A Potpourri of Ethical Concepts

Locate yourself first: our self-awareness and self-knowledge is an essential tool

An understanding of one’s own strengths, resources and needs allows for more efficient use of all of these things. Self-awareness plays a big role in how we process and communicate and manage our feelings. If you’ve practiced meditation, you are already familiar with the idea of appreciating thoughts and feelings using a curious, non-judgemental lense. Resisting unpleasant feelings can often be more unpleasant than the feelings themselves: don’t fight it, don’t feed it, just notice it and let it be. 

Questions to enhance self-awareness: how is this situation impacting me? How do I experience stress, how does it impact my behaviour, my thought patterns, my body? What are my personal triggers; how do I respond and react to these triggers? Do I have needs that are not being met right now as I prioritize work and adapt to changes in all areas of life? What social support systems do I have access to through my personal relationships, my job, the government, my spiritual community, online networks?

Trauma and Post-Traumatic Stress Disorder 

Although most aspects of this situation are out of our control, it is possible to mitigate the impact of trauma on our mental health. Only a fraction of people who experience traumatic events and developmental trauma will experience post-traumatic stress disorder. Studies on first responders have identified what are known as protective factors: processes that alter the effects of adversity (Yuan et al, 2011, p.2). You undoubtedly already possess protective traits and behaviours that help you cope with everyday work stressors. It may be helpful to consider how to employ these strengths to reduce the harm caused by COVID-19. Below is a list of some of protective factors, as they are characterized in the literature:

Resilience and Conscientiousness 

Resilience describes a set of behaviours that allow us to “bounce back” more easily from negative experiences. As a nurse, you already exercise resilience. Yuan et al. (2011) describe the correlation between resilience and conscientiousness, a measure of emotional regulation: effective self-regulation during traumatic experiences decreases fear conditioning and memory consolidation, which decreases the risk of developing PTSD. Emotional regulation is a key aspect of resilience and it protects our mental health.

Adaptability

One of the greatest tools we have at our disposal is our adaptability. Just as hospitals across the world are shuffling departments around and developing and implementing new protocols at a tremendous speed, our individual family systems are adjusting to optimize collective resources and their use. There is no guidance to be offered here, only an acknowledgement of this powerful tool that you already possess and are constantly strengthening in your role as a nurse.

Perceived Social Support 

For some folks, asking for help may be one of the hardest things about this experience. Knowing who to ask and for what is daunting, especially while faced with high stress levels. Receiving unsolicited support may feel uncomfortable. We exist in community with others because everyone experiences times of need and times of abundance. All of our strengths are needed right now. Relying on whatever social support exists for you during this time is an evidence-based approach to bolstering our mental health – even though it is hard to ask.

Positive World Assumptions

 “A more positive world view is believed to influence the stress appraisal process and be helpful in coping with traumatic events” (Yuan et al, 2011). Tapping into whatever aspect of a challenging situation feels like an opportunity for growth and connection and deriving meaning from that potential allows us to cultivate positive worldviews. Positive reinterpretations of traumatic events decrease the impact of posttraumatic stress symptoms on quality of life (Nygaard & Heir, 2012), whereas negative ideas about the world and an overall lack of meaning may exacerbate or worsen PTSD symptoms (Kimble et al, 2018). Cultivating or restoring meaning in one’s life is an integral component of healing after loss or trauma. 

Coping Flexibility: accepting that which we cannot change, focusing on what is in our control

Some relevant research on the psychological impact of epidemics on nurses specifically has come out of areas most affected by the 2003 SARS outbreak, namely China, Taiwan and Hong Kong. 

A 2005 study by Cheng, C & Cheung, M. explored personality traits and coping strategies of undergraduates in Hong Kong. Their findings point to the inverse relationship between what is described as coping flexibility, a measure of the ability to apply different coping strategies according to the extent of controllability of a situation, and anxiety. Anxiety levels may be reduced by putting our energy into accepting that which we cannot change and working towards change when possible. 

Another important finding by Cheung & Cheung was that adopting a set of behaviours categorized as “avoidant strategies”, essentially abiding to strict social distancing practices, was associated with decreased levels of anxiety. The authors draw the conclusion that avoidant strategies may have eased anxiety during the outbreak. The takeaway here: focusing on the things we can control, such as the precautions we take to reduce the risk of transmission, can have a positive impact on our mental health. 

Pre-TSD: The Not-So-Calm Before the Storm

When regional efforts to flatten the curve are successful and hospitals are able keep up with the acute needs of the population, there may be less direct trauma incurred by those on the frontline. The impact of bearing witness to tragedies unfolding in neighbouring areas and from periods of intense preparation and fear is also very real. To whatever degree your worksite has changed or suffered during this crisis, there are big feelings to process and massive adjustments to be made. Your feelings are valid and your emotional responses do not need to look a certain way. 

Safety is defined by presence of cues of safety, not by the absence of danger

When we are unable to eliminate the threat to personal safety (such as during a pandemic) we can increase safety through the introduction of safety cues. A safety cue is a stimuli that signals to our nervous systems that we are safe. An increased sense of personal safety can go a long way towards improving health and reducing the wear and tear of sustained stress.  

Caring for sick patients who are surrounded by strangers in masks and isolated from family, nurses are faced with the challenge of bringing safety to the feeling of being unsafe – with limited tools to do so. How do we do this without previous knowledge of our patients’ stories and backgrounds, without visitors or personal objects, while we are also in a heightened or fearful state?  In fact, our nervous systems are all that we need to engage in co-regulation: the practice of communicating safety and connection from one person’s nervous system to another’s. Humans are wired to regulate one another’s nervous systems. It is a relational experience. It is also the basis for emotional self-regulation. Through small acts of care – words of reassurance, patience, eye contact, listening with presence – a nurse will not only signal safety to their patient’s nervous system, but to their own system as well. Communicate safety to another person and you will increase your own sense of safety,, despite the presence of danger. 

