Dan:
Liz, thanks for joining the show today.

Liz:
Absolutely. Thank you, Dan.

Dan:
Hey Liz, can you give the listeners a little background on what brought you into the ethics realm of nursing practice?

Liz:
My ethics vision started when I was at the bedside as a frontline nurse. I encountered so many ethical dilemmas with patients and families, and there was no handbook. There was no procedure or guidance. And I really thought somebody has to know the answer to these questions.

Liz:
And it's funny, I remember working in an intensive care unit and going to the attending and saying, "Look, we have this huge ethical dilemma and no one knew what to do." And it was something that I couldn't reference back in nursing school. And I thought, "There's got to be a path and an avenue for this," and it was bioethics.

Dan:
Can you give the listeners a little bit of an overview of bioethics? When I think of it and when I was involved with it as a frontline nurse, it seemed like this magical committee that met with a bunch of smart people that read a lot of things, but there was also a lot of gray area in there. And there was no finite answers and everything was kind of a debate, but I would love to hear your description of that process in the bioethics field.

Liz:
Most of the time when people think of ethics, they think of what's right and what's wrong. And I generally think of ethics as what's right and what's right. Because you have two or more different options that are really feasible and you got to figure out which one is the best for everyone who is involved. And so there is no black and white answer. And a lot of the times and nurses get so frustrated because they'll come to their committee or they'll come to the ANA Center for Ethics and they'll say, "Tell me what to do. Here's my dilemma."

Liz:
And I always say, "I'm not going to tell you what to do." I said, "I'll tell you how to think through it." So we'll tell people how to make good ethical decision-making, but we're not going to give you the answer because it's really based on so many different factors, including someone's own personal and professional values. And so you think about it in the hospital, you're dealing with patients and families and they're coming to you with different personal values and preferences, spiritual or religious preferences. And you're coming to them with science and medicine.

Liz:
You're saying, "This is what we're going to do for you." And the patient might say, "No, actually that's not what I want. I want something different." And so you've got to really come to a meeting and it's almost like mediation. You've got to come to a place where everyone is in agreement and it's something that's medically sound and safe in order to proceed. There's a lot of gray and it makes people uncomfortable, but ethics is really there to help make sure you think through it.

Dan:
Sure. No, that's great. How much do you go back to the nursing code of ethics? I mean, I assume that's like a foundational document for a lot of these discussions, but how much do you reference that? And then what else is out there that you can point people to get more into healthcare ethics?

Liz:
I use the nursing code of ethics probably every day or every other day.

Dan:
You probably memorized it, right?

Liz:
I do, I do. It's kind of scary if I can throw out a specific provision or even a page number, I often frightened myself. I'm very familiar with the code of ethics. And I do think it is one of the foundational documents for the nursing profession. And it is not something, again, that's going to give you that open page seven and there's your answer. But it's going to give you a foundation and an ability to really think about, "Okay, what are the important ethical considerations?" Is it an end of life situation? Is it a beginning of life situation and kind of what are the factors that involved?

Liz:
Nurses can also absolutely go to ANA. They can come to ANA to the Center for Ethics. We have actually an ethics inbox. We used to call it a mailbox because people used to mail us. And so we know the center has been around for 30 years, so we've advanced to email. So now we call it the ethics inbox. But we get roughly 300 or so questions each year from nurses and patients from around the world that are asking us things, complicated things. And sometimes things that aren't so complicated, but questions like, "I'm a nurse manager and I have two applicants and they're husband and wife, and they want to work together on my unit. What are the ethical situations?"

Liz:
We get questions about, "I hear nurses using discriminatory language towards patients. I don't know what to do. Can you help me?" So there's a range and a whole host of things that we can do to help nurses as well as patients and families with ethical decision-making. And then there's actually a huge society. It's called the American Society for Bioethics Humanities, and that society kind of wraps everybody in it. So there's nurses, physicians, philosophers, lawyers. There's tons of health professionals that are all interested with ethics as a part of that organization.

