Our Next Pandemic Ethics Challenge? Allocating "Normal" Health Care Services

The pandemic creates unprecedented challenges to society and to health care systems around the world. Like all crises, these provide a unique opportunity to rethink the fundamental limiting assumptions and institutional inertia of our established systems. These inertial assumptions have obscured deeply rooted problems in health care and deflected attempts to address them. As hospitals begin to welcome all patients back, they should resist the temptation to go back to business as usual. Instead, they should retain the more deliberative, explicit, and transparent ways of thinking that have informed the development of crisis standards of care. The key lesson to be learned from those exercises in rational deliberation is that justice must be the ethical foundation of all standards of care. Justice demands that hospitals take a safety-net approach to providing services that prioritizes the most vulnerable segments of society, continue to expand telemedicine in ways that improve access without exacerbating disparities, invest in community-based care, and fully staff hospitals and clinics on nights and weekends.

'Your country needs you': the ethics of allocating staff to high-risk clinical roles in the management of patients with COVID-19

As the COVID-19 pandemic impacts on health service delivery, health providers are modifying care pathways and staffing models in ways that require health professionals to be reallocated to work in critical care settings. Many of the roles that staff are being allocated to in the intensive care unit and emergency department pose additional risks to themselves, and new policies for staff reallocation are causing distress and uncertainty to the professionals concerned. In this paper, we analyse a range of ethical issues associated with changes to staff allocation processes in the face of COVID-19. In line with a dominant view in the medical ethics literature, we claim, first, that no individual health professional has a specific, positive obligation to treat a patient when doing so places that professional at risk of harm, and so there is a clear ethical tension in any reallocation process in this context. Next, we argue that the changing asymmetries of health needs in hospitals means that careful consideration needs to be given to a stepwise process for deallocating staff from their usual duties. We conclude by considering how a justifiable process of reallocating professionals to high-risk clinical roles should be configured once those who are 'fit for reallocation' have been identified. We claim that this process needs to attend to three questions that we consider in detail: (1) how the choice to make reallocation decisions is made, (2) what justifiable models for reallocation might look like and (3) what is owed to those who are reallocated.

Thinking clearly about the FIRST trial: addressing ethical challenges in cluster randomised trials of policy interventions involving health providers

The ethics of the Flexibility In duty hour Requirements for Surgical Trainees (FIRST) trial have been vehemently debated. Views on the ethics of the FIRST trial range from it being completely unethical to wholly unproblematic. The FIRST trial illustrates the complex ethical challenges posed by cluster randomised trials (CRTs) of policy interventions involving healthcare professionals. In what follows, we have three objectives. First, we critically review the FIRST trial controversy, finding that commentators have failed to sufficiently identify and address many of the relevant ethical issues. The 2012 Ottawa Statement on the Ethical Design and Conduct of Cluster Randomized Trials provides researchers and research ethics committees with specific guidance for the ethical design and conduct of CRTs. Second, we aim to demonstrate how the Ottawa Statement provides much-needed clarity to the ethical issues in the FIRST trial, including: research participant identification; consent requirements; gatekeeper roles; benefit-harm analysis and identification of vulnerable participants. We nonetheless also find that the FIRST trial raises ethical issues not adequately addressed by the Ottawa Statement. Hence, third and finally, we raise important questions requiring further ethical analysis and guidance, including: Does clinical equipoise apply to policy interventions with little or no evidence-base? Do healthcare providers have an obligation to participate in research? Does the power-differential in certain healthcare settings render healthcare providers vulnerable to duress and coercion to participant in research? If so, what safeguards might be implemented to protect providers, while allowing important research to proceed?

Understanding and addressing missed care in clinical placements - Implications for nursing students and nurse educators

This paper addresses the issue of substandard care and its effects on healthcare practice. It explores some recent concerns about the problem in nursing, its potential effects on students, how it can be conceptualised and what action needs to be, by both nurses and educators to prevent it. Recent healthcare scandals have tarnished the public image of nursing, and are also likely to influence nursing students' images, expectations and experiences of nursing. While much attention has been paid to the examination of such lapses in care, and potential corrective actions, little attention has been paid to the potential or actual effect on nursing students in practice. While good resources and staffing levels are crucial to ensuring optimal nursing care, developing and encouraging nursing students' awareness of and openness about personal behaviours, reflecting critically on practice reflection and strengthening nurse educators' collaborative links with healthcare practice can all serve to positively influence care deficits.

Exploring the Moral Distress of Registered Nurses

Registered nurses (RNs) employed in an urban medical center in the USA identified moral distress as a practice concern. This study describes RNs' moral distress and the frequency of morally distressing events. Data were collected using the Moral Distress Scale and an open-ended questionnaire. The instruments were distributed to direct-care-providing RNs; 100 responses were returned. Morally distressing events included: working with staffing levels perceived as `unsafe', following families' wishes for patient care even though the nurse disagreed with the plan, and continuing life support for patients owing to family wishes despite patients' poor prognoses. One high frequency distressing event was carrying out orders for unnecessary tests and treatments. Qualitative data analysis revealed that the nurses sought support and information from nurse managers, chaplaincy services and colleagues. The RNs requested further information on biomedical ethics, suggested ethics rounds, and requested a non-punitive environment surrounding the initiation of ethics committee consultations.

