On Oct. 16, when a nurse from a Texas hospital took to the national media to decry unsafe conditions for workers exposed to the Ebola virus, the echoes carried all the way to Baltimore, to Johns Hopkins University ethics professor Cynda Hylton Rushton, and, she hopes, to the student nurses making their way toward tomorrow’s front lines.
There was what Dallas nurse Briana Aguirre asserted: that nurses had been left unprotected and unprepared to fulfill an ethical mandate to treat any patient, no matter the diagnosis.
But perhaps most important was that Aguirre had the courage to “speak up and speak out,” says Rushton, the Anne and George L. Bunting professor of clinical ethics at Johns Hopkins. It’s an obligation that can be difficult to embrace amid a swirl of technological demands, understaffing, an aging population with more complex chronic conditions and pressures to make care more efficient and less costly.
That it took Ebola’s arrival in the United States to trigger such a moment is not lost on Rushton, founding member and core faculty of the Johns Hopkins Berman Institute of Bioethics. Nor was it a big surprise.
How to deal with the fear, finger-pointing and rush to judgment that all featured so prominently in Texas already had been put forward for discussion as Rushton gathered a team of national nurse leaders in Baltimore in August for the first-of-its-kind National Nursing Ethics Summit. The idea was to debate these and other aspects of nursing ethics ahead of a push by the American Nurses Association to revisit and clarify its own Code of Ethics, a framework for the conscientious caregiver.
“For many reasons, the environments in which nurses work are changing rapidly, yet one core principle holds constant: nurses’ desire to serve their patients, families and communities while fulfilling nursing values,” says the resulting Blueprint for 21st Century Nursing Ethics.
The blueprint seeks “organizational arrangements and work designs that enhance the practice of nursing and create for the next generation the chance to fulfill their desire to have meaningful careers in service to others.”
The report is a roadmap, and Rushton admits that there are miles to go before health care systems (and nurses) can sleep.
What Keeps Nurses Up at Night?
Without fail, nurses join the profession to help heal the sick or injured. But ethical dilemmas on the job can create a chasm between nurse and patient, affect the level of care and even drive frustrated caregivers from the field or to throw up their hands and “go along to get along.”
These dilemmas can be as seemingly mundane as bean counting and as fraught as risking peer scorn and employment status by speaking up when patient care doesn’t measure up.
There are disagreements with the course of care, pain management, a sharp increase in dementia cases, decisions to end life, respectfully caring for those with diverse backgrounds and rituals, workplace hierarchies or red tape, worker shortages, legal uncertainty, privacy rules and fatigue.
Or perhaps, in the case of Ebola, there is the notion of performing herculean tasks – at the risk of personal health – to resuscitate patients or to save their failing kidneys when death appears likely anyway.
"Tacit in the caregiving pact is the understanding that such brave souls will be protected at all costs." – Steve St. Angelo
“Ever since Florence Nightingale took it upon herself to care for the sick and the wounded in the Crimean War in the 1850s, nurses have proven their value and their valor where care is most daunting and risky,” Dean Patricia Davidson wrote in an op-ed for the Baltimore Sun as first reports of nurse deaths from Ebola in West Africa reached the U.S. “We were never promised it would be easy, or safe. They didn’t tell us that because nurses don't wait to be told. We are called, we act, and we save lives.”
Nevertheless, tacit in that caregiving pact is the understanding that such brave souls will be protected at all costs.
Ebola is spread through contact with bodily fluids, the flows of which increase as a patient nears death. Droplets of saliva, vomit, diarrhea and blood are bursting with the lethal virus, and one unsafe touch can mean infection. There is no known cure.
Given the uncertainty, “nurses are understandably concerned about how to weigh their personal risks with their professional responsibilities,” says Rushton. “What are the consequences if a staff member refuses [to treat a patient]?”
And despite the serve-any-and-all underpinnings of the profession, Rushton suggests that perhaps there are classes of nurses who, ethically, should be excused from treating Ebola patients: the pregnant, the inexperienced and those with medical conditions that might leave them more susceptible.
“Nurses do not have an ethical responsibility to be martyrs,” Rushton insists.
Fear and Loathing
In late October, Kaci Hickox landed at a New Jersey airport, offered that she had been working with Doctors Without Borders to treat Ebola victims in Sierra Leone, and was immediately whisked against her will to quarantine though she had no Ebola symptoms and tested negative for the virus.
Like Aguirre, Hickox spoke out from her isolation tent in New Jersey against an unfair quarantine policy built on ignorance and fear. She was released after public outcry against her treatment for service the White House called “deserving of praise and respect.”
"How do you build an ethics system that recognizes and overcomes the human tendency toward blame, shame and a rush to judgment?" – Steve St. Angelo
“This is not a situation I would wish on anyone, and I am scared for those who will follow me,” Hickox wrote in an essay she emailed from the quarantine tent to the Dallas Morning News. “I am scared that, like me, they will arrive and see a frenzy of disorganization, fear and, most frightening, quarantine.”
Davidson applauded Hickox. “She epitomizes a Hopkins nurse. Kaci upheld the first provision of the American Nurses Association Code of Ethics by offering her services to those in need and delivered care with compassion and competence.” And she spoke up.
An Ethical Environment
Ebola has raised with force many of the issues that Rushton works daily to address as the co-chair of the Johns Hopkins Hospital Ethics Committee and Consultation Service, a teacher at the School of Nursing, and a leader of the Berman Institute of Bioethics.
Through the Blueprint for 21st Century Nursing Ethics, the association’s retooled ethics code, and continued interprofessional cooperation, Rushton hopes a truly ethical health care culture can be achieved. Here, Rushton says, ethical issues could be addressed openly, with courage and integrity.
But how do you build a system that recognizes and overcomes the human tendency toward blame, shame and a rush to judgment?
“Self-awareness would be a good first step,” she says, adding that ethics must become a foundational element of all nursing curricula as they are at Hopkins. “We need to strengthen a culture that genuinely supports doing the right thing, at the right time, for the right reason.”
For today, the U.S. health care profession and the world will have learned much from their handling of a frightening disease. By the time the next outbreak comes, of Ebola or something else, new policies for care of the stricken and the safety of the caregiver very likely will be in place.
If not, Hopkins nurses still have their voices, and they won’t be afraid to use them – if Rushton and Davidson have anything to say about it.