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DEPARTMENTS: Interprofessional Learning Environments

Ethics and Interprofessional Learning Environments During a Pandemic

Implications for Nursing Professional Development Practitioners

Holtschneider, Mary Edel MEd, MPA, BSN, RN, NPD-BC, NREMT-P, CPTD; Park, Chan W. MD, FAAEM

Editor(s): Holtschneider, Mary Edel MEd, MPA, BSN, RN, NPD-BC, NREMT-P, CPTD; Park, Chan W. MD, FAAEM

Author Information
Journal for Nurses in Professional Development: 9/10 2020 - Volume 36 - Issue 5 - p 304-306
doi: 10.1097/NND.0000000000000670
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The impact that coronavirus (COVID-19) has had on our nation’s public health policy, economics, infrastructure, and the safety of healthcare professionals is incalculable and unprecedented. Along with others, nursing professional development (NPD) practitioners have risen to a situation that has, until now, remained largely a tabletop exercise related to our ability to confront a pandemic. The salient question is no longer are we prepared, but rather, how do we continue to address the pandemic head on, remain resilient, and emerge even stronger tomorrow?

In this next series, we will draw attention to the importance of individual safety, interprofessional team preparedness, and healthcare system resilience. We will explore the importance of recognizing ethical viewpoints and often cited healthcare principles within the interprofessional learning environment and the key role that NPD practitioners have in this ongoing dialogue. Indeed, Standard 7 in the Standards of Professional Performance for NPD relates to Ethics, whereby the NPD practitioner “integrates ethics into all areas of practice” and “guides peers and others through resolution of ethical conflicts” (Harper & Maloney, 2016).

INTERPROFESSIONAL EDUCATION COLLABORATIVE

To structure our discussion, we will use the Interprofessional Education Collaborative (IPEC) Four Core Competencies for Interprofessional Collaboration: Values and Ethics for Interprofessional Practice, Roles/Responsibilities, Interprofessional Communication, and Teams and Teamwork (IPEC, 2016). These four competencies, originally developed in 2011 and reaffirmed in 2016, serve as the framework for educating preprofessional healthcare students to practice in today’s increasingly complex environment. The competencies extend to the clinical practice environment beyond academia, with the goals of improving team-based care and improving population-based outcomes.

To provide context and a proper backdrop for the interprofessional learning environment, we will examine a common scenario that NPD practitioners have faced during this pandemic.

SIMULATION SCENARIO: CODE RESPONSE TEAM TRAINING IN THE COVID-19 ERA

An NPD practitioner plans an educational in situ simulation to reinforce emergency response procedures for COVID-19 patients, including the proper technique for donning and doffing personal protective equipment (PPE). Referencing the American Heart Association Interim Guidance, the NPD practitioner intends to lead the discussion exploring ways to “reduce provider exposure, prioritize oxygenation and ventilation strategies with lower aerosolization, and consider the appropriateness of starting and continuing resuscitation” (Edelson et al., 2020).

As the team gathers for this in situ scenario, the NPD practitioner acknowledges the importance of having resuscitation-related goals of care discussions with patients positive for COVID-19 and their family members upon admission. The simulated patient in this scenario is a full code, so the NPD practitioner begins the simulation by facilitating ways to decrease the number of responders who enter the room by redistributing tasks to a smaller core group to minimize healthcare provider exposure.

The NPD practitioner also emphasizes the need for appropriate donning and doffing of PPE to protect all responders, which includes N95, goggles, gown, gloves, head cover, and shoe covers. The airway responders don extra PPE and verbalize that they are at added risk because they are intubating the patient. Several of the team members identify personal discomfort over how long it takes to don their PPE and enter the room, thereby delaying lifesaving measures.

As the simulation progresses, a member of the interprofessional team raises an objection to the differing level of PPE, stating he should have the same protection as those managing the airway. Another team member who belongs to one of the “at-risk” demographic groups does not feel safe and asks if there exists any situation when the risk to the safety of the healthcare provider is sufficiently high that they are not required to offer care.

IPEC CORE COMPETENCIES: VALUES/ETHICS AND TEAMS/TEAMWORK

When released, the American Heart Association guidance brought sharp focus on healthcare provider safety given the nature of COVID-19. Naturally, this shift in perspective has led to a variety of ethical conversations for the interprofessional team surrounding the optimal way to respond to a cardiac arrest patient. In this scenario, the NPD practitioner is faced with facilitating discussions not only related to specific hands on skills, such as safely donning and doffing PPE, but broader questions regarding healthcare provider safety and responsibility. Let us look at these two questions and consider the ethical principles involved.

ETHICS GOVERNING PPE

In this scenario, the code team members question the different levels of PPE and articulate their individual discomfort with their potential risk of infection. The utilitarian principle is often used to justify how healthcare systems distribute limited PPE to their healthcare employees. Under this principle, PPE allocation is governed by the action that achieves the most good for the greatest number of people. It views the healthcare system resources, energy, money, and time as finite and to be used to achieve the best healthcare for the society. Unlike an egalitarian approach which seeks to treat all healthcare providers as being equally important for providing patient care, during times of limited PPE, the utilitarian approach supports providing different levels of protection among the healthcare team based on who can do the most good for the greatest number of patients. As an example, because there are a limited number of healthcare providers who can provide definitive airway support, including anesthesia, critical care, and emergency care, these individuals may be offered a different level of PPE based on their assessed risk for COVID-19 exposure.

