Doctor examining african female patient with fingertip pulse oximeter in bed. Nurse putting oximeter on finger of sleeping afro-american sick woman in hospital ward

Bioethics Forum Essay

Who Will Be There to Care If There Are No More Nurses?

Imagine you have just been admitted to the hospital. These days it is likely that it would be related to the SARS-Covid virus and your need for 24/7 nursing care to monitor your breathing and bodily functions, assess your progress, deliver treatments, and listen to your fears and anxieties. For 18 months, nurses–more than four million nationwide–have provided care to patients in untenable circumstances, which have included working in unsafe conditions with insufficient personal protective equipment and inadequate staffing while bearing witness to daily suffering and death. They have been there in the middle of the night when patients had questions, were worried about not being able to connect with their families or were scared that this virus really might take their lives. Nurses have used their expertise and clinical skills to educate, support, and grieve with patients, doing so with courage, compassion, and self-sacrifice. They have also been the targets of verbal and physical violence and disrespectful behaviors, and they have been accused being part of conspiracy theories and lying about patient’s diagnosis. They have felt betrayed by the people they have committed to serve

The pandemic has laid bare the significant shortcomings of a health system rooted in an unsustainable financial model that exploits the physical and emotional labor of its nurses. Nurses are not an endless resource. Increased enrollments in nursing schools cannot make up for the number of nurses leaving the profession and taking years of experience and wisdom with them. In hospitals across the country many units are understaffed, and the staff nurses have just a few years of experience. Nurses do not become expert clinicians overnight. Research indicates that nurses become proficient with three-to-five years of experience working in the same clinical area; to become an “expert” requires five or more years of experience. Cultivating such expertise requires skilled precepting and dedicated mentorship—resources that are in extremely short supply or, in some places, nonexistent.

The public must acknowledge the grave risk that current working conditions and public response to the pandemic impose on the sustainability of the nursing profession and the quality of care that patients receive. While you may not need nursing care right now, that reality can change in a heartbeat. Your patient experience, especially in hospitals, is largely determined by the availability and quality of nursing care you receive. At this moment, it is likely that in many areas across the country if you have the benefit of a nurse to provide your care, the nurse is likely to be exhausted, discouraged, and stressed. 

Nursing’s relationship with the public has often been framed as a social contract that outlines what society expects from nurses and what nurses expect from society, thus providing the basis for the professional practice of nursing. The Code of Ethics for Nurses with Interpretative Statements puts forth the obligations, values, and ideals of the nursing profession, guides nursing practice, and grounds nurse’s moral authority. Society needs caring in health and in illness. The public looks to nurses to provide skilled, knowledgeable, and competent care and promote the public’s health without prejudice, and to be accountable as individuals and as a profession for the quality of their actions.

Nurses witness, firsthand, the human condition. They are expected to be the “vanguard of emerging health related issues” and they are indeed privileged to be engaged in some of the most intimate moments of persons life and death. But those privileges are not to be exploited or taken for granted. The public has a reciprocal responsibility to honor nurses’ dignity by treating them with respect and fairness; extending them authority to practice in accordance with legal, ethical, and practice standards; allow for self-regulation and professional autonomy; and provide just remuneration and resources necessary to provide care to those in need. The public also bears a responsibility to engage with nurses to create the conditions for health and healing. Yet, nurses who have advocated for common sense public health measures and Covid vaccination have been subjected to verbal and physical abuse from patients and a public resistant to science or actions in support of communal welfare. Public response to the pandemic calls for urgent reassessment of the social contract. 

The alarming state of the America’s nursing workforce is not a failing of individual nurses but rather the failing of society to provide nurses with the environments and resources they need to provide the care their code of ethics requires. This includes a corollary contract of health care organizations to provide the conditions for nurses to safely and competently practice. In a recent report, frontline care nurses recommended 14 local and national solutions to avoid the failures of the current pandemic. These solutions are encapsulated in three pleas. Listen to us—we have our ears to the ground and will tell you what is needed to make the system work. Protect us—give us the resources we need to do our jobs. And empower us—to do what we do best, provide care to people facing disease, injury, or death so that they have safe passage through these transitions.  

If nurses are not safe, patients are not safe. The public must call for state and federal actions that require health care organizations to guarantee safe and appropriate staffing levels on each unit and an adequate supply of personal protective equipment and other resources needed to provide competent care. Strong support of vaccination for all health care workers, which promotes a safe working environment, is also urgently needed. Health care organizations must provide comprehensive vaccine education for employees, respectfully acknowledge cultural concerns, and ensure time off for employees to get vaccinated and manage side effects.

Citizens must do their part. Our lives are interconnected; the health of one depends on the health of everyone. Take responsibility for your own health to protect yourself and those you encounter. Follow public health guidelines. Second, if you do become sick, treat the nurses who  care for you with the honor and respect you expect of them. Third, advocate for local, state, and national standards for healthy workplaces where nurses practice. Achieving those standards requires investing resources to create nursing workforce reserves to meet the challenges during crises, supporting policies to expand funding for nursing education and nurses’ well-being, and holding political leaders accountable at every level for their actions in dismissing common sense measures that provide protection for all during this crisis. Nurses are, and always have been, the linchpin in our health care system. Without appropriate public response, there will be no more nurses.