Dan:
How did you get first started into this? I mean, you mentioned at the bedside, you had some interest in these ethical dilemmas as they happen to you. But what made you jump in and go full bore and end up going to law school and really diving into this as an expert?

Liz:
It was the guidance of a peer on the front line. So at the time I was working in North Carolina at Duke University Hospital in their intensive care unit. And one of my colleagues said, "Hey, I know someone who actually went to law school. She went to law school and she's interested in ethics and kind of the same things that you're interested in." And she partnered with me and I reached out to her. She partnered with me and said, "Oh my gosh. Yeah, sure. This has been my career path. I'm happy to share it with you." And crazily, I found an organization. It's always about organizations.

Dan:
It's about networks.

Liz:
It is. I found an organization called the American Association of Nurse Attorneys. And I said, "Oh my gosh, this is so cool." And so I applied to law school, I got into law school and I joined TANA, that's their acronym. It was great. They just put me under their wing. And I got to meet a whole host of nurse attorneys. I said, "This is me. There are other people in the world that are like me."

Liz:
And it's interesting when you're going through these career choices and paths especially as you're pivoting, you're always like, "Am I making the right decision? Is there anybody else out there like me that wants to do this?" And to find your group or to find your people is always so refreshing and rewarding. And so that really helped shape my path and my career. As I delved into ethics, I studied ethics while I was in law school. And then as I got out, I just loved it. It was something that invigorated me. I felt really passionate about it and I just continued to pursue it.

Dan:
That's awesome. And I'm sure you're mentoring nurses now who are getting involved as well.

Liz:
Absolutely. The nursing ethics profession is very, very small and I'm trying to spread it. I wish I had a sign or a megaphone where I could say, "Come to nursing ethics." Because we are a small profession, a mighty profession, but we definitely need more nurse ethicists in the field.

Dan:
And what's coming to mind is as I've looked across the country with nurses going into hotspots related to COVID and things. It's accelerated the number of ethical dilemmas I think nurses are facing. And I'd love to hear from your view seeing pretty much across the country, what trends have you seen since COVID started that have bubbled up as ethical dilemmas that nurses are really struggling with?

Liz:
When this pandemic first started, I started putting some feelers out among colleagues to say, "What are you guys talking about in the ethics space? Are you guys ready for this? Are you prepared? Are you talking about it?" And a lot of people said, "There's no ethical dilemmas. There's no ethical issues." They're more worried about, "Okay, do we have staff? Do we have PPE? Do we have et cetera, et cetera." And I said, "We've got to be thinking about these ethical issues. You can't sweep these under the rug."

Liz:
And so I reached out to my nursing ethics community and they were on it. And so we were able to really talk about issues ahead of time. We were able to talk about things at a national level, but as well as a state and organizational level because that's where it really counts. And so I was able to connect with several nurse ethicists that are working in acute care facilities across the country and say, "What are you facing?"

Liz:
And so when this first started, we were able to touch base with a nurse ethicist in Seattle. And she's talking about how, yes, PPE is such a significant issue. And as a result of the PPE, nurses are feeling moral distress. So they're feeling burnout. They're feeling moral distress thinking, "I don't want to come to work because I don't feel safe. I don't have what I need, i.e. PPE to adequately care for my patients and to deliver the care and I might get exposed. And then that means my family might get exposed and my loved ones might get exposed."

Liz:
And so, as we thought about this moral distress, we could see more and more nurses that were really starting to just break down. And there were some nurses who said, "I can't do this. I cannot do this. I can't deliver this care." And so they quit their job. They actually quit their job. And then that leaves the units in a more dire situation when you don't have enough staff. And so we could kind of just see the ripple effects of things that were happening related to PPE, but also related to the number of people that were dying and especially in the hotspots.

Liz:
We knew that nurses were literally seeing people die and then they were moving them out and getting someone else in their room, and they would see someone else die. I spoke to one nurse who actually witnessed six people die in one day.

Dan:
Oh my gosh.