It's time for consensus on the future of the NHS

Guidance on the number of nurses needed in A&E departments was issued last week by the National Institute for Health and Care Excellence (NICE). No nurse should have to look after more than four patients - and only two if their conditions are more serious. The guidance is out for consultation, but hospital managers would be well advised to take heed straightaway.

Patient acuity should be a factor in A&E staffing equation, says RCN

Proposed guidance on minimum staffing levels could help struggling A&Es, but should be viewed with caution, according to the RCN.

Professional values, value conflicts, and assessments of the duty-hour restrictions after six years: a multi-institutional study of surgical faculty and residents

BACKGROUND

the aim of this study was to explore professional values, value conflicts, and assessments of the Accreditation Council for Graduate Medical Education's duty-hour restrictions.

METHODS

questionnaires distributed at 15 general surgery programs yielded a response rate of 82% (286 faculty members and 306 residents). Eighteen items were examined via mean differences, percentages in agreement, and significance tests. Follow-up interviews with 110 participants were explored for main themes.

RESULTS

residents and faculty members differed slightly with respect to core values but substantially as to whether the restrictions conflict with core values or compromise care. The average resident-faculty member gap for those 13 items was 35 percentage points. Interview evidence indicates consensus over professional values, a gulf between individualistic and team orientations, frequent moral dilemmas, and concerns about the assumption of responsibility by residents and "real-world" training.

CONCLUSIONS

the divide between residents and faculty members over conflicts between the restrictions, core values, and patient care poses a significant issue and represents a challenge in educating the next generation of surgeons.

Perspective: limiting resident work hours is a moral concern

The author outlines the cross-cultural and widespread expectation that the moral character of physicians is built on dual possession of skill and compassion. The details of the moral makeup of physicians are often hotly debated in the biomedical literature. Despite a lack of consensus regarding the required aspects of character, the author demonstrates that little debate exists that at a minimum physicians should possess not only knowledge but also a willingness to care for and comfort patients. The primacy of the patient in the physician's life is reflected in the panoply of oaths taken by new physicians despite great variability in other aspects of these oaths. The author details recent worrisome reports demonstrating the erosion of medical trainees' empathy and compassion by long work hours. Further, the continued linkage of these attitude changes and fatigue to poor medical outcomes is a call to action. Changes enacted by the Accreditation Council for Graduate Medical Education to reduce resident work hours are insufficient to achieve the goal of improved patient care while promoting moral development among resident physicians. The debate regarding resident work hours is often framed as an idealistic discussion of placing patients first. However, residents are used as an inexpensive labor force, and efforts to curtail this usage would have a significant economic impact. Economic concerns play a larger part in decision making than is generally discussed. The author calls for further alterations of resident work schedules to improve patient care and ensure the preservation of the moral ethos of medicine.

Perspective: creating an ethical workplace: reverberations of resident work hours reform

Medical professionals are a community of highly educated individuals with a commitment to a core set of ideals and principles. This community provides both technical and ethical socialization. The development of ethical physicians is highly linked to experiences in the training period. Moral traits are situation-sensitive psychological and behavioral dispositions. The consequence of long duty hours on the moral development of physicians is less understood. The clinical environment of medical training programs can be so intense as to lead to conditions that may actually deprofessionalize trainees. The dynamic relationship between individual character traits and the situational dependence of their expression suggests that a systems approach will help promote and nurture moral development. Ethical behavior can be supported by systems that make it more difficult to veer from the ideal. Work hours limits are a structural change that will help preserve public safety by preventing physicians from taking the moral shortcuts that can occur with increasing work and time pressures. Work hours rules are beneficial but insufficient to optimize an ethical work and training environment. Additional measures need to be put in place to ensure that ethical tensions are not created between the patient's well-being and the resident's adherence to work hours rules. The ethical ideals of physician autonomy, selflessness, and accountability to the patient must be protected through the judicious and flexible use of work hours limits, physician extenders, census caps, nonteaching services, and high-quality handoffs.

Ethical aspects of limiting residents' work hours

DEFINITION OF THE PROBLEM

The regulation of residents' work hours involves several ethical conflicts which need to be systematically analysed and evaluated. ARGUMENTS AND CONCLUSION: The most important ethical principle when regulating work hours is to avoid the harm resulting from the over-work of physicians and from an excessive division of labour. Additionally, other ethical principles have to be taken into account, in particular the principles of nonmaleficence and beneficence for future patients and for physicians. The article presents arguments for balancing the relevant ethical principles and analyses the structural difficulties that occur unavoidably in any regulation of the complex activities of physicians.

