Ethics in practice: nurses' ethical considerations in a pandemic or other emergency part III.

"The nursing profession plays an integral role in all aspects of emergencies, including mitigation, preparedness, response and recovery" (CNA, 2007, p. 1). The following examples highlight some of the different challenges that nurses may experience in relation to a pandemic or other emergency.

* Shelley works in the emergency department in a large urban hospital. She is a single mother with two small children. During an influenza pandemic, she is torn by apparent conflicts among the financial need to work, her responsibilities to her employer and patients, and her worries that she will become infected and in turn infect her children.

* George is the nursing union representative on the joint worker-management health and safety committee in his community hospital. The committee is reviewing the hospital's draft pandemic plan. He wants to ensure that all nurses are given the best protection as well as sufficient information to protect their health and safety in the case of a pandemic.

* Adele works in a nursing home, and on the basis of her personal beliefs she has decided not to have the annual influenza vaccine offered by her employer. She doesn't know what she would do during a pandemic if she is required to take antiviral medication or be vaccinated.

* Lashmi works in a public health agency. She has been asked to set up a clinic in the community that will be used to triage sick people in the event of a large-scale emergency.

* Roseanna works in the out-patient clinic of her hospital. She fears that during a pandemic she will be redeployed to the medical floor, an area where she does not feel competent to practise.

* Antonio has just completed his fourth night shift in a row. He is asked by his nurse manager to stay and work an extra shift: the floor is short-staffed because many of his colleagues are sick.

Reciprocity between Health Professionals and Society

Reciprocity requires that society supports those who face a disproportionate burden in protecting the public good and takes steps to minimise their impact as far as possible. In an influenza epidemic, measures to protect the public good are likely to impose a disproportionate burden on health care workers, patients, and their families (Thompson et al., 2006, Table 2).

The Canadian Pandemic Influenza Plan for the Health Sector (PHAC, 2006) states that health-care workers will be the first group to receive the pandemic influenza vaccine as soon as it is available. The principle of reciprocity between the public and health-care workers is implicit in this priority setting. That is, in exchange for priority in receiving prophylaxis, health-care workers are expected by the rest of society to provide care during a pandemic. Ruderman, Tracy, Bensimon, Bernstein et al. expand on three reasons from Clark (2005) why health-care professionals provide care during an outbreak: "(1) The ability of physicians and health care professionals to provide care is greater than that of the public, thus increasing the obligation to provide care; (2) By freely choosing a profession devoted to care of the ill, health care professionals have assumed risk; (3) The profession is legitimated by social contract and therefore its members should be available in times of emergency. Society has granted and permits professions to be self-regulating on the understanding that [health-care professionals will respond in an infectious disease emergency]" (2006, p. 3).

Thus, the example of Adele, the nurse working in a long-term care facility who does not think she will take the antiviral medication or be vaccinated during a pandemic, is ethically challenging. During regular influenza season, health-care professionals working with elderly people are encouraged to take the annual influenza vaccine to protect their own health and that of their patients. This immunization is not mandatory in any province; however, during an influenza outbreak in a healthcare facility, public health units have the mandate to withdraw from the workplace health-care workers who are not immunized. This is an example of the public health ethics notion of balancing the rights of the individual with the protection of the public's health (CNA, 2006). At the moment, there is no clear legal decision or directives about the right of health-care workers to refuse antiviral medication or vaccination during an influenza pandemic. Pandemic planners, public health agencies and health-care organizations all anticipate that health-care workers would take the prophylaxis offered, with the expectation that health-care workers will provide care.

A controversial issue is the possibility of emergency legislation compelling health-care workers to work during a crisis. The following is taken from Annex H: Resource Management Guidelines for Health Care Facilities during an Influenza Pandemic of the Public Health Agency's Canadian Pandemic Influenza Plan for the Health Sector (2006, p. 12-13):

3.2.2 Review Emergency Legislation Pertaining to Health Care Workers

Emergency Preparedness Legislation makes many provisions for the management of workers during a crisis. This includes the recruitment of professional and other paid staff as well as volunteers, managing human resources and protection of people who volunteer ...

The following provisions of legislation are particularly applicable to human resource issues including:

* authority regarding licensing and scope of practice issues, and the ability of government to make unilateral changes during a crisis;

* safety and protection of workers, (one of the primary responsibilities);

* fair compensation;

* insurance, both site insurance, workers compensation and other forms of insurance;

* training;

* provision of clothing and equipment;

* protection of the jobs of workers who take leave to assist during the crisis.

Compelling Workers

Under Emergency Legislation, provinces/territories may have the authority to designate "Essential Services" and workers and have the ability to compel people's time or property with due compensation as a last resort.