Liz:
Yes. So you just imagine the trauma that that can cause as you're in adrenaline mode, right? So you're not only are you witnessing it, but you're actually involved because you're giving that compassionate care that nurses give at the end of life and you're doing it without their families or their loved ones there to support them. It's almost like the nurses are pseudo-family. So you've got to deliver the actual care, the nursing care, but you've got to deliver that emotional care and you're packing all of that in, and then you're shifting it out and you're getting it again and you're doing it over and over and over.

Liz:
And so we knew that the emotional distress, the potential for post-traumatic distress disorder was going to be huge. It still is. That potential is still huge. The interesting thing about the pandemic is the way that it traveled. We could see the effect on nurses in other countries. So we could see the effect of nurses in China. We could see the effect of nurses in Italy where nurses were just breaking down, where nurses were losing sleep. Sadly, we saw nurses that were actually committing suicide. And so we really were saying, "We need to be prepared. This is going to happen. What are we going to do to address this ahead of time and address it proactively?"

Dan:
It's amazing what nurses are going through and how they continue to push on through it.

Liz:
Agreed. One of the things that I've also been hearing is that nurses are saying, "I was prepared in school to deal with the clinical aspects of this. I can handle a dying patient. I can handle a critically ill patient. I'm able to do this or I can quickly obtain this skill set." They said, "What we're not prepared for is not having the adequate resources or PPE to deal with this." And so that was really a pain point is they said, "This isn't supposed to happen. This is the United States. We should have resources and we should be prepared for this."

Liz:
And to your point, I think really trying to just give nurses the clear picture. You may be in a situation where you are rationing, where you're rationing resources or you're rationing devices or medications, and how to best prepare for that. And I think that that helped alleviate some of the issue and some of the distress, but I don't think its done that completely.

Dan:
One of the things I've been mentioning to colleagues is the worst thing that can happen after this pandemic is we go back to the way it was. And so when it comes to moral distress and preparing nurses to deal with these situations. Because I'm sure this is not the last time we'll have some major event like this, where healthcare workers have to step up and kind of be that hero.

Dan:
But what are some resources that nurse leaders and healthcare leaders can start instituting now so that the workforce is better equipped for the next time?

Liz:
At the American Nurses Association, we started a Well-Being Initiative and this was an initiative that was directly in response to COVID-19 and thanks to the American Nurses Foundation, we partnered with the American Psychiatric Nurses Association, the Emergency Nurses Association and the American Association of Critical Care nurses to develop this really incredible initiative that is a comprehensive mental wellbeing program and it includes virtual support systems. So nurses can actually virtually get support and receive support.

Liz:
And then it also has this really cool digital toolkit. And this supports what we call near and long-term needs for all of America's four million registered nurses. And so there's an app. So of course the digital piece, there's an app to help with wellness goals. And one of the things that we strongly, strongly support at ANA is a healthy nurse. So we have a program called Healthy Nurse, Healthy Nation. We've had that for quite some time now. And that goal is to improve the health of the nation by first improving the health of its nurses.

Liz:
So there's four million registered nurses. That means every single person knows a nurse, is related to a nurse or married to a nurse or somehow or another, there's a nurse in your life. And so our goal is if we can improve the health of the nurses, we can improve the health of the nation. And so we really want to help encourage nurses to reach out, to use those support services. I've heard a lot of nurses find tremendous benefit in peer-to-peer. And so the Well-Being Initiative actually offers this peer-to-peer call where nurses can talk to other nurses from around the country to receive support.

Liz:
And then there's also this component of journaling. And that's something that I actually have just recently within the last year I've been doing myself and really gotten interested in and learning the benefits of journaling. And this is simply just having nurses, sometimes it can be guided, but other times it's just writing down your thoughts or your emotions as you're going through them. And then doing a period of reflection. We're actually going back and you're saying, "Oh my gosh, I remember this was really a hard time. It's really great to see that I've advanced" or it might be the opposite.

Liz:
I could just say, Oh my gosh, "Things were better than, but I'm not in such a great place that I was in before. What do I need to do to help myself change?" And then on an organizational level, this has been so great to hear all of the hospitals and organizations that have proactively addressed mental health through different programs. So there's different programs such as Care for the Caregiver. And this is a program where different hospital personnel will actually go out to the units and talk to the nurses and provide support to the nurses.

