Nurses across Ontario have submitted hypothetical situations to the College highlighting the challenges nurses can face during a pandemic. Reviewing these scenarios can support you in developing strategies for applying the practice standards in the event of a pandemic.
If you have a question or want to submit a scenario, contact your sector’s Outreach Consultant.
Over the past three weeks, an influenza pandemic has had an enormous impact on the medicine in-patient unit where Cindy, an RN, works. Recently, the unit became dedicated to clients with influenza. Today, one-third of the scheduled nurses are absent, and Cindy has been assigned four clients on top of her usual client load. She also has the time-consuming task of putting on personal protective equipment with every client contact.
At the beginning of the shift, Cindy assesses her clients and takes their vital signs. For the remainder of the shift, though, she cannot check their vital signs as frequently as ordered, and she only has time to document abnormal findings. There isn’t time to assist the clients with daily hygiene tasks. Cindy also can’t administer all of the clients’ medications within the required timeframe. She attempts to meet each client’s emotional needs but can only stop to speak with those who ask to talk to her. Cindy is aware of the College’s Preparing for an Influenza Pandemic fact sheet. She is concerned that she’s not meeting the College’s expectation of adhering to the practice standards and guidelines during a pandemic.
Prior to a pandemic, health care organizations need to create policies that establish procedures to follow during such a serious event. Advance planning can establish ways to avoid circumstances in which nurses find themselves faced with difficult decisions in a complex environment. It also provides employers with the opportunity to use foresight to set up the necessary resources, policies and organizational supports that nurses will need to provide safe, effective and ethical care.
During a pandemic, nurses need to use critical thinking to establish priorities that protect the client and add value to client outcomes. Cindy could collaborate with her team members to prioritize the clients’ care needs and eliminate any non-critical care activities; for example, they could reduce the frequency of taking the vital signs of certain clients. These decisions need to be communicated through documentation that reflects the assessment, intervention and client outcomes.
Cindy is concerned that she can’t meet all of her clients’ emotional needs. A nurse establishes and maintains the therapeutic nurse-client relationship through the use of professional nursing knowledge, skill, and caring attitudes and behaviours. During the initial introduction, it is important for the nurse to inform the client of the general composition of the health care team. At this initial meeting, Cindy could also indicate to the client that his or her essential care requirements will be met. In collaboration with the client, Cindy could outline what the client’s essential care needs are and inform the client of the expert resources available to meet his or her particular needs.
Sharing this information with the client helps place the therapeutic nurse-client relationship in the context of the current environment. The nurse meets the Therapeutic Nurse-Client Relationship, Revised 2006 practice standard by actively including the client as a partner in the care. The nurse further meets the standard by discussing expectations with the client and informing the client of what will be done to meet critical needs given the available resources. To achieve identified client goals, it is essential to negotiate the role of the nurse and the client, including the client’s family members and significant others.
Cindy has responded to those clients who have asked to speak with her. Cindy could collaborate with the health care team regarding her concern about ensuring that all of her clients’ emotional needs are met. Through advocacy and collaboration, the team could develop a supportive infrastructure of volunteers, pastoral care workers, psychologists, psychiatrists and/or palliative care workers to provide a consultative/referral resource to assess/meet the clients’ psychosocial and emotional needs. During a pandemic, nurses need to be leaders in influencing organizational decisions to ensure the most efficient use of the health care team to meet client care requirements.
To prepare for a pandemic, it’s key to become aware of the expectations outlined in the College’s practice standards. The standards can help nurses understand their accountability and assist them in making informed decisions.
For example, the practice standards address issues around accuracy and timelines but do not establish specific medication administration times, documentation methods, frequency of assessments or hygiene requirements. The process of achieving these expectations needs to be established prior to a pandemic.
Identifying potential situations that may occur during a pandemic and working them through with the practice standards as a basis for decision-making allows both nurses and organizations to be proactive.
In the paediatric unit of a community hospital, extended family members and close friends form part of the circle of care. In the event of an influenza pandemic, though, the hospital’s leadership team intends to restrict visitors. During a pandemic, only the parents or guardians of the paediatric client will be allowed to visit the child.
The unit’s nurses are worried that this policy will reduce their ability to provide family-centred care to the infants and small children in the unit.
Mary, an RPN, is concerned about how the restricted visitor policy will affect family dynamics. Aunts, uncles and grandparents frequently take shifts staying with the child in the hospital. Siblings visit on a daily basis, and parents have expressed how much they value being able to care for their children during a hospital admission.