It is worth noting that, as the facilitator of this discussion, the NPD practitioner may anticipate two unintended consequences of the utilitarian approach to PPE distributions. First, it can inadvertently introduce conflict among the team members who feel marginalized and less well protected. Second, it can undermine team cohesion and the collaborative effort built on a team model, which can negatively impact the quality of patient care.

ETHICS GOVERNING DUTY TO TREAT DURING A PANDEMIC

Regarding concern about individual healthcare provider safety if proper PPE is not available, an article in Time Magazine entitled, “COVID-19 Health Workers Are Not Soldiers,” likened the risks healthcare providers face by reusing masks and gowns to the risk soldiers faced over 15 years ago when patrolling Iraq in unarmored vehicles (Akerman & Detsky, 2020). The shortage of PPE, particularly at the start of the pandemic, was one of the defining characteristics of the COVID-19 crisis, which many compare to a war.

In contrast to the utilitarian principle that helps guide how PPE is allocated during a time of limited availability, this question probes deeper into aspects of one’s duty to treat patients, even at one’s own personal risk (Binkley & Kemp, 2020). Ethicists often cite five grounds that govern one’s duty to treat, which includes express consent, implied consent, special training, reciprocity, and professional oaths and codes (Malm, et al., 2008). Without getting too deep into ethics, if one searches healthcare provider professional oaths and codes of ethics, invariably one will find a statement regarding provision of care to patients even at one’s own risk.

Healthcare systems rely on the healthcare provider’s inherent sense of duty to treat patients, particularly in times of overwhelming need, such as a pandemic outbreak. The issue of limited PPE in the midst of the recent deadly viral pandemic outbreak has raised the difficult question regarding whether a healthcare provider is morally obligated to treat a patient during a pandemic when the risk of harm to the provider is high. This very issue was highlighted in a 2008 article found in the American Journal of Bioethics entitled “Ethics, Pandemics, and the Duty to Treat.” The pandemic referenced in the article involved a different coronavirus that caused the severe acute respiratory syndrome, which had a 10% mortality rate. After considering all of the ethical arguments, the bioethicist community concluded that none of the arguments supporting the duty to treat “provided a convincing basis for asserting that healthcare workers (or even healthcare professionals) have a ‘duty to treat’ during events like a pandemic” (Malm et al., 2008). As NPD practitioners training interprofessional healthcare providers, it is important to recognize that issues involving ethical decisions and dilemmas are rarely clear cut, and failure to consider opposing viewpoints can negatively affect our goals of improved interprofessional learning and collaboration.

The lasting effects of the COVID-19 pandemic will continue to have implications for NPD practitioners as new information is discovered about the virus and its effects on our society. As we continue this conversation, we invite you to share your experiences with us and what you have learned. What challenging conversations have you had regarding resuscitation training for COVID-19 patients? How have you implemented the NPD Scope and Standards of Practice in your work as a result of the pandemic? What opportunities have you discovered with the framework of the IPEC Core Competencies of Values and Ethics, Roles and Responsibilities, Interprofessional Communication, and Teams and Teamwork? How have you seen the interprofessional environment change as a result of this pandemic? Please share your thoughts with us at [email protected] and [email protected] as we continue to explore this ongoing issue in upcoming columns.

References

Akerman E., Detsky A. E. (2020). COVID-19: Health workers are not soldiers. Time, 15–17.
Binkley C. E., Kemp D. S. (2020). Ethical rationing of personal protective equipment to minimize moral residue during the COVID-19 pandemic. Journal of the American College of Surgeons, 230(6), 1111–1113.
Edelson D. P., Sasson C., Chan P. S., Atkins D. L., Aziz K., Becker L. B., Berg R. A., Bradley S. M., Brooks S. C., Cheng A., Escobedo M., Flores G. E., Girotra S., Hsu A., Kamath-Rayne B. D., Lee H. C., Lehotsky R. E., Mancini M. E., Merchant R. M.; American Heart Association ECC Interim COVID Guidance Authors. (2020). Interim guidance for basic and advanced life support in adults, children, and neonates with suspected or confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the American Heart Association. Circulation, 141(25), e933–e943, 10.1161/CIRCULATIONAHA.120.047463.
Harper M., Maloney P. (Eds.). (2016). Nursing professional development: Scope and standards of practice (3rd ed.). Chicago, IL: Association for Nursing Professional Development.
Interprofessional Education Collaborative. (2016). Core competencies for interprofessional collaborative practice: 2016 Update. https://aamc-meded.global.ssl.fastly.net/production/media/filer_public/70/9f/709fedd7-3c53-492c-b9f0-b13715d11cb6/core_competencies_for_collaborative_practice.pdf.
Malm H., May T., Francis L. P., Omer S. B., Salmon D. A., Hood R. (2008). Ethics, pandemics, and the duty to treat. The American Journal of Bioethics, 8(8), 4–19.
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