Liz:
I know there've been some units actually have had a psychiatrist on the units to help during COVID and during these times, and sometimes it's virtual. Sometimes it's actually in person. There's some organizations that have pet therapy. So they actually have a pet or a dog that will come out. And the research shows people will always come up to you if you have something cute and furry. People are more likely to come up to you and talk to you versus when you're not.

Liz:
And then there's actually programs that have been existing, that again are well-researched and supported such as moral distress rounds or moral distress consultation services and there's a pager. So if you feel like you're having moral distress or if your unit has experienced something traumatic on your unit, you can page the moral distress team and they'll actually come and help the teams debrief and talk through and work through these issues.

Liz:
And so knowing that we can continue these programs and then for the organizations that don't have these programs, this is the time. This is the time to start them. People can always contact the American Nurses Association because we can give services and provide guidance on how to start these types of programs, because we know they're critical for nurses and they're critical for the success and recovery of nursing as well.

Dan:
Yeah, I totally agree with you on that. And there are a lot of resources out there and I was super excited to see that ANA put together the resource center and all the amazing partnerships there. It's exactly what we need. And I'm an underling of Dr. Bern Melnyk so Healthy Nurse, Healthy Nation is front and center for every single day at school at Arizona State. And now I worked with her at Ohio State. So supportive of that too.

Dan:
A lot of it is nurses want to leave things at the bedside and you don't realize until you've been through some of those traumatic shifts and seeing some of those things that it lives with you as soon as you walk out of the door too. And so equipping the profession with tools to take care of themselves, both at home and at the bedside I think is critical for us.

Dan:
As we pivot away from COVID, what are some of the other top issues that are on the minds of nurses? You said, you get 300 queries into the inbox a day or a month. What are some of those other things that are top of mind of nurses as they kind of question the ethical dilemmas in their lives?

Liz:
I can tell you what's top of mind with the nurses now and that's specific to what's going on in our society related to racial injustice. So we've gotten several inquiries recently related to, as a nurse of color and also as nurses that are not of color, what should they do? What can they do in order to advance justice in America and especially within healthcare? And so a lot of the times, we talk about racism and health care related to our peers or racism as a result, health disparities among patients and families.

Liz:
But what we don't always talk about is the racism that is exhibited by patients towards healthcare workers. So it's kind of that reverse thing. And there's not a lot of policies. I think Mayo Clinic is one organization that I'm aware of that actually institute a policy, I think last year or the year before related to addressing racism exhibited by patients. But it's usually the other way around. And so we're hearing a lot of that from nurses that are saying, "I have patients that say, 'I don't want you to take care of me because of the color of my skin.' What do I do? Is my organization going to support me, or what is ANA saying about this?"

Liz:
And so we really want to try to help nurses encourage them to go towards the organizations and be leaders and be advocates. It's really powerful for ANA as an organization to say, "This is where we stand on this. We condemn racism. We are support a racial justice in America." However, getting that down to an organizational level or an institutional level really depends on the leaders in that organization.

Liz:
And so we are giving nurses the tools for advocacy and leadership to help them speak up within their organizations to make sure that there is health equity and organizations. And so I know especially right now, that is something that is incredibly top of mind, and I'm sure we'll continue. As we continue to see this issue play out into the world.

Dan:
We've had similar thoughts around it too is how do we support nurses? Travel nurses are moving from site to site every 13 weeks or so. And so they see a lot of different things and they want to bring that up and have their voices heard similar to what a staff nurse would expect from the hospital that they're working at. And so we've launched a couple of projects around that as well to see how can we aggregate reporting so we can know, do we need to intervene through our channels to help hospitals see if there's something going on?

Dan:
But also to direct nurses in their practice and their duties to feel safe in work, and then also give them tools so they can address it. And yeah, I would agree the social injustice piece is definitely top of mind. And it seems like every day in the news, there's something new that comes out that directly impacts decision-making for nurses. And at some point it feels almost overwhelming. I mean, have you noticed nurses just feeling completely stuck in another thing and like, "How do I manage all of this?"

