Along with many of the pressures seen during the pandemic’s height, the need to enact crisis standards of care has, thankfully, abated. Yet, one of the ethical principles included in many organizations’ crisis standards of care documents seems more relevant than ever today: the ethical duty to safeguard the healthcare workforce. Why is this an ethical issue? A healthcare organization’s mission is to provide high-quality, competent care to those served. To do this, the organization’s professionals must be able to experience both physical and psychological safety while meeting patients’ needs. In this way, a healthcare organization’s duty to care necessarily extends to those served as well as to those doing the serving.
At the pandemic’s onset, the rationale behind safeguards, such as prioritizing personal protective equipment, was to maintain healthcare workers’ strength so they could provide care to the thousands of patients who would be impacted by pandemic-related illnesses. Today, nurses, physicians, technicians and support staff are in increasingly short supply, and the forces that threaten the safety and vitality of these precious resources continue to multiply.
Some threats are well-known to the industry and, therefore, have strong, evidence-based mitigation strategies. Examples include management of blood-borne pathogen exposure, back and repetitive motion injuries, and exposure to stressful situations. Other threats, however, though certainly present prior to the pandemic, have escalated dramatically during the past few years, requiring healthcare organizations to double down on their duty to protect their workforce. Following is a look at some of the more urgent threats and related ethical issues.
With the regional and seasonal ebb and flow of COVID-19, healthcare organizations have faced the seemingly endless dilemma of deciding when and for whom infection prevention measures, including mandatory quarantines, should be instituted. The polarizing issue of mandatory masking not just for healthcare staff but for patients, their families and visitors seems to be in constant debate. And the requirement of up-to-date vaccination as a condition of employment has become a determinant of whether an individual accepts or stays in a job. Facing dire workforce shortages, employers often struggle with knowing the right thing to do in these situations, and individuals’ autonomous decision-making conflicts with the duty to protect others, which is one of the most basic of all moral dilemmas.
A proactive approach to many of these tough challenges, which relate not only to the ongoing pandemic but also to future infectious disease threats, is the establishment of a standing interprofessional, interdisciplinary team charged with surveillance, data analysis and policy development. Useful to this group’s work is having access to the latest scientific evidence regarding effective preventive measures for and treatment of infectious diseases. A trusted organizational expert who can translate difficult-to-understand choices and terminology can assist executives as they communicate with employees, patients and the community.
Lastly, and perhaps obviously, it is far preferable to create policies, plan organizational responses and draft communications while not in the throes of an active crisis. Reaching out to and collaborating with other local, regional and state organizations provides healthcare organizations access to additional expert resources and reduces the burden of going it alone.
Escalating Workplace Violence
It is impossible to ignore the rise in healthcare-related workplace violence. The causes are multifactorial and have been exacerbated by pandemic-related stressors and the opioid crisis. ACHE and most healthcare-related professional organizations have taken bold positions regarding the sector’s responsibility to “treat and take steps to mitigate violence and to advocate for cultures of safety” (see the ACHE Policy Statement “Healthcare Executives’ Role in Mitigating Workplace Violence”).
Many contemporary interventions are aimed at this workforce threat. Healthcare organizations are investing in education for their employees and communities regarding the public health impacts of violence. Many have posted signs in their facilities regarding expectations for respectful communication and behavior. Training for all staff on how to recognize and mitigate workforce violence has become commonplace, and steps to make facilities more secure (access restrictions, patient and visitor screening, augmenting security staff) are being implemented.
A plan that spells out how to manage patients who display threatening behavior should also include policies and procedures for declining offenders’ access to the organization’s services. Collaboration between organizational ethics and risk management resources can manage such eventualities.
Creating an organizational committee to monitor occurrence data, review results of all cause analyses when events do occur and implement targeted mitigation strategies is an important step to keep the workforce safe. This committee’s routine reporting—directly to the organization’s C-suite and governance body—is critical to ensuring accountability for the workforce’s adequate protection.
Declining Workforce Well-Being
Pandemic-related workforce stressors and labor shortages have led to a decline in healthcare worker well-being. Whether the stressors are external to the job (childcare and schooling disruption, inflation, political polarization) or internal (working short-staffed, negative effects on work teams due to contract labor deployment) and likely a combination of the two, it is clear that the healthcare workforce is suffering. Resignations, presenteeism (when an employee is present at work but not as productive or engaged as usual due to health or other issues), reductions in work hours and callouts (last moment calling off from a scheduled shift) are at an all-time high. The healthcare literature is full of studies describing disturbing levels of stress and burnout among the healthcare workforce.
Fortunately, most organizations already are actively responding to these threats. For example, multidisciplinary wellness committees are examining data specific to their organizations and are creating plans to address workplace-related stressors. Specialists trained to reduce EHR-related workloads are being deployed to help physicians and advanced practice providers. Innovative methods of providing 24/7 mental health supports are offered to employees for little to no cost. And, strong efforts to introduce programs, services and policies that improve organizational diversity, equity, inclusion and belonging are evident. Healthcare executives have a duty to continue applying efforts and resources to these and other strategies to ensure the physical and emotional well-being of their staff members.
Protecting the Workforce Is Essential to Organizations’ Missions
As the necessary policies, procedures and programs are developed to protect the workforce, it is inevitable that ethical questions will arise. Thorny issues such as implementing mandatory immunization or masking policies, terminating a relationship with a patient due to actual or high potential for verbal or physical violence, and prosecuting patients for assaults on staff all raise moral questions that should be addressed by an organizational or clinical ethics committee.
While navigating this challenging time in history, healthcare executives will benefit from continually grounding their decisions and actions in their organization’s mission—remembering that the organization exists to provide healthcare to its community. And to do so, it needs to protect its workforce.
Susan A. Reeves, EdD, RN, CENP, is executive vice president, Dartmouth Hitchcock Medical Center, Lebanon, N.H. (susan.a.reeves@hitchcock.org).