Moral outrage in COVID19—Understandable but not a strategy

Abstract

SARS-CoV-2, the virus that causes COVID-19, has likely changed the worldview of health care—at least for a generation. The unprecedented impact of COVID-19 has generated feelings of fear, grief and helplessness for people around the world, and for many health professionals, these emotions are particularly accentuated. Facing uncertainty, surrounded by death and suffering, has led many health professionals to experience moral distress, particularly because of the feeling of being unable to meet the needs of patients and colleagues. This distress has also been fuelled by concerns about healthcare rationing based on factors such as age, and feelings that healthcare systems have not been prepared for the pandemic and that patients and healthcare professionals have been put at an unnecessary risk. When moral distress is prolonged, moral outrage may follow (Rushton 2013). Moral outrage is a response to the behaviours of others, not of the individual feeling the emotion. In the context of COVID-19, moral outrage manifested as anger or frustration is evident, particularly in the context of discussion of the rationing of treatments, stifling of health personnel speaking out, shortage of personal protective equipment (PPE), threats presented to patients and service users by shortages of resources, and the level of risk to health professionals and themselves. Fundamentally, moral outrage is provoked by the perception of a violation of ethical and professional principles. Although these feelings and emotions are justified in the current situation (particularly as the road ahead is so uncertain), it is critical that we channel these often visceral emotions into actions that are going to ensure that our colleagues of the future are better prepared to face the next major health pandemic. Although we ourselves feel anger, frustration and sometimes outrage over the predicament that the world is currently in, in part because, despite multiple and authoritative warnings, there was a failure to properly prepare for a pandemic. These emotions cannot dictate professional practice in a time when patients and communities need “our” help. It is crucial that we direct these emotions into meaningful action, to convert that emotional energy into effective strategies with measurable outcomes. This involves asking some fundamental questions, how did we get here? and how do we avoid future pandemics? The threat of infectious diseases has been with us since human civilisation. For many decades, scientists have warned us about the threats of future pandemics and zoonotic diseases (Monto & Fukuda 2020). The unpredictability and infrequency of pandemics challenge effective planning. Many recent threats such as Zika, Ebola, severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) have been impactful and burdensome but not on the global scale of COVID-19. What is real is the persistent threat by RNA viruses and the ability to rapidly evolve and adapt to both environmental and host changes (Reperant & Osterhaus 2017). The COVID-19 epidemic began in China in December 2019, and the extraordinary measures taken in China, involving travel restrictions and lockdown of an entire population, should have been a clear signal around the world that we were confronting a challenge (MacIntyre 2020). Many of us were listening, watching and concerned but could not predict the rapidity and devastation of the spread. The forces of nationalism, populism and othering have not been our friends in developing integrated global solutions. The highly politicised global health environment has not enabled the cooperative agreements needed to address the threat of a global pandemic (Jacobsen 2020). In many parts of the world, public health services have not received the investment and focus required, and certainly, supply chain management has not been focused or coordinated. Moreover, structurally and functionally many public health services have not been well aligned with acute care health services. Before we can shift to addressing global pandemics, we have to shift our worldview from one of isolation and nationalism. We also need to have a broader view of health that emphasises the interconnectedness of humans, animals and ecosystems (Schneider et al., 2019). Urbanisation, migration and climate change all impact on global health. Clearly, there is a need for robust, resilient and responsive public health systems that are enabled with the data and access to technology to allow prompt and effective response to any threat. There are lessons to be learned from the much more predictable occurrence of seasonal influenza where strategies of prevention, vaccination and surveillance are robust and also the focus areas below We have looked at data from the World Health Organization (WHO) indicating that every additional 1.0 nurses per thousand in the population is associated with a −2.0 reduction in COVID-19 mortality per million. Given that understanding that high-quality nursing care is inextricably linked to saving lives during a pandemic of this nature, it is not a time to think about cutting cost to the most valuable element of a health systems labour force. Instead, health systems need to embrace the value that skill provides in addition to technology that saves lives (e.g. ventilators and vaccines). Nations are