The social contract of nurses with society is not a one-way street. Both parties must commit to the terms of the contract and be responsible for fulfilling their part of the bargain.  Nurses have demonstrated their commitments—have you?

Eileen K. Fry-Bowers, PhD, JD, RN, CPNP, FAAN (@efrybowers), is Professor and Associate Provost at the University of San Diego Hahn School of Nursing and Health Science. Cynda Hylton Rushton, PhD, RN, FAAN (@CyndaEthx), is the Anne & George L. Bunting Professor of Clinical Ethics & Nursing at Johns Hopkins University’s Berman Institute of Bioethics and School of Nursing and member of the American Nurses Association Ethics Advisory Board.

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  1. Immensely appreciative of this article and the message(s) articulated….I have known several nurses, including a younger sister, who suffered both physical and emotional harm from months of working during the height of the pandemic….

  2. Whereas I sympathize with this article in general and I don’t mean to detract from the argument, I feel it fails to acknowledge other healthcare professions who are facing similar challenges. We in those fields are used to being neglected by the “doctors and nurses”, who — as it would appear by much media representation and general attitudes in healthcare at large — comprise the entirety of healthcare.

    If I may speak for the rest, I guess what I’m trying to say is that we non-physician, non-nursing healthcare professionals who share in your struggles are, yet again and as usual being largely ignored.

  3. I very much appreciate the article for shedding light on the “plight” of nurses. People’s lives have been changed for the better by nurses for years. However, I doubt we can depend on citizens to advocate for nurses. I have been in Nursing for 40 years and there has been a shortage of nurses, to varying degrees, for the entire duration of my practice. Portrayal of nurses in the media has been less than flattering adding to the public’s misunderstanding of their role, strength, and perseverance. I do agree that we need policies and funding at the local, state and federal levels that provide resources to strengthen education while providing incentives to draw more folks to the nursing profession. Having a “Nurse Reserve” to draw on for disasters and the next pandemic (which certainly will come) would be ideal. Unfortunately, thinking and functioning proactively is not what occurs. It’s usually always a crisis that puts something into sharp focus. A good example is that of Hurricane Katrina, when the levees of New Orleans were overtopped and the city flooded. There were calls to shore p the levees for years before but it was never done. This pandemic is Nursing’s Katrina. And, if there is inaction now the situation will never be remedied.

  4. The gauntlet has been dropped. Who will be the first courageous pioneer healthcare administrator to truly value Nurses and all the other care providers for the work and care they provide ?

  5. As a retired nurse of over 30 years in practice I agree this article states the sad situation today. In retrospect I do not understand how nurses who are so needed refuse to get vaccinated with their background in the sciences and microbiology would support the value of vaccination for their patients and their own family

  6. Your article certainly resonated with me, as a school nurse practicing in the midst of this endless pandemic. It has now impacted our 3rd school year. School nursing shortages are happening across the country. This is on top of 25% of schools not having any nursing coverage and 35% of schools only having part-time school nurses. Amid the Delta variant surge, those school districts that have nurses are experiencing vacancies. School nurses have reached our tipping point, the frustration and impossible working conditions have caused many seasoned school nurses to either retire early or resign. We are no longer tolerating the intolerable, nor should we. Altruism aside, school nurses are not “angels of mercy,” or “superheroes.” Those attributes create unrealistic expectations of selfless service that martyrs our profession and causes an epidemic of compassion fatigue across an already beleaguered workforce.

    I have spoken to school nurses from across the country and we are beyond stressed, stretched, and feeling unsupported. The biggest frustration is that there is funding available to throw us a lifeline so we can actually do the work of school nursing and not function as the de facto health department. We have become a legion of contact tracers, with no bandwidth to do anything else.

    While our dedication may seem admirable to some, it is crushing our workforce, leading many to make the difficult decision to resign or retire. We are not machines.

  7. Thank you for bringing this article forward. I am not a nurse, but as a chaplain, I have been with them through some of the toughest stuff. Everything this article says fits my experience of the levels of burnout, anxiety and exhaustion our nurses are facing. The shortage is real and the risks they are taking are real. “If nurses are not safe, patients are not safe.” This is a complex issue, and many of my nursing friends change their clothes before leaving work, whether or not they work on COVID floors (yes we still have COVID floors) because of the flack they get in the grocery story or other public venues driven by the assumptions we make because they are in scrubs. We speak of them as heroes or martyrs – both sacrificial or mythical images – and neither of them desirable to the people so labeled. Our nurses are human beings with a huge range of skills, doing the best they can every day. This is not a job, it is a vocation, something they’ve invested greatly in emotionally, financially, physically and spiritually. The social contract between nursing and healthcare and the community is indeed a two way street. For a chaplain or a physician, there is no better caregiving partner than a skilled, seasoned nurse who is mentoring or precepting another. It takes time to become an expert, we need to find ways to support and respect our nurses everywhere in ways that allow them to grow into the compassionate, wise, skilled experts they were called to be.

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