The Future: The Nursing Profession

June 16, 2020 by David Nitkin | Categories: Healthcare Series Two: Futures | Tags: morale

The Issue

If nurses are the bedrock of the health-care system, then the COVID-19 epidemic has exposed both the essential character of their contributions as well as the precarious and vulnerability of their service. This blog exposes the challenges involved in a nurse’s duty of care. It also asks what do experts, inside and outside the profession, say are the prospects for enhancing their safety, role changes into the future, and prospective enhanced contribution to health care that can address all manner of natural disasters.

Nursing and COVID

The World Health Organization (WHO) report, State of the World’s Nursing, 2020, estimates there was a global shortage of 5.9 million nurses, many of whom are serving on the frontlines of the COVID-19 response. More specifically, the report authors note:

There are 27.9 million nurses around the world, an increase of 4.7 million between 2013 and 2018.
The world needs at least 6 million more nurses by 2030 primarily to address shortages in low- and middle-income countries, to achieve the global development goals and targets.
There is a need to invest in the massive acceleration of nursing education to address global needs, meet domestic demand, and respond to changing technologies and new models of integrated health and social care. This includes more nursing training in how to deal with unexpected events from moral, ethical and self-care perspectives.
There is a need to strengthen nurse leadership to ensure that nurses have an influential role in forming health policy and decision-making, and contribute to the effectiveness of health and social care systems.
Countries need to develop workforce policies that take account of the fact that the nursing workforce is still predominantly female. Laws addressing the gender pay-gap must apply to both the public sector and the private sector, and encourage flexible and manageable working hours.

Unthinkable and unsustainable top-down demands every single day are what landed us in our current nursing shortage to begin with. As global health systems creak under the strain of the coronavirus, the 2020 Future Health Index (FHI) report shows there are not enough nurses, as well as nurse and midwife training, to meet global development goals on health – even without a global pandemic. Worse, more than one out of three nurses (and doctors) has considered leaving the profession. The demands of working in health care have long been immense, often resulting in burnout. Nurses and clinicians across the world were struggling even before the pandemic. Half of young health care professionals surveyed feel they are not able to drive change within their place of work

Nursing Duty of Care

During a natural or human-made disaster, including a communicable disease outbreak, nurses have a “duty of care” to provide care using appropriate safety precautions in accordance with legislation, regulations and guidelines provided by government, regulatory bodies, employers, unions and professional associations. Professionally, they are required to do so even when doing so puts their own health and life at risk (for example, when they work in war-torn areas, places of poverty, places with poor sanitation or during a pandemic).

From the Canadian Nursing Association (CNC) Code of Ethics, we learn that when nurse professionals are in the midst of a disaster or disease outbreak, they are ethically required to:

Refer to regulations and guidelines provided by government, regulatory bodies, employers and professional associations;
Help make the fairest decisions possible about the allocation of resources;
Help set priorities in as transparent a manner as possible;
Provide safe, compassionate, competent and ethical care (including in disasters, as much as circumstances permit);
Help determine if, when and how nurses may have to decline or withdraw from care; and
Advocate for the least restrictive measures possible when a person’s individual rights must be restricted.

This CNA code outlines criteria to consider when member nurses contemplate providing that care in a disaster or communicable disease outbreak:

the significance of the risk to the person in care if the nurse does not assist;
whether the nurse’s intervention is directly relevant to preventing harm;
whether the nurse’s care will probably prevent harm; and
whether the benefit of the nurse’s intervention outweighs harms the nurse might incur and does not present more than an acceptable risk to the nurse.

There may be some circumstances in which it is acceptable for a nurse to withdraw from providing care or to refuse to provide care. “Unreasonable burden” is a concept raised in relation to the duty to provide care and withdrawing from or refusing to provide care. An unreasonable burden may exist when a nurse’s ability to provide safe care and meet professional standards of practice are compromised by unreasonable expectations, lack of resources, or ongoing threats to personal and family well-being.

A previous blog “Why Are We Failing Health-Care Workers?” (April 27, 2020) outlined various serious ways that nurses were being compromised in providing care during the first wave of this crisis. Trends and forecasts indicate that current public policy decisions being considered to deal with wave two are different but fraught with a lack of public discourse, knowledge-based choices, and questionable implications. Another EthicScan blog “The Future of Work Post-Virus” (April 9) explained what were the emerging essential new categories of care-workers.