Liz:
Absolutely. And I think that is probably a part of COVID. So again, I think a lot of nurses plugged through COVID especially those that already went through the hotspot. So they plugged through, it's adrenaline, they did it, it was traumatic. And now they're kind of coming down from that high, one of my colleagues the other day told me it was the craziest time in her 25 years of nursing. She's like, "I've never been through anything like that." And her COVID unit dismantled almost a month and a half ago and she's just now kind of feeling the effects of that.

Liz:
And so when you partner that with everything that's going on politically in our country, politically in the world, and you're looking at racial injustice, there's so many factors that I think are really hitting nurses. In addition, we're looking at issues related to isolation, right? Because we can't have that connection that we generally have with other people. I had a nurse who called me, this was a while ago and she said, "In our COVID unit, it's so stressful" and they're underneath this really hot PPE for hours, and they're sweating and they smell. And it's horrible. And they're dealing with these really critical people that are really, really sick.

Liz:
And in the past, they would have been able to just reach out and hug their coworker and to say, "It's a tough day, we're going to get through this" or hug their unit clerk or just get support, get that physical touch or embrace and they can't do it. So you can't even get that support that you need from work. And then you go home and nurses who are scared to expose their family, they can't get it at home either. And so it's this constant effect that COVID has had on our professional lives, on our personal lives.

Liz:
And to your point, I think nurses, a lot of nurses are absolutely exhausted. I think some nurses that are exhausted are now just experiencing COVID, right? So COVID is not gone. COVID is not over. We are nowhere near being over with this. And so as we see the nurses that are living through the hotspots now, they've been exhausted in their personal lives already up until now. Some nurses actually were laid off.

Liz:
So I've heard some nurses were laid off and furloughed initially because hospitals were closed, but now they're getting the hotspots and they're getting the surge from COVID. And so now they're in it. So they're emotionally exhausted now just entering the surge of COVID. And so nurses are at different places, I think all over the country. But to your point, I think a general consensus is exhaustion.

Dan:
I can relate to that and attest to it. I think you're right. We notice trends of nurses wanting to take big breaks after contracts and things too just to recharge in some way. A lot of people aren't even allowed to go back to their families because that state is now on a quarantine list and they wouldn't be able to go back to work if they went and visited people. And so I think it's just social isolation, no place to vent, no personal contact. And then you're looked at as this hero that's sacrificing things, but then the world's also afraid of you because you're exposed to COVID every single day. And so it's just this weird place where nurses are in and you need to do better I think supporting them.

Dan:
One of the things that you mentioned was the peer-to-peer support piece as a tool. That was something that came out of a survey we did of about 1500 nurses. Basically 80% of them said, "Hospitals don't really support their mental wellbeing." And even if they do it's these EAP programs, employee assistance programs that may be generic, don't really have the understanding of what a frontline nurse does or has been exposed to. So have you seen any improvement or any more engagement with a peer-to-peer network versus kind of a generic employee assistance type program?

Liz:
Yeah, I think you're absolutely right. The peer-to-peer program through the Well-Being Initiative is actually called Nurses Together and it really allows nurses to connect through conversations. It's virtual. So it's through Zoom and it's 24 hours a day, right? Because nurses work 24 hours a day. So nurses are able to really connect with other people and other nurses to give them that experience that's shared.

Liz:
So it's a shared experience. You're not talking to a counselor who, again, like you said, may not understand the nuances of what you're saying. And we know with all of the medical jargon that we spit out if we're naming a medication or a drug or talking about some experience, someone without clinical knowledge, they just might not be able to relate to you. And so you're spending time trying to explain the foundation and the fundamental pieces of the story. And you're like, "But wait, that's not the point of what I'm saying."

Liz:
And so having that peer-to-peer relationship, I think really helps nurses feel connected. It's funny, I actually interviewed, this was a while ago. I was interviewing a nurse just to talk about if he thought that a Well-Being Initiative or a mental health program in his organization would be of benefit. And he said, "I'm not really sure it would be a benefit. Because again, I'm talking to someone who has no idea what I've been through." I said, "Well, what if it was a physician or a nurse?"

