Time to Adjust the Sails
The pessimist complains about the wind; the optimist expects it to change; the realist adjusts the sails.
– William Arthur Ward
After a year of living a masked, isolated, virtual existence, there is much reflection among healthcare decision makers and providers around the world. What have we done well? What could we have done better? And more importantly, how will we ensure that our learnings inform decisions and actions the next time? In this latest installment of crisis leadership papers, authors address the toll exacted upon our profession thus far. Although profound, the psychological sequelae of the COVID-19 pandemic are directly related to a number of pre-existing conditions that have been festering below the surface for several years. In particular, blame for the state of health inequities, ageism, staff shortages and workplace violence cannot be ascribed to the pandemic. Rather, each has been exacerbated because of it.
We need to seriously consider the consequences of continuing to be collectively oblivious to these issues; we ignore them at our peril. Not to mention the effects of a workforce enduring sustained uncertainty and compromise – will the profession experience a mass exit of nurses suffering from post-traumatic stress disorder (PTSD), burnout and/or sheer exhaustion?
While nursing shortages are becoming a reality in many parts of the country, some jurisdictions are eliminating positions, further compounding the physical and psychological burdens on those left behind. Dire conditions in nursing homes have been exposed and in part can be directly attributed to insufficient staffing of both professional and support personnel. It has been suggested that nurses at the coalface of caring for COVID-19 patients have probably surpassed burnout and moral distress and are likely now suffering from "moral injury" (Hossain and Clatty 2021). Typically, this term has been used to convey the combat experience of soldiers faced with circumstances contrary to their values and moral beliefs (Norman and Maguen n.d.). Over the course of the pandemic, many nurses have confronted incredibly difficult situations, being forced to make critical choices about care and decisions counter to their morals and professional ethics. While it may seem overly dramatic, this comparison is not a hyperbole but a very real and tragic consequence.
In this issue, Sriharan and colleagues (2021) describe the findings of a rapid scoping review, summarizing the empirical research on COVID-19-related burnout and moral distress in nurses. They identify the interventions being utilized to mitigate these adverse outcomes and provide nurse leaders with strategies for consideration. Caxaj et al. (2021) posit that actions on health inequities have been insufficient to date and offer approaches to close the gaps and address disparities made visible by the pandemic. Whether it is the aged, the Indigenous, the homeless, the newcomer or the rural community, all have shouldered their share of burden throughout. In this commentary, the authors emphasize the need to move from discussion to action for a principled, moral approach to the provision of healthcare – one clearly guided by a health equity lens.
Ouellette et al. (2021) detail the experiences of two emerging nurse leaders in leading a national virtual health trial during the COVID-19 pandemic. They share the experiences and lessons learned from training and leading a national team of nurses to deliver a post-discharge virtual intervention for surgical patients. Of note is their assertion that an effectual "webside manner" be considered a central dimension of virtual care provided by nurses and others.
Informed Cultural Change
Using the question-and-answer approach of Socrates and Aristotle, Giannouli and Giannoulis (2021) contemplate the origins and application of critical thinking and emphasize the importance of considering the context of cultural factors when making decisions. Furthermore, in the context of a technology-mediated world and the increasingly prevalent alternate realities and truths, they suggest the need for not only novel approaches to decision making but also the teaching and application of critical thinking capabilities. Critically thoughtful, skilled and informed decision makers are the order of the day, now and into the future.
Nelson and Baumann (2021) compare and contrast professional and union positions on issues of workplace violence against nurses. They argue that it is important to consider specific patient circumstances wherein nurses' ability to provide skilled, ethical care is not threatened. Furthermore, differing union and association views impede rather than support effective approaches to workplace safety. They identify the need to examine the efficacy and consistency of approaches to workplace violence in order to allay nurses' moral distress.
Three illustrations of innovation in clinical care and nursing practice are described by Ackerman et al. (2021). Using exemplars from three clinical settings, they describe the processes used by nurse leaders to free nurses to develop new ideas and adjust practice to ensure cost-effective, high-quality and efficient patient care. Regardless of the opportunities and benefits to be realized, the authors acknowledge that there are challenges associated with cultural change, capability and capacity development, and the ability to secure investments for nurse-led innovations.
Over the course of this and the previous two issues of the Canadian Journal of Nursing Leadership, our contributors have shared their strategies and innovations in the face of the pandemic. In our next issue, authors will specifically focus on the challenges and responses to nurses' mental health. During the ensuing months, it will be critical for nurse leaders to take action to bolster morale and resilience and minimize a post-COVID exodus of nurses. While new challenges have surfaced during the pandemic, issues of staffing shortages, ageism, health inequities, moral distress and workplace violence have been further amplified and laid bare. These issues are clearly jeopardizing the "moral determinants of health" as described by Berwick (2020) for nurses and citizens alike. To this end, nurse leaders are called upon to advance and render changes in practice settings that will ensure the realization of a moral and ethical healthcare future. The revelations of the past year dictate the need for several course corrections; now is the time to adjust the sails to realize our preferred destination.
Lynn M. Nagle, PhD, RN, FAAN, FCAN
Director, Digital Health and Virtual Learning
Faculty of Nursing, University of New Brunswick, Fredericton, NB
Adjunct Professor, University of Toronto, Toronto, ON
Adjunct Professor, Western University, London, ON
Ackerman, M.L., L. Jeffs, B. Simpson and S. Williams. 2021. Developing a Culture of Support to Advance and Accelerate Innovation. Canadian Journal of Nursing Leadership 34(1): 60–71. doi:10.12927/cjnl.2021.26454.
Berwick, D.M. (2020). The Moral Determinants of Health. Journal of the American Medical Association 324(3): 225–26. doi:10.1001/jama.2020.11129.
Caxaj, S., A. Oudshoorn, M. Ford-Gilboe, F. Webster, L. Donelle, C. Forchuk et al. 2021. Taking a Stand to Remedy the Inadequacies of Action on Health Equity Exposed by COVID-19. Canadian Journal of Nursing Leadership 34(1): 20–29. doi:10.12927/cjnl.2021.26458.
Giannouli, V. and K. Giannoulis. 2021. Critical Thinking and Leadership: Can We Escape Modern Circe's Spells in Nursing? Canadian Journal of Nursing Leadership 34(1): 38–44. doi:10.12927/cjnl.2021.26456.
Hossain, F. and A. Clatty. 2021. Self-Care Strategies in Response to Nurses' Moral Injury during COVID-19 Pandemic. Nursing Ethics 28(1): 23–32. doi: 10.1177/0969733020961825.
Nelson, S. and A. Baumann. 2021. Not Part of the Job: An Analysis of Characterizations of Workplace Violence against Nurses in Canada by Unions and Professional Associations. Canadian Journal of Nursing Leadership 34(1): 45–59. doi:10.12927/cjnl.2021.26455.
Norman, S.B. and S. Maguen. n.d. Moral Injury. PTSD: National Center for PTSD. Retrieved February 24, 2021. <https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp>.
Ouellette, C., M. Bird, P.J. Devereaux, J. Lounsbury, A. Djuric-Paulin, B. LeBlanc et al. 2021. A Case Study of Two Emerging Nurse Leaders Specializing in Virtual Health during the COVID-19 Global Pandemic. Canadian Journal of Nursing Leadership 34(1): 30–37. doi:10.12927/cjnl.2021.26457.
Sriharan, A., K.J. West, J. Almost and A. Hamza. 2021. COVID-19 Related Occupational Burnout and Moral Distress among Nurses: A Rapid Scoping Review. Canadian Journal of Nursing Leadership 34(1): 7–19. doi:10.12927/cjnl.2021.26459.
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