This issue has been raised both because of the existing shortage of health care workers and concerns that health care workers and others may refuse to work during a pandemic due to changed job responsibilities, fear of infection, family responsibilities or other reasons. However, the [Resource Management] Subgroup notes the extreme difficulty of enacting or enforcing such legislation and would strongly encourage the jurisdictions to review all other methods of obtaining health care workers, in advance of a pandemic.

Obligation To Anticipate and Prepare

The main lesson learned from the SARS outbreak and all other recent emergencies is the importance of planning ahead and being prepared. Certainly, pandemic planning and generic emergency preparedness is well underway in Canada. However, each nurse must ponder some of these issues for himself or herself: "Deciding whether to report to work in a disaster is not always easy. But being prepared, individually and through institutional policy, is the primary ethical demand disasters make of health care professionals" (Olsen, 2006, p. 57). To anticipate, deliberate and prepare is part of the "social contract" or duty of health professionals to provide care (ICN, 2006). The CNA Code of Ethics (2008) presents a number of helpful ethical models for reflection and decision-making in its appendices. Multiple accountabilities are shared among professional associations, unions, regulatory colleges, employers, governments and all key stakeholders. All parties need to work together in a transparent and collaborative manner to analyze the issues and make appropriate policy decisions for everyday situations and in preparation for pandemics and other emergencies.

Conclusion

Nurses value the ability to provide safe, compassionate, competent and ethical care. Current legal frameworks, collective agreements, standards of practice and ethical codes provide a foundation for nurses in their ethical deliberations concerning their work during a pandemic or disaster. Individually, nurses need to reflect upon and think through their ethical responsibilities, including their competing duties and personal and professional values, before an emergency occurs.

The examples at the beginning of this paper point to differing priorities in decision-making. Shelley must weigh her family's financial and physical well-being and her responsibility to her patients. In his role as a nursing union representative for a community hospital, George has to advocate for the safety of nurses. Adele must examine her own values surrounding vaccinations and determine whether she can fulfill her professional duties. Roseanna and Antonio both need to examine the limits of their competence so that they are aware of how to perform safely in the event of being posted to another floor or being asked to work an extra shift. Before setting up a clinic, Lashmi needs to work with her employer and various stakeholders to plan for a disaster. But ethical responsibilities do not apply only to individual nurses. Employers, public health officials, and representatives from professional associations, regulatory bodies and government must also collaborate and make decisions both in anticipation of and during an emergency in a "reasonable, open, transparent, inclusive, responsive and accountable" manner (Upshur et al., 2005) so that the public is protected as much as possible from harm and so that nurses may practise in the best interests of the public.

CNA's website (www.cna-aiic.ca) provides valuable information and links on pandemics and other emergencies:

Documents

* Code of Ethics for Registered Nurses (2008)

* Position Statement: Emergency Preparedness and Response

information

* Emergencies, Disease Outbreaks and Disasters--What Every Nurse Should Know. This webpage includes helpful links to government websites and other resources.

Links

* NurseONE: The Canadian Nurses Portal Includes emergency and surveillance links.

* Provincial and territorial nursing regulatory bodies

GUIDANCE FROM THE CNA CODE OF ETHICS (CNA, 2008, P.48-49)

In anticipation of the need for nursing care in a disaster or disease outbreak, nurses:

work together with nurses and others in positions of leadership to develop emergency response practice guidelines, using available resources and guidelines from governments, professional associations and regulatory bodies;

learn about and provide input into the guidelines the region, province or country has established regarding, which persons are to receive priority in care (e.g., priority based upon greatest need, priority based upon probability of a good outcome, and so on);

learn how support will be provided for those providing care and carrying the physical and moral burden of care;

request and receive regular updates about appropriate safety measures nurses might take to protect and prevent themselves from becoming victim to disaster or disease;

assist in developing a fair way to settle conflicts or disputes regarding work exemptions or exemptions from the prophylaxis or vaccination of staff; and

help develop ways that appeals or complaints can be handled.

When in the midst of a disaster or disease outbreak, nurses' ethical obligations are 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 (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.

Editors's note: This is the final article of a three part series. It contains an excerpt from the Canadian Nurses Association (CNA)'s Ethics in Practice paper Nurses' Ethical Considerations in a Pandemic or Other Emergency. (For a complete copy of the paper visit: www.cna-aiic.ca)

The full references noted in this series can be found in CNA's publication Nurses' Ethical Considerations in a Pandemic or Other Emergency at www.cna-aiic.ca.

Reprinted with the permission of the Canadian Nurses Association (CNA). CNA Ethics in Practice papers are available for download from www.cna-aiic.ca.