With ethical obligations must come structural supports: What did I sign up for?

Healthcare workers assume risk to protect the public at the best of times. With the increased risk associated with working during a pandemic, the moral obligation to provide care is a central consideration. As a self-regulating profession, nursing bodies are responsible for professional codes of ethics that act as guidelines for ethical reasoning. One of the greatest benefits of a clear and comprehensive code of ethics is that it provides healthcare workers with a framework for understanding the duty to care, thereby facilitating decision-making and increasing awareness and comfort  (Ruderman, et al. 2006 p. 3). 

Despite the learning opportunities provided by smaller-scale epidemics than what we are currently experiencing, there is still tremendous room for ambiguity on what sacrifices a nurse is ethically bound to make given their job and life circumstances. As stated by Ruderman et al, “as members of a self-regulating profession, nurses also have a commitment to help regulate nursing to protect the public’s right to quality nursing services”. To return to the subject of self-awareness, it is a nurse’s individual responsibility to identify what structural supports are necessary to fulfill their duty to care and to communicate these needs to the regulating bodies that hold us accountable to our code of ethics. When we emerge from this pandemic, we will be well-positioned to develop ethical contracts that state the roles and responsibilities of nurses during an outbreak and provide guidelines on everything from self-isolation to personal protective equipment – with a renewed sense of the importance of a professional code of ethics that includes the duty of care obligations during an infectious disease emergency. 

Resources and Supports 

Counselling

How to get the most out of counselling sessions: think about the protective factors that support good mental health and identify the ways in which you naturally incorporate these factors into your life in your own way. Do you feel the impact of dwelling on negative stories and naturally course correct to a more balanced narrative? Counselling sessions can be a very fertile space to develop the brain muscles that support whatever good mental health means to you.

Housing and Food 

In addition to the options available through employers and unions, groups are mobilizing quickly to provide organized support to assist people working in high risk areas to provide housing and facilitate food preparation. Find out what is happening in your area that can make your life easier. 

Your Team

Mutual support: as always and more than ever, we are each others’ safety net. It may be daunting to appreciate the extent to which we keep each other safe through mutual care, but ultimately it is powerful and effective. Our strengthened relationships with our colleagues will continue to grow and your team’s ability to cooperate and adapt is reinforced by challenging moments. 

Creative outlets

Do you like to write? Draw, play the guitar, have solo dance parties, draw or paint? Have you tried making puppets?? Articulating our feelings to those around us is important. It can also be really helpful to lift the expectation of coherent communication when expressing your feelings and to release complicated emotions in abstract, playful ways. 

References

Alexander, D.A. and Klein, S. (2009), “First responders after disasters: a review of stress reactions, at-risk, vulnerability, and resilience factors”, Prehospital and Disaster Medicine, Vol. 24 No. 2, pp. 87-94. 

Cheng, C., & Cheung, M. W. L. (2005). Psychological Responses to Outbreak of Severe Acute Respiratory Syndrome: A Prospective, Multiple Time-Point Study. Journal of Personality, 73(1), 261–285. doi: 10.1111/j.1467-6494.2004.00310.x

Kimble, M., Sripad, A., Fowler, R., Sobolewski, S., & Fleming, K. (2018). Negative world views after trauma: Neurophysiological evidence for negative expectancies. Psychological Trauma: Theory, Research, Practice, and Policy, 10(5), 576–584. https://doi.org/10.1037/tra0000324

Lai, J., Ma, S., Wang, Y., Cai, Z., Hu, J., Wei, N., … Hu, S. (2020). Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Network Open, 3(3). doi: 10.1001/jamanetworkopen.2020.3976

Perrin, P. C., Mccabe, O. L., Everly, G. S., & Links, J. M. (2009). Preparing for an Influenza Pandemic: Mental Health Considerations. Prehospital and Disaster Medicine, 24(3), 223–230. doi: 10.1017/s1049023x00006853

Morrigan, Clementine. Trauma Magic (zine)

Nygaard, E., & Heir, T. (2012). World assumptions, posttraumatic stress and quality of life after a natural disaster: A longitudinal study. Health and Quality of Life Outcomes, 10(1), 76. doi: 10.1186/1477-7525-10-76

On pandemics and the duty to care: whose duty? who cares?

Carly Ruderman, C Shawn Tracy, Cécile M Bensimon, Mark Bernstein, Laura Hawryluck, Randi Zlotnik Shaul, Ross EG Upshur

BMC Med Ethics. 2006; 7: 5. Published online 2006 Apr 20. doi: 10.1186/1472-6939-7-5

PMCID: PMC1459179

Shiao, J. S.-C., Koh, D., Lo, L.-H., Lim, M.-K., & Guo, Y. L. (2007). Factors Predicting Nurses Consideration of Leaving their Job During the Sars Outbreak. Nursing Ethics, 14(1), 5–17. doi: 10.1177/0969733007071350Yuan, C., Wang, Z., Inslicht, S. S., Mccaslin, S. E., Metzler, T. J., Henn-Haase, C., … Marmar, C. R. (2011). Protective factors for posttraumatic stress disorder symptoms in a prospective study of police officers. Psychiatry Research, 188(1), 45–50. doi: 10.1016/j.psychres.2010.10.034