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.