moral component of distress by way of taking a closer look at the moral distress of our team members including our nurse leaders of what they're experiencing as a result of having to make decisions that yield great tension in our day-to-day routines. Imagine the nurse leader you know, who we've empowered to do the right thing, who simply can't because of all the adversity that they face on a day-to-day basis. I've given several examples already, over the course of this podcast so far, but you know here's another example nurse leaders know they support the turning of patients every two hours to prevent skin breakdown and prevent pressure injury for our patients, yet they can't enforce this evidence-based nursing practice because they just don't have enough staff to do the right thing for patient care. There's not enough staff to do what's right. So, then it's not just the nurse leader, but also the nursing staff now experiencing the effects of this moral distress. So, there are also times when the patient and their family members request things of the nurse, can you do this for me. Can you do that for me? But they simply can't do it because they don't have time or they don't have the bandwidth. Their staffing resources that once have to pull to do other tasks or other job duties or to other units that were short-staffed. So, many nurses are not burning out, I would argue. They're already burnt out. They just can't code the patient again. They just can't continue giving aggressive treatments at the request of a family member while watching the patients suffer through treatment that they don't think is in the best interest of the patient.

In the current context of the pandemic, they just can't handle the fear, the trepidation and distress of balancing their professional role as a registered nurse and the values of that nurse with the safety and wellbeing of their own families at home. They gotta somehow or another lead through it, they have to nurse through it. They have to keep handling all of these situations and more like these that I just mentioned, every single day. All of this moral distress not only impacts the wellbeing, Bill of the nurse leader and the nursing staff, it impacts patient care. Let's just be honest. The problems that are creating the moral distress, impact patient care for sure. But the exhaustion, the anger, the frustration, moral distress causes our nursing teams impacts the work climate on the clinical floors way that they care for their patients and their families. Moral distress harms not just the individual experiencing it, it impacts our ability to hold our values or hold true to our values and the mission. It ends up harming the whole system. Nurse leaders just don't have the resources they need I would say, to support the work that they're doing on a daily basis.

They don't have the resources to help them make decisions. And the decisions that they have to make for their teams and for patients. When I speak of resources, I'm talking about resources to support them in moments of moral distress specifically, clinical ethics resources. Nurse leaders should feel empowered and have at their ready the call a call to ethics experts to help them gain the expertise they need to lead in these moral distress situations. But oftentimes either they don't have the resource or they don't feel empowered to do so Accessibility to clinical ethics experts quite simply may not even be available to the nurse leaders. And so the nurse leader could try to turn to the literature in times like this, but I'll tell you after searching the literature and looking for evidence, it's lacking as well. So the ethical issues experienced by nurse leaders and how the COVID-19 pandemic has affected the issues they face, have not been systematically surveyed or addressed. And there's next to no educational tools to help foster ethical development in nurse leaders. So, they make some of the highest stake ethical decisions. And the literature is practically absent I would say on ethical help for nurse leaders and their specific challenges and roles.

Host: Well it is easy to see the stress that nurses and nurse leaders are under and the phrase that you use, moral distress, really explains it. And you also said they are not burning out, they are already burned out. So, thank you for covering these important and pressing moral and ethical dilemmas that nurses and nurse leaders face in managing COVID patients. So, when dealing with these ethical dilemmas in the context of healthcare crisis, what ethical principles should guide nurses and nurse leaders behavior and choices?

Dr. Downs: Drawing from the discussion so far that you and I have had over the last few minutes, there are definitely some ethical principles that play a crucial role in decision-making and behavior in the particular context of a crisis. One of the biggest I would say, is justice. Nurse leaders want to be fair. They want to be fair in scheduling and fair to the patients. They want to be fair to their teams. They want to be fair in how limited resources such as nursing staff are used in their units. And another big one is non-maleficence. There are so many constraints and barriers to providing adequate care for patients during a crisis and giving the constraints, not doing harm as much as possible becomes increasingly important. That's a nurse's mantra you know, first do no harm. The same can be said for nursing staff, that not doing harm to their nursing staff whenever possible is definitely a principle nurse leaders have in mind as they try to navigate this pandemic. There are many more principles I could bring up but fidelity is also another one. One that I think is especially unique and highlighted during times of crises. Nurses and nurse leaders alike are leaning on fidelity to their profession. They're loyal nurses are very loyal to their patients, their communities and the obligations that they have as a nurse as they face this pandemic and continue to maneuver.

Host: So, Dr. Downs, you just talked about constraints to not doing harm and throughout our conversation, you've spoken of the ways these principles conflict with each other and cause tensions. So, what strategies can be deployed to strengthen leaders ethical responsibilities and their ability to make ethical decisions in such complex situations?

Dr. Downs: Glad you asked that. And that's where I want to help. I think though to your point about strategies, before we can first formulate strategies to strengthen the nurse leaders ethical responsibilities, we need to hear directly from them. My insight is limited over my leadership, over the course of the pandemic, I have a very narrow focus in one area, one micro chasm if you will, of the country not at the macro level. So, during the pandemic, and in our previous work in nurse leader ethical development, we have realized that there is an extensive knowledge gap in understanding these ethical issues that nurse leaders have faced, continue to face and what the associated strategic priorities would be that we could deploy so that we could better prepare them; better equip them to face these ethical challenges. Our goal now is to complete a national survey of nurse leaders, to look at the types of ethical issues they experience on a day-to-day basis. What is it? Let's ask them. Let's hear directly from them. And honestly I don't think we can really give a good solid strategy at this point until we conduct this research. Educational tools, literature, ethics services, et cetera; all of that is so lacking for the nurse leader that without more contributed to this area, we don't have a lot of practical and feasible things to point them to for guidance and help them right this second. So we're proposing as I mentioned, a survey a national survey and survey questionnaire that we proposed for this research will question the nurse leaders regarding the ethical issues that they've encountered as well as the frequency in which they've encountered those ethical issues over the last several months. In addition to gaining information on how frequently and what kinds of ethical issues are seen by nurse leaders, we then plan to ask for other pertinent facts, such as the nurse leaders access to ethical resources. And how the COVID-19 pandemic has impacted their leadership responses around these ethical tensions. So given the high stake challenges, nurse leaders face, that we've been talking about for the last several minutes, this national level data, is absolutely essential to effectively fostering nurse leader ethical development. And to preparing nurse leaders for the many challenges, they must face, as we continue to navigate the present pandemic. And I would also say even into the future.

Host: Absolutely. And that's why this discussion is so important. So, thank you for spending some time with us today, Dr. Downs, to talk about these pressing concerns facing nurse leaders as you talked about staffing, patient family centered care and moral distress. Really interesting and informative. And I'm so happy that you're here to discuss these issues with us. Dr. Downs, as always. Thank you so much for your time.

Dr. Downs: Thank you Bill. Great being with you today. I much appreciate it.

And that's Dr. Stuart downs. And for more information, please visit a O N l.org. And once again, this podcast is supported by an unrestricted grant from the Johnson and Johnson foundation in partnership with the Johnson and Johnson center for health worker innovation. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is leadership beyond the pandemic care delivery innovations. Thanks for listening.