realising that in a global pandemic, they cannot count on a neighbouring country or region that manufactures important technology such as PPE, or has higher concentrations of nurses to make those resources available. Nations and states need to re-evaluate the local availability and manufacturing capabilities of these types of resources so that such important elements can be produced in large volumes quickly for a local market. For many years in many countries, the “solution” to chronic shortages of nurses has been in international recruitment. This is a practice that (though widespread and well-established) has caused concern for years because it has generally seen a shift of the world's health workers from poorer to richer nations. Aside from the obvious ethical issues associated with this, this strategy has also meant that the world's wealthiest countries have been able to avoid real examination of the causes of (and implementing the solutions for) chronic and continuing threats to balance in the nursing workforce. The WHO State of the World's Nursing Report (2020) has provided a roadmap for action but will need investment and political will to implement recommendations. The COVID-19 pandemic has laid open wide cracks evident in society, amplifying health disparities. The poor, vulnerable and marginalised in society have been at the highest risk and have been most impacted by the virus. Essential workers, Indigenous populations, and people in nursing homes and prisons have been disproportionately affected, emphasising the need for individualised and strategic initiatives in the context of a pandemic (Davidson & Szanton, 2020). Despite the large number of independent pharmaceutical and device manufacturers in the world today that are multi-billion companies, now is not the time for these stakeholders to compete against each other. Collectively, they have the scientists, clinical resources and manufacturing capabilities to innovate life-saving technology in the next 12-24 months if they work together. A world in need of a vaccine or curative treatment would be much better off, and given the billions of lives at stake, these manufacturers could rest assured that their collective effort will be highly rewarded. The speed and spread of COVID-9 highlights the importance of not only having an adequate global nursing and healthcare workforce, but also that personnel are adequately prepared to meet the needs presented by a global health emergency. This means access to suitable PPE and knowledge about how best to use it, strategies to provide appropriate care to whole populations, so the focus needs to go well beyond emergency departments and critical care environments. There needs to be plans in place for immediate outreach and deployment of appropriate support and expertise into residential care settings, primary care settings—in all settings and environments where there are people, and the needs of particularly vulnerable populations must be considered and planned for. The qualities of a good, effective leader are debatable, but three things are certain that in times of a pandemic a leader must act on. First, a leader must anticipate and respond to the needs of their people with actionable methods. Second, a leader must respond with empathy to the patients, families and frontline healthcare workers who are all at risk. Third, a leader should not politicise a pandemic for their personal reward or that of their party; these are times when divisions should be bridged, as nations are strong when we work together to fight a pandemic rather than split apart. Boin et al. (2020) comment that leadership practice in a pandemic such as COVID-19 presents challenges, priorities and demands. They describe five challenges to be considered: ‘detecting incoming issues in a fast-changing situation, making sense of a dynamic threat with limited information, making life-or-death decisions, the art of strategic co-ordination, and keep worried public and wary workers on side’ (Boin et. al., 2020 p2-3). Within health care, and particularly (for us) is the need for strong global nursing leadership that can effectively advocate for nursing in all staging of health crises, including in preparatory phases to ensure a global nursing workforce that is adequately prepared to meet the healthcare needs of populations during pandemic, but also to ensure that the nursing workforce is safe and adequately resourced to be able to provide the care that is needed with as much safety as possible. The COVID-19 pandemic is a reminder that all life on the planet is inextricably linked and there is a need for an intensified commitment to integrated and coordinated healthcare systems with embedded global public health preparedness. This will require shifting our focus from local and national strategies to a broader and collaborative international consensus and methods of governance. Failing to do this will place each one of us at risk. Nurses need to engage not only in workforce preparedness but advocacy for vulnerable populations. We are in a moment in history where moral outrage and moral distress are features of the current situation. It is up to us all to harness the energy and dynamism generated by this pandemic to create and contribute to positive change that will benefit future populations and generations of nurses.

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