Training Nurses to Better Deal With Ethical Dilemmas During Pandemics

As countries, public health professionals, and policy-makers work together to confront the 2019 coronavirus disease (COVID-19) pandemic, difficult ethical and social decisions and implications arise. Among them are issues related to rationing limited health resources, including protective equipment for medical staff and respiratory machines for sick patients, especially in the critically care units; imposing limits to individual freedoms and movement with a possible distinction between groups of people, that is, the elderly as opposed to the younger generation; expanding the access to palliative care to dying COVID-19 patients; upholding professional and ethical duties to treat and care in the face of serious health risk and personal danger; and so forth.

While these “big questions” are serious and acute, one has to pay not less attention to other questions that are hidden and, at times, even pushed away from the public discourse. Media converge in Israel, as in many other Western countries, focuses on the health-related and economical aspects of the pandemic. The voice of medical teams, especially nurses’, is hardly raised not even by their own professional organizations.

Caring in times of the COVID-19 outbreak is extremely stressful. A recent study in China, questioning more than 800 nurses and nursing college students during the pandemic outbreak, unsurprisingly reveals that the closer that COVID-19 is to participants, the more it causes anxiety and anger. ¹ We know from previous pandemics that the conflict between the duty of care, especially at times of crisis, and high perceived risk of infection, along with low agreement with infection control measures, creates more ethical problems and dilemmas for nurses. Nurses can refuse to care for patients with contagious diseases due to fear of stigmatization. ² The most complex dilemma concerns having a mindset of patient avoidance and preference for caring for non-infected patients. ³

As nurses are expected and feel obligated to provide care, despite the health risk and threat to themselves and to their beloved ones who live in their personal surroundings and whose well-being is their responsibility, they feel more ethical pressure. This ethical tension is exacerbated the more that nurses are aware of the lack of professional resources, and they feel a strong responsibility not only to their patients, but also to the society at large. In Israel, as in many other Western countries, the shortage of nurses, which is even more severe when some of them are sick or under quarantine, serves as another considerable factor to weigh against nurses’ unwillingness to report for work.

Schools of nursing as well as professional organizations should be aware of these ethical conflicts and discuss them in advance with nursing students and nurses. They should find meaning to the various alternatives and modes of action to resolve them and better prepare nurses to handle them in real time. Use of simulations may be useful ⁴ . Given the influence of peers toward one’s decision to work under threatening conditions ⁵ and, more generally, on deliberating ethical dilemmas, peer learning and discussions of such dilemmas may be more fruitful for the nursing community and for the society at large. These important revisions in the education of nurses follow previous calls to re-examine the teaching approaches and methods of nursing ethics education ⁶ so that nurses will indeed be able to “deliver the good(s).”