Mary is also worried about whether her clients will receive enough attention, and whether the children’s developmental needs will be met with fewer visitors to interact with them. Also, as the pandemic progresses, there will be staff shortages as members of the health care team become affected by the influenza.
She has discussed these issues with the other nurses on the unit. Together, the unit nurses have alerted the hospital’s leadership team of their concerns.
Nurses, as leaders, need to advocate for organizational pandemic plans that reflect the care requirements and best interests of their clients.
It is important that Mary and the other nurses on the unit become familiar with all of the details of the organization’s pandemic plan. Then they can develop strategies to educate families and clients about the changes in hospital visiting policies. When discussing infection prevention and control, appropriate, timely communication strategies help clients, their significant others and the community.
In collaboration with the health care team and clients’ families, Mary can develop a plan of care for her clients that will meet the Professional Standards, Revised 2002 practice standard during the pandemic. This standard is applied by demonstrating respect for, empathy with and interest in clients, and by developing collaborative partnerships with clients and families that respect the client and family’s needs, wishes, knowledge, experience, values and beliefs. By involving the family when an infant or child is admitted, a plan of care that will meet the needs of the client and the family can be mutually agreed on.
When direct visitation is not possible, innovative care planning – such as the use of technologies to link siblings and significant others to the client – could be considered. You may also want to ask other members of the health care team – such as unregulated care providers and pastoral care workers – if they are willing to perform other responsibilities, such as interactive play, to meet the young clients’ developmental needs.
Marion is an RN who works full-time in a 32-bed, secure Alzheimer’s unit in a long-term care facility. Three weeks ago, there was an influenza outbreak in the facility. The administrator and the director of resident care, in consultation with the medical director and the designated infection control professional, decided to “close the unit.” Closing the unit meant no one was admitted to the unit, there were no outside appointments or activities for residents permitted, and visitors, except for family members and non-essential staff, were limited. These actions were taken to minimize the spread of the influenza outbreak to other units in the facility and to the outside community.
The outbreak lasted for six days and did not spread to other units.
During the outbreak, the facility was consistently short-staffed due to staff illness. Marion was concerned that she and other nurses were working too many shifts to do their jobs properly. Marion felt that residents’ care needs were met with the assistance of residents’ family members and available staff. However, during a pandemic, family support would be limited and may be inadvisable.
Now that the outbreak is over, Marion has reflected on the challenges everyone faced. Marion is concerned that in the event of a pandemic, staff might not be able to meet residents’ care needs and the College’s expectations in the Therapeutic Nurse Client Relationship and Decisions About Procedures and Authority standards. She worries that if a resident needed to be transferred to an acute care facility during a pandemic some of the resident’s care requirement might not be met.
Marion has asked for a meeting with the director of resident care to discuss the facility’s influenza pandemic plan. Before the meeting, Marion plans to review the College’s Ethics and Therapeutic Nurse-Client Relationship practice standards.
Marion demonstrated leadership by reflecting on the outbreak and asking to meet with the director of resident care. She is also prepared for her meeting by being aware of and using the resources that are available to her such as College practice standards.
Based on her reflections and follow-up discussions with the director, Marion could work with the health care team to create potential clinical scenarios and plans to address them to promote the best possible outcomes for residents. Even though staff and resources would be stressed in a pandemic situation, she recognizes that nurses are still accountable for providing safe, effective and ethical care.
Marion should collaborate with colleagues within her practice setting (and potentially across practice settings) to create policies that establish procedures to follow during an event such as a pandemic. Planning in advance can help organizations establish processes for making difficult decisions in emergency situations. Such planning also gives employers the opportunity to anticipate the need for and set up the resources, policies and organizational supports that nurses need to provide safe, effective and ethical care to residents and their significant others.
The public health unit where Owen works as a nurse recently completed its pandemic plan. Many of Owen’s colleagues have said they will refuse to work during a pandemic. In the event of a pandemic, Owen is worried about his family’s health.
He is unsure how to balance his professional and family commitments, and how much personal risk to accept as part of his job. He wonders if he will have to report for his shifts and what process he should follow if he refuses an assignment he feels is too risky.
When it comes to ethical choices, there are no right or wrong answers. It is difficult for nurses to determine the level of risk to accept as part of their job. Sometimes, personal factors influence your professional life. Providing care in a pandemic may affect and even impair a nurse’s ability to fulfil other commitments to family and colleagues.
