The Moral Obligation of Nurse Leaders:

Abstract

The international pandemic of COVID-19 is unprecedented. Nurse leaders play a pivotal role in balancing the needs of their staff with the needs of the patients. Maintaining one’s moral compass during critical decision times is of the utmost importance. They do so to minimize the negative impact and maximize success for all key stakeholders and avoid moral distress. Transparent communication that is truthful, mindful, and relevant is only one of the competencies necessary to accomplish this. This article explores these challenges and offers some suggestions on staying resilient and upholding one’s moral obligations.

Key Points.

• •When leading through crisis, maintaining one’s moral compass is nonnegotiable.
• •Balance the needs of the staff with the needs of the patients.
• •Be a “truth-teller.”
• •Work to ensure your actions minimize negative impact and maximize success for all.

Leadership requires relationships cultivated over time and steeped in mutual respect and trust. The authentic, caring nurse leader recognizes that the leader–follower relationship is actualized when there are mutually shared personal values.¹ This connection has never been more important than at this time of international pandemic caused by coronavirus 2019 (COVID-19). Nurse leaders have a pivotal role in balancing the care of their staff with the care of the patients they serve. As critical members of the executive team, nurse leaders represent and give voice to the frontline realities, no matter how difficult or how much resistance they fear.

This pandemic has opened a door few have dared to walk through. Many have been forced to enter, wishing this burden was someone else’s. Education and previous experience can only take a leader so far. It is the number and weight of decisions that test moral bandwidth second by second. This is what creates the anguish. This article speaks to the overwhelming responsibility of nurse leaders to follow their moral compass and provides suggestions for continued advocacy.

Background

There have been epidemics in recent history that have challenged nursing leadership. There was the AIDs epidemic in the 1980s, Ebola in 2015, and Zika in 2016. None of these have challenged the resilience, creativity, supply chain, and human resources of our health care profession as our current situation. Only 1, the Spanish Flu pandemic of 1918, has internationally rivaled COVID-19. This is primarily due to the length of time it challenged the health care system. The Spanish Flu began in January of 1918 with victory only declared in December 1920.² During this time, schools, theatres, dance halls, churches, and businesses were shut down. Pictures from this historical event show nurses wearing masks as they care for patients.

Compounding and perhaps confounding today’s COVID-19 pandemic is the accessibility of information via the Internet. The Centers for Disease Control and Prevention (CDC) updates its website daily. There are the impassioned blogs of health care colleagues pleading for supplies. Twitter offers the conversational rants of unfairness surrounding organizational management. Television broadcasts are an avenue for the over-dramatic newscaster reporting the latest statistics. It is difficult for the nurse leader to respond timely to this simultaneous cacophony. It is difficult not to prematurely respond to staff concerns when facts are elusive or only partially understood. Leaders want to do something, but suggested actions may be in direct conflict with their moral compass.

There are some leaders who have been at the helm in times of crisis. Their accounts of the situation provide some guidance for current nurse leaders. Due to the magnitude of the current COVID-19 crisis, some of their wisdom may not applicable; however, some may be. There is wisdom in considering that the goal of any unplanned event is to ensure maximum success and minimize any negative impact.³ Frequent communication delivered with a calm demeanor is essential.⁴ Utilizing content experts and the resources they provide is vital. The nurse leader must manage the ambiguity and provide all key stakeholders truthful information. Check your actions by combining the critical elements of self- awareness and reflection.⁵ This will help you monitor your own moral compass.

Moral Distress

When leading through crisis, maintaining one’s moral compass is nonnegotiable.⁶ The underlying ethical principle of beneficence requires actions that refrain from harm and ensure the welfare of those served.⁷ Nurse leaders are held to a higher standard of ethical behavior due to the duality of their responsibility: doing what’s right for the patient, and doing what is right for the staff they serve. Frontline staff and those in leadership roles are not so different. Both will experience moral distress if they are unable to react ethically to a situation.⁸

Moral Distress of Staff—COVID-19

There are a plethora of newsfeeds reporting the grave concerns of frontline nurses in caring for patients with suspect or confirmed COVID-19. Nurses in New York City are requesting hazard pay for working in what they believe are substandard conditions.⁹ The lack of personal protective equipment (PPE), the scarcity of hydrogen peroxide wipes, inadequate equipment, and inaccessible testing contribute to the fear of constant exposure to airborne illness. Others begin the shift crying, having panic attacks, and state company leadership has threatened them with losing their jobs if they speak out.¹⁰

Nurses involved in both the Ebola crisis and the COVID-19 crisis verbalize the understanding that as nurses, they realize that caring for the sick is their responsibility. “This is what I went to school for. This is why I’m a nurse.” “I absolutely signed up to take care of the sick and dying, there’s nothing else I’d rather do, but… we have inadequate protection.”^{10 , 11} Knowing the correct procedure for handling patients with infectious diseases and not being able to act accordingly creates the moral distress.