Liz:
And he said, "Maybe." He said, "But when you're in the moment, when you're in the moment of a crisis or a debrief, you want to just plug somebody who knows who was there or who understands. It's just I'm really having a rough moment. I'm really having a rough day. Can we sit in and can we talk about this?" And it's probably dependent on the person. I think it's personality-driven.

Liz:
There's some nurses who just want to speak to their peers or their colleagues. There's some nurses who are able to go home and share this with their friends and their loved ones to help them debrief. But then I think to your point, there are some nurses who do need that expertise, who need the counseling, or who need the guided benefit of healing and recovery. So I think it just depends on that person's personality.

Dan:
That's definitely true. And having all those resources available is what the profession needs and people can pick and choose. And so that's why I'm excited about ANA's Resource Center, the Trusted Health Resource Center. The more we can get this out there, I think the better. And I think it'll support people through the next, well, the current pandemic and then whatever the next thing that comes down the pike is going to be.

Dan:
What is one of those things that you'd want to hand off to the listeners about your role and ANA and bioethics in general?

Liz:
I was going to say if it's a resource, it would be the code of ethics.

Dan:
Yeah. Everyone needs to have that in their back pocket for sure.

Liz:
Exactly, exactly. And the code of ethics is available online. People are able to view it for free. So I always like to put that out there as well. But I do think knowing that you have resources and realizing that nurses are not alone or in isolation. And so I say this when I think about when I go to hospitals and talk to nurses about moral distress, every single presentation I've ever done at a hospital, I've had at least three to four nurses either come up to me afterwards or email me and thank me and are so grateful because they thought they were alone.

Liz:
They said, "Oh my gosh, I thought that there was something wrong with me. Everything you talked about related to moral distress is exactly how I feel. And I thought something was wrong with me." I've nurses say, "I'm actually thinking about quitting. I'm thinking about going to a different profession because I'm so burnt out. And I thought it was just me." And so as I continually hear that, and I think, "Well, of course, everybody knows about distress and burnout." Nurses don't. They really don't. And there's this level of isolation.

Liz:
There's this level of not feeling comfortable about talking about what you're experiencing and what you're going through, but I think we need to give visibility to, and actually amplify this message and let nurses know that it's okay to share how you're feeling. It's expected. That's part of the challenges of nursing. Nursing is such a beautiful profession and it's a very challenging profession.

Liz:
And being able to recognize both of these and come to a place where we're comfortable talking about it, I think is so important and so significant. And so that would be my send off message for nurses is know that you're not alone in this and. That we want to be able to rely on each other and trust our profession. We're the most trusted profession. We've got to trust each other that we'll help each other continue to heal and recover through this.

Dan:
I've been in that spot too where I've been burned out and one of my passions is around toxic leadership. And so you feel like you're in this situation, no one else is seeing it, that you're crazy that this could only be your experience. And then you talk to other people and know how ubiquitous it is. And so I love that. Know that you're not alone and there's a lot of people out here willing to help and listen and get you the resources and tools you need so that you can be the best nurse you are.

Dan:
So Liz, thank you so much for being on the show. Really appreciate it. Where's the best place for people to find you if they have questions or where's that inbox in case they want to send some ethical dilemmas your way?

Liz:
Absolutely. ethics@ana.org.

Dan:
Perfect. And we can find you on LinkedIn and a website and all that good stuff?

Liz:
Yeah. Correct. We're also on Twitter and our Twitter handle is @ANAEthics

Dan:
Liz, thank you so much for all the insights and we'll get all those resources into the show notes. And if you have an ethical dilemma, turn to the code of ethics and check Liz out online and all the resources ANA has. Thank you so much, Liz.

Liz:
Awesome. Thank you so much, Dan.

Dan:
Thank you so much for tuning into the Handoff. If you like what you heard today, please consider writing us a review on iTunes or wherever you listen to podcasts. This is Dr. Nurse Dan. See you next time.