Here are some issues Owen should consider:
- Does he have the appropriate supports (e.g., infection control guidelines or policies) and resources (such as protective gear such as gloves and masks) to minimize the risk of infection?
- Does he have other obligations (e.g., to elderly parents or young children) that are significant enough to outweigh his duty to his clients?
- Does he have the knowledge, skill and judgment to perform his assignment?
As a self-regulated professional, Owen is required to practise according to professional standards and codes of conduct to demonstrate his commitment to clients, colleagues and the nursing profession.
As a nurse, Owen’s primary concern is his professional commitment to clients, as outlined in the College’s Ethics practice standard. When nurses make evidence-informed decisions using their knowledge, skill and judgment, they meet the expectations of their profession.
By choosing to enter the nursing profession, Owen has agreed to assume a certain amount of personal risk. He understands that as a nurse he may come into contact with infected fluids or airborne contagions in a wide range of care situations.
During an outbreak, however, many nurses assume a level of responsibility and risk they may not have considered when they initially chose nursing. Nurses working directly with clients with highly infectious diseases may find themselves assuming a high level of risk. In these cases, they may need to determine for themselves if the risk is too high.
All nurses are expected to understand and apply precautionary measures to minimize the risk of infecting themselves, colleagues, clients and others. One way Owen can increase his sense of control and manage the risks of his profession is to learn about infectious diseases, infection prevention and infection control. (To learn more about these topics, refer to the Infection Prevention and Control resource.)
While Owen is responsible for providing care to clients, he can still set parameters. He should discuss his concerns with his employer, identify the supports he needs, and explore options and alternatives.
If Owen considers refusing an assignment due to inadequate resources or support, he can demonstrate his commitment to a quality practice setting by following these steps:
- assess the situation to determine the problem, the key individuals affected and the decision needed;
- gather additional information to clarify the situation;
- identify the ethical issues;
- identify personal and professional positions or any value conflicts (e.g., conflicts based on religious principles);
- identify the positions of the key individuals involved;
- identify the range of possible actions and their anticipated outcomes;
- decide on a course of action and implement it; and
- evaluate the results of the decision and action.
This decision-making process can be applied in any situation involving an ethical conflict. Using this process shows a commitment to ongoing reflective practice.
If Owen chooses to refuse an assignment, he can still meet professional obligations to his clients by informing his employer of his reason(s) for refusing, documenting his decision-making process and providing his employer with enough time to find a suitable replacement. (For more information, see the College’s Refusing Assignments and Discontinuing Services practice guideline.)
June, a nursing coordinator in a correctional facility, has volunteered to be part of the institution’s pandemic planning committee. June’s top pandemic planning priority is staffing.
Currently, there are number of vacant positions at June’s institution. The nursing staff work a lot of overtime and say they are overwhelmed. The nurses are concerned that in the event of a pandemic, staffing levels will dip further, making it even more difficult for them to provide client care. They also say they will not be able to work any more overtime shifts than they currently work. They worry that the institution will perceive this refusal to take on additional overtime as abandonment.
June could address her co-workers’ fears by providing them with information. The College’s Infection Prevention and Control resource and the Decisions About Procedures and Authority practice standard helps nurses create a safe practice environment for themselves, and for their co-workers and clients. By reducing the risk of infection, nurses also help maintain staffing levels.
The Refusing Assignments and Discontinuing Nursing Services practice guideline addresses the issue of abandonment. June could use the document to engage staff and organizational decision-makers in a discussion about the supports, resources and workload issues that would arise in the event of a pandemic. She could also take on a leadership role in developing policies and contingency plans to help staff provide optimum health care during such an event.
When working in an environment where the primary focus is not health care, nurses may face unique challenges in preparing for a pandemic.
For example, nurses who work in a correctional facility will need to take security issues into account during a pandemic. They may also need to be flexible about how care is delivered. For example, non-nursing staff may have to help distribute medications to inmates. To prepare for this, June and her co-workers should review the College’s Working with Unregulated Care providers practice guideline.
June and the pandemic planning committee should develop a communications plan for staff and clients that:
- addresses staff questions;
- clarifies how staff roles may change; and
- explains to clients how facility nurses will provide care in the event of a pandemic.
The committee and organizational decision-makers should also develop a plan for staff to acquire any new skills they identify as being necessary in such a situation.
For more resources, see the College’s Decisions about Procedures and Authority, Revised 2006 practice standard.