Ethical imperatives in staffing and managing a trauma intensive care unit

As U.S. trauma surgery evolves to embrace the concept and practice of acute care surgery, the organization and management structure of the intensive care unit must also grow to reflect new challenges and imperatives faced by trauma surgeons. Key issues to be explored in light of acute care surgery include the role of the traumatologist/intensivist in the intensive care unit, as opposed to the traumatologist without specific critical care training, and a potentially expanded role for nonsurgical intensivists as the critical care time available for trauma/intensivists wanes due to increased surgical and non-critical care patient volume. Each of these changes to the practice of trauma/surgical critical care and acute care surgery are evaluated in light of the primacy of appropriately trained intensivists in the critical care unit. The ethics of providing the best care possible is interrogated in light of different service models in both the university and community settings. The roles of residents, fellows, and midlevel practitioners in supporting the goal of the intensivist and the critical care team is similarly explored. A recommendation for an ethical organizational and management structure is presented.

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Representatives of two nursing organisations offer a summary of nurses' legal position in relation to unsafe staffing levels.

Said another way. Our obligation to float

TOPIC

Floating is one method that can help alleviate the burden and consequences of the nursing shortage.

PURPOSE

The devastating effects that occur as a result of the nursing shortage are discussed. As a result, floating is argued as a viable solution. The practice of floating is explored from an ethical approach.

SOURCES OF INFORMATION

Professional literature, electronic resources, nursing textbooks, from statements provided from the American Association of Colleges of Nursing, Joint Commission on Accreditation of Healthcare Organizations, Six Sigma, legal cases, and personal experience.

CONCLUSION

Although many nurses oppose the practice of floating, it remains not only necessary, but it is also our obligation. It is acknowledged that floating has its opposition, but the arguments posed are not justifiable when they are weighed against the consequences of not floating.

The demands of 24/7 coverage: using faculty perceptions to measure fairness of the schedule

OBJECTIVES

Ensuring fair, equitable scheduling of faculty who work 24-hour, 7-day-per-week (24/7) clinical coverage is a challenge for academic emergency medicine (EM). Because most emergency department care is at personally valuable times (evenings, weekends, nights), optimizing clinical work is essential for the academic mission. To evaluate schedule fairness, the authors developed objective criteria for stress of the schedule, modified the schedule to improve equality, and evaluated faculty perceptions. They hypothesized that improved equality would increase faculty satisfaction.

METHODS

Perceived stress was measured for types of clinical shifts. The seven daily shifts were classified as weekday, weekend, or holiday (plus one unique teaching-conference coverage shift). Faculty assigned perceived stress to shifts (ShiftStress) utilizing visual analog scales (VAS). Faculty schedules were measured (ShiftScores) for two years (1998-1999), and ShiftScore distribution of faculty was determined quarterly. Schedules were modified (1999) to reduce interindividual ShiftScore standard deviation (SD). The survey was performed pre- and postintervention.

RESULTS

Preintervention, 26 faculty (100% of eligible) assigned VAS to 22 shifts. Increased stress was perceived in progression (weekday data, 0-10 scale) from day to evening to night (2.07, 5.00, 6.67, respectively) and from weekday to weekend to holiday (day-shift data, 2.07, 4.93, 5.87). The intervention reduced interindividual ShiftScore SD by 21%. Postintervention survey revealed no change in perceived equality or satisfaction.

CONCLUSIONS

Faculty perceived no improvement despite scheduling modifications that improved equality of the schedule and provided objective measures. Other predictors of stress, fairness, and satisfaction with the demanding clinical schedule must be identified to ensure the success of EM faculty.

Ethics and human rights issues experienced by nurses in leadership roles

The aims of this study were to identify (1) the ethics and human rights issues experienced by nurses in leadership roles (NLs); (2) how frequently these issue occurred in the NLs'practices; and (3) how disturbed the NLs were by the issues. Dillman's Total Design Method (1978) for mailed surveys guided the study design. Data analysis was performed on 470 questionnaires from New England RNs in nursing leadership roles. The most frequently experienced ethics and human rights issues during the previous 12 months were (1) protecting patient right and human dignity; (2) respecting or not respecting informed consent to treatment; (3) use or nonuse of physical or chemical restraints; (4) providing care with possible risks to the RN's health; (5) following or not following advance directives; and (6) staffing patterns that limit patient access to nursing care. The most disturbing ethics and human rights issues experienced by the NLs were staffing patterns that limited patient access to nursing care, prolonging the dying process with inappropriate measures, working with unethical, incompetent, or impaired colleagues, implementing managed care policies that threaten quality of care, not considering quality of the patient's life, and caring for patients and families who are uninformed or misinformed about treatment, prognosis, or medical alternatives. Nearly 39% of the NLs reported experiencing ethics and human rights issues one to four times a week or more, and more than 90% handled their most recent ethics issue by discussing it with nursing peers. Study findings have implications for ethics education and resource support for nurses in leadership roles, and for further research on how NLs handle ethics and human rights issues in the workplace.