Moral Distress of Nurse Leaders—COVID-19

For nurse leaders, moral distress can occur when the right course of action is not pursued because of an error, lack of judgment, or a decision made at a higher level or beyond one’s control.⁸ Here are some examples of each. A nurse leader may report misinformation to their staff unintentionally as they incorrectly interpret the CDC’s latest recommendations. In an attempt to maintain a sense of control during chaos, the nurse leader may exhibit poor judgment in overpromising and underdelivering. Consider the leader who ensures their staff of an abundance of PPE, only then to be told the latest shipment has not arrived. Finally, a decision made at a higher level places the nurse leader in a precarious position. The nurse leader may be chastised for expressing personal convictions at administrative team meetings. Actions contrary to those of the C-suite may cause the nurse leader to be ostracized and powerless.⁸ Any further attempts at advocating for staff and patients are futile. Despite the consequences of opposition, distrust, or faith, nurse leaders must continue to persevere and never lose sight of their morals and ethics.

Moral Obligation—Truth Telling

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases has been lauded in his efforts to combat the COVID-19 crisis. He is seen as a “truth-teller.”¹² He often restates information that may have been messaged differently to ensure that truth be told. The nurse leader must exemplify his behavior of clear communication, ensuring truth, mindfulness, and relevance.¹³

Truthful Communication

The truth can be fleeting, as information received can change instantaneously.¹³ This is why it is so important for nurse leaders to communicate frequently, qualifying statements with phrases like “To the best of my ability, we are cohorting all suspected patients,” or “based on the latest recommendations from the CDC,” or “as of this moment in time, we are due to receive a shipment of PPEs.” In her article on impactful messaging, this author instructs nurse leaders to be forthright, but vulnerable. This allows the staff to see the leader as authentic, trustworthy, and human.

Mindful Communication

Mindful communication requires nurse leader to remember their audience and place important information into context. Anxious, frightened nurses need to hear that the leader cares and respects the staff nurse for their contributions during this time of crisis. They want you to acknowledge how they are feeling before you share what you are doing. Craft messages clearly and simply to avoid confounding communication that is incorrectly received.¹³

Relevant Communication

Relevant communication creates an emotional tie between sender and receiver.¹³ When the information is perceived as relevant, a bond is created between leader and follower. This bond paves the way for interactive communication. Staff feel the leader truly understands and cares about them. Their ideas will be heard. This is fertile ground for innovative developments and possible solutions to insurmountable challenges. Use these tools to create that balance of power. Remember, as a nurse leader, you need to balance the best interest of your staff with the best interest of your patients. There will be no staff to care for patients if you do not recognize the importance of this. Maintain your moral compass.

Minimize Negative Impact/Maximize Success

During this time of unimaginable challenge, remember the goal of the nurse leader is to minimize the negative impact and maximize success for staff and patients. This can be achieved in part by enabling the potential of those around you. This is the time to call into action your think tank. This may include a mentor, as well as those trusted, intelligent leaders that you have surrounded yourself with. Now is the time to “push the boundaries to make things better.”^{14 (p.1)} This brain trust will not only advise you, they will “put your potential to the test.”^{14 (p.2)} They will compliment your strengths and negate your weaknesses. They will hold your moral compass in check. Most importantly, they will also tell you when its time to go home and rest.

Moral distress leaves moral residue.⁸ Physical and emotional manifestations of illness can drain the reserves of even the most resilient of nurse leader. You have a moral obligation to do what is right for the staff, your patients, and yourself. Stay strong, so that you can return even more resolute to bring order to the confusion that this virus has created.

Biography

Angela S. Prestia, PhD, RN, NE-BC, is director of patient care at Trustbridge in West Palm Beach, Florida, and adjunct faculty at the Christine E. Lynn School of Nursing, Florida Atlantic University, in Boca Raton. She can be reached at aprestiacap@gmail.com.