By Lindsey Boechler, Natasha Hubbard Murdoch, Heather Nelson
The social contract or the ‘duty to care’ is variably addressed in health professional programs. Students and practitioners may describe a deeply rooted duty to serve embedded within their internal ethical value system. This arises from a sense of a calling, an obligation to family, history or community, or a commitment to upholding the relationship between healthcare professionals and society. The Covid-19 pandemic has publicized ethical discussions within and between professionals; changing individual or team discussions on morals and values. With the Government of Canada holding primary care providers responsible for the assessment and treatment of patients suspected to have Covid-19, the pandemic has created more role conflict than previously experienced by healthcare providers. (1,2) The unprecedented circumstances surrounding the outbreak has led to healthcare providers experiencing conflict when pressed to limit or expand their scope of practice. (3) Covid-19 has, for many healthcare providers, forced the examination and reflection on roles in the health system, the duty to care, and the impacts on physical and mental health.
Relationships with the health system
Nationwide calls to increase the health workforce through temporary emergency licensure for healthcare professionals has resulted in individuals deciding if, and in what capacity, they will return to serving on the frontlines. This call to action also led to difficult decisions for our team of interprofessional researchers with backgrounds in paramedicine and nursing.
The majority of paramedics and nurses work in direct patient care, but as with any profession, domains include administration, education and research. Our pathways to joining forces as interprofessional team members was unique, but included some variation of practice to clinical education to educational administration for each of us, culminating in research (for now). Advanced Care Paramedic, Lindsey Boechler, and Registered Nurses, Natasha Hubbard Murdoch, and Heather Nelson, had competed for the opportunity to hold research chair positions with the Centre for Health Research, Improvement and Scholarship at Saskatchewan Polytechnic. The research positions were an opportunity to advance social science research with a patient-oriented focus. Initially, each of us began pursuing separate programs of research but, like so many others, our carefully formed research plans were disrupted by Covid restrictions. We had to make decisions about our professional roles during the pandemic, each asking ourselves how we could best serve our professions.
Assessing Duty to Care
Each of us contemplated returning to the frontlines, internally driven towards a duty to serve. Recognizing there is more than one way to fulfill the duty to serve, we had to decide how we could best serve our professions throughout the pandemic- by returning to practice or through research.
Although returning to practice was never out of the question, we decided to remain on the research track. Our approach turned to utilizing our skills to provide a record of the lived experiences of health professionals with the actionable effort to inform future practice. To date, our team has conducted four separate provincial studies focusing on the lived experiences of clinical nurse educators, practicing nurses, paramedics, and police officers. Each of these studies started with a provincial focus, but as interest grew from practitioners and researchers, national and international exposure has been gained.
We began by research the experiences of nursing clinical educators because from within our educational institution we heard the conflict of risk for educators, students, nursing staff and patients: Was the risk of students in clinical worth the risk to others? Who needed to be protected? Where would replacement staff come from as the toll of the pandemic weighed on? This led to practice discussions for nursing, paramedicine, and police who had all been hearing mixed messages from local health leadership. Each of these projects asked specific questions about administration in practice, sense of preparedness and education contexts. Focusing predominately on qualitative methodology for the research has provided rich data that crosses professions and revealed the complexity of practicing in each domain.
At the team level, we began mastering interprofessionality, collaborative inquiry at the crux of education and practice. (4) Working as an interprofessional team, we built on each research project, sharing diverse perspectives of education and practice while ensuring that our research questions and data collection tools were appropriate for domain and discipline. Our diverse experiences helped to grow the projects, allowing us to increasingly include students, faculty and practitioners on our research teams. Through this process we discovered that in spite of obvious differences between professions many of the experiences of frontline professionals were shared.
Impacts of the social contract
Through this research the value of frontline professionals was clear, as was their assessment of risk and sense of obligation. Although frontline professionals were distressed by many of the things that occurred during the pandemic, they were willing to provide care for individuals each and every day. Frontline professionals have gone above and beyond in extremely challenging conditions. Some participants were frustrated with the lack of communication from management and the absence of a plan. Particularly early in the pandemic, frontline professionals were afraid of getting sick and were even more concerned about passing Covid-19 onto their loved ones. Many frontline professionals who lived alone had no in person contact with their friends or families for weeks. Some frontline professionals with families stopped hugging their children and would not see them until they had fully scrubbed down. Other frontline professionals separated themselves from their children altogether as they felt it was the only way to protect them.