Changing Trends in Nursing

As COVID-19 continues its deadly spread across the country, nurses on the front lines of the pandemic have been adapting their behaviour in a variety of ways, both in hospital and at home. Nearly every routine has changed—how often and how they interact with critically ill patients; how they eat their meals while on duty; and what they do before they even walk in the door at home after a shift. These new normal realities include:

Multi-stakeholder goals: Focusing on the overriding goal of helping patients who are suffering, while also protecting themselves and others, including their loved ones, from catching COVID-19.
Working safely: Fighting to ensure they have enough training in infection control and enough personal protective equipment (PPE) to ensure the safety of patients, themselves and their families.
Working smart: Trying to protect their own mental health in the face of changes at the system level like expanding hospital capacity, training staff for new (often involuntary) roles, and inviting retired health-care workers to return to duty.
Coping with teams shrinking: Before the pandemic, several doctors, nurses and respiratory therapists would rush into the room if a patient needed to be resuscitated. That was before masks, face shields, gowns, gloves and other gear needed to be preserved. Now critical care teams typically are two staff.
Multi-tasking: Instead of going into a patient’s room whenever called, nurses now plan to accomplish several tasks in a single visit. Such tasks include: providing medication, getting blood work, and repositioning a patient in their bed, as well as trying to use long extension tubes to roll IV pumps out of the room so someone doesn’t need to go in to make adjustments.
Taking infection precautions: This includes washing hands literally “hundreds of times a day”, updated training in infection control, and wiping down everything, including glasses and cellphones.

Forecast Changes in Nursing

While it is hard to make predictions in the middle of a global health issue, it is clear this unprecedented crisis has raised awareness of what else is needed to prepare nurses for future pandemics. One possible outcome is a severe contraction of both the existing and new nursing workforce. Researchers and experts offer or identify many forecasts, including the following:

(a) More nurse training needs to move beyond the physical aspects of their jobs to address and incorporate more tools on psychology, infection control, and resilience, as well as on self-care because many nurses have a tendency to keep going to the point where they can burn out and get sick.

(b) The media and public health agencies should be doing a better job specifying the various skills sets the public needs from nurses, such as placing an IV or infection ward protocols, so nurses could feel more confident in volunteering, rather than being placed into a setting simply to have another body on the front lines.

(c) Ensure that emergency room and intensive care unit nurses are appropriately financially compensated for putting their lives on the line every single day, thus providing incentive for retention as well as recruitment into disaster treatment and critical care nursing specialties.

(d) Nursing must follow suit with medicine, which both will need to focus upon monitoring and drawing implications from changing professional challenges and responses.

(e) Nurses must have access to necessary personal protective equipment (PPE), including surgical and N95 masks, shields, and hand sanitizers. This means not just having these items stocked, but within easy reach. There have been situations where, because of shortages or anticipated shortages, supplies are not kept in an accessible place or are otherwise not available. It is the employer’s duty to protect and support nurses as well as to provide necessary and sufficient protective equipment and supplies that will “maximally minimize risk” to them and other health-care providers.

(f) Apply digital training and role re-definitions to encourage more virtual (telehealth or online at-home) consultations. This will help to screen and monitor COVID-19 patients in their own homes as well as prevent any delay in critical patient care.

(g) Encourage and empower critical-care nurses to be able to monitor patients in the ICU and be able to apply remote-hub-using predictive analytics to prioritize patients based on acuity and need.

(h) Allow nurses to work in locations where and when they are most needed. Enact expedited licensure, temporary reinstatement or temporary emergency rules to bring nurses from other jurisdictions into hard-hit areas when necessary, including recently retired, semi-retired and equivalent qualification, emergency-care professionals.

(i) Open the door for uniform nurse licensure. If nurses can cross provincial and state lines and safely care for patients, without licensure restrictions or long waits for endorsements, then move to change cross-border regulations and apply consistent minimum standards.

(j) Expand the role of telehealth nurses who are vital in triaging, educating, and performing virtual assessments on patients who feel symptoms but are afraid or unable to seek in-person treatment.

(k) Train, license and hire more competent, experienced nurses with mental health and clinical specialties to satisfy the needs of survivors dealing with the effects and co-morbidities that may arise as a result of a pathological virus.

(l) The federal government should roll out education with incentive programs and placement-funding priority for workers in growing, newly-emerging essential industries–with nursing and personal-care workers in high demand. Candidates would include many people who have been laid off or lost their jobs as a result of COVID-19 closures.

(m) Disperse rapid molecular point of care tests that can produce infection test results in under an hour. This should alleviate the burden on nurses and public-health laboratories, and also expand availability and efficiency of testing many people, including those in rural and remote areas.

(n) Overhaul the long term care (LTC) system from the ground up, with regulated nurses having a duty to be involved in these health-system transformations, including discussions and planning specifically related to reform of LTC.

(o) Give nurses, especially those working in LTC facilities, mental-health counselling and supports to address the psychological trauma associated with this pandemic. LTC staffs have to watch residents with whom they have formed long-standing relationships die a difficult death, alone, without family present, at an unprecedented rate. They bear the brunt of the epidemic, caring through the greatest amount of loss, and potentially experiencing great amounts of moral distress.

(p) Develop specific, family responsibility assistance programs for front-line, essential-care nurses, including grocery shopping, child care, schools and daycare, so that nurses can meet their family obligations as well as remain part of the workforce.

Conclusion

No matter how many “thank you” pizza parties get thrown for nurses, no matter how much the media calls nurses “heroes” during or after this virus, nursing thought-leaders “in the know” will expect and rightfully demand much, much more in terms of overdue, genuine and far-reaching reform. One positive ripple effect from COVID-19 should be a complete re-evaluation of the nursing profession’s needs and its contribution to health-care delivery.