Scant research was completed pertaining to frontline professionals during pandemics prior to Covid-19 but existing data had been predominately conducted retrospectively. The memory of an event is often very different from what the person experiences at the time of the event, therefore, collecting data while people are amidst an experience is important. Capturing, in real time, the feelings of fear, lack of preparation, lack of communication, and lack of supplies was important as the experience changed with subsequent waves, proving that a longitudinal view in research is valuable as well. Few Covid-19 research studies began so quickly with the onset of the pandemic and many collected only data in delimited timeframes.
Collecting data quickly is most valuable to frontline professionals if the results are immediately accessible. One of our goals was to mobilize knowledge to be useful across domains. We have produced practice based videos and podcasts, written lay and academic articles, and contributed to a variety of outlets including digital news, social media (@AIR_Sask) and our own website (www.appliedinterprofessionalresearch.com). These dissemination activities described the experiences of frontline professionals through the voices of those professions. Having a knowledge translation plan that was tailored to our partnerships in the early stages meant we never lost sight of our obligation to share experiences back to the frontlines so that we all could learn from it and strengthen professional domains.
Working on an interprofessional team is an opportunity to learn and grow. The experiences of paramedics, police officers, and nurses was in many ways the same and in other ways vastly different. One of the similarities found amongst frontline professionals was moral distress. Throughout data gathering feelings of moral distress were evident by frontline professionals being asked to do things that did not align with their personal moral values or professional ethics. Some examples that created moral conflict included being asked to delay entering an emergency situation to apply full PPE, refusing entry of family and caregivers, or not performing airway management to one’s full scope of practice because of the restrictions in place.
Currently, student team members are examining the Saskatchewan data from all four frontline professional studies, seeking examples of ethical dilemmas experienced throughout the pandemic. Circling back to a patient-oriented approach, our next research project will include frontline personnel as patient partners as we explore the lasting mental heath impacts of the ethical dilemmas faced by frontline professionals throughout Covid-19. The aim is to understand the antecedents to moral distress with the intent of providing actionable information to prevent moral injury. While an unconsciously applying the Interprofessional Education for Collaborative Patient-Centred Practice (IECPCP) framework (4), our work together has built strong research partnerships and networks to reciprocate the duty to care.
Conclusion: The value of the research domain
As researchers, the ethical dilemmas we had to wrestle with were whether we were adding value to the work of frontline professionals, were we asking too much of frontline professionals, or should we have been involved in direct patient care. One of the survey respondents added in an open text box that the researchers were benefiting from the misery of others. This comment was received early in data collection and is a constant source of reflection for each of us, individually, and as a team. Participants should question the value added by contributing to research. Our goal was not to benefit from the stories of the frontline professionals. This research is performed out of a duty to serve the voices of frontline professionals in sharing the continuum of experiences that will be used by providers now and in the future to advance practice, education, administration and research.
- Government of Canada (2020). Covid-19 pandemic guidance for the health care sector. https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals/covid-19-pandemic-guidance-health-care-sector.html#a3
- Lipworth W. (2020). Beyond Duty: Medical “Heroes” and the COVID-19 Pandemic. Journal of Bioethical Inquiry, 17(4), 723–730. https://doi.org/10.1007/s11673-020-10065-0
- Stokes-Parish, J., Elliott, R., Rolls, K., & Massey, D. (2020). Angels and Heroes: The Unintended Consequence of the Hero Narrative. Journal of Nursing Scholarship, 52(5), 462–466. https://doi.org/10.1111/jnu.12591
- D’Amour, D., & Oandasan, I. (2005). Interprofessionality as the field of interprofessional practice and interprofessional education: an emerging concept. Journal of Interprofessional Care, 19 Suppl 1, 8–20. https://doi.org/10.1080/13561820500081604