Disciplinary Action, Terminations, Gag Orders: ‘Avalanche Effect’
When the COVID-19 pandemic started, hospitals suddenly had to determine how to ration scarce critical care resources, something they never had to do before.
Fortunately, multiple guidelines already existed based on mass casualties and previous epidemics. “But we really had never talked about how to ration equipment for providers,” says Charles E. Binkley, MD, FACS, principal and founder of ProNobis Health, a San Francisco-based healthcare quality and bioethics consulting firm.
Hospitals could not change the fact they were caught without enough personal protective equipment (PPE) and could not immediately obtain more of it. However, they could control whether they responded ethically to this terrible situation. “Some hospitals have failed miserably during this crisis. The whole situation around PPE has eroded trust,” says Diana J. Mason, RN, PHD, FAAN, senior policy service professor at the George Washington University Center for Health Policy and Media Engagement in Washington, DC. Mason has heard these firsthand accounts:
- An experienced intensive care unit nurse went through the proper channels to report concerns, and was called in the next morning and fired.
- Nurses and physicians were told they could not bring in their own N95 masks from home, even though the hospital was not providing them.
- An immunocompromised nurse was told she would have to care for COVID-19 patients, and ended up quitting her job as a result.
“The message is: ‘You are expendable, and we want you to put your life on the line — and choose between your family and your job,’” Mason says.
Some hospitals imposed gag orders on staff, barring them from voicing concerns about PPE publicly. Nurses and physicians have been disciplined or threatened with termination for reporting inadequate PPE on social media.1,2 (Editor’s Note: The American Medical Association argues, according to the organization’s Code of Medical Ethics, that physicians are ethically obligated to address conditions that put them and patients at risk.)
Mason says these kinds of practices are unethical, and that hospitals could have handled things differently. “If I were the head of the hospital, I would say to staff, ‘If you don’t have adequate PPE, you speak out. Go tell the world what you are working with, and that we are working to find it but we can’t get it.’”
Instead, some hospitals doubled down on efforts to tightly control messaging. “That message, for many hospitals, was ‘We’re doing just fine, thank you.’ That says the priority is the hospital’s image, and not their workers,” Mason says.
Physicians and nurses have had to choose between protecting themselves and taking care of patients. This dire situation brought underlying problems to the surface. “Nurses and physicians have been feeling they’re being put in impossible situations for a long time now,” says Binkley, former chief of hospital quality at Kaiser Permanente. “It’s been an avalanche effect.”
On one hand, the crisis could have rallied healthcare providers, with the feeling that they are fulfilling their mission. “But if there is a sense that people are being forced to do things, if there’s not a transparent process, if there’s any sense that administrators are making unjust decisions, that’s where the moral injury comes into play,” Binkley notes.
Hospital policies on PPE allocation must be transparent and equitable, with a mechanism to address grievances.3 This raises complex ethical questions. “But it’s the right process. It’s the way we need to be doing things to avoid moral injury,” Binkley argues.
Creating a “safety culture,” where staff are encouraged to report concerns without fear of retribution, has been a major focus at many organizations. If healthcare staff perceive workplace safety culture positively, they tend to also feel positively about patient safety culture, according to the authors a 2018 study who analyzed data from 132 medical centers.4 “Unfortunately, this is unmasking some of the superficiality of those initiatives,” Binkley laments.
Many healthcare providers already distrusted hospital administrators’ priorities to some extent. “These issues have been bubbling up for a long time. Now, COVID is showing us the fault lines,” Mason observes.
Hospitals appeared hypocritical by first implementing wellness programs for providers, then punishing them for reporting concerns about PPE. “It’s having it be real and not just there to protect the image of the brand,” Binkley says. “I think most people can discern the difference.”
That is not to suggest hospital administrators are unethical as individuals. Yet faced with prioritizing financial viability, risk management, and public relations during the pandemic, some lost sight of the hospital’s mission. “That’s where ethicists can really contribute to the conversation,” Binkley offers.
Ethicists have unique expertise when it comes to resolving conflicts between families and providers, or within the care team. Now, ethicists can put these skills to work in resolving disagreements between administrators and providers. “Ethicists can come in and be objective, hear both sides, and look at it through an ethical lens,” Binkley says.
Conflicts between hospitals and staff ended up playing out in the public eye. If ethicists had been involved when issues with PPE first came up, that possibly could have been prevented. “Ethicists could have helped formulate policies that were just, transparent, equitable, and accountable,” Binkley says.
Ethicists also could have mitigated myriad problems, ranging from poor morale to legal action, when staff did voice concerns publicly. “Most ethicists would support the right of staff to speak up, without fear of retaliation, but may qualify it based on intention,” Binkley explains.
The ethical intent should be to avoid harm to patients and staff, not to get back at administrators. Ethicists could have sorted out whether internal processes were followed by the staff, and whether staff complained publicly only as a last resort. This is a better option than hospitals implementing blanket gag orders and punishing anyone who violates them, Binkley says.
“The voice of ethics should be present whenever you are making difficult decisions, not just involving patients but also the medical and nursing staff and all of the ancillary staff,” Binkley says.
Hospital leadership sets the tone for everyone else, namely that ethical behavior is expected. “When hospitals do the right thing, the staff are right there with them,” Mason says.
Modeling ethical leadership is particularly crucial during a crisis. Unfortunately, hospitals are not always well equipped in this regard. “Quite frankly, not all hospital CEOs were prepared, not just for the management of the situation but also the ethical context of that situation,” Mason notes.
Mason says hospital leaders should ask themselves two questions: Who is paying attention to employee wellness? How am I showing I care about employees’ well-being right now? “It may be as simple as making rounds on a regular basis, saying ‘How are you doing? What do you need? How can we better support you?’” Mason suggests.
The hospital CEO should be “visible, supportive, and observing how critical situations are being managed,” Mason adds. Hospitals need to get serious about putting plans in place to support staff over the long term and, hopefully, restore trust. “We have a lot of deep work to do around the ethics of all this,” Mason says.
- American College of Emergency Physicians. ACEP strongly supports emergency physicians who advocate for safer working conditions amidst pandemic. March 30, 2020.
- American Nurses Association. ANA disturbed by reports of retaliation against nurses for raising concerns about COVID-19 safety. April 9, 2020.
- Binkley CE, Kemp DS. Ethical rationing of personal protective equipment to minimize moral residue during the COVID-19 pandemic. J Am Coll Surg 2020; Apr 9. pii: S1072-7515(20)30304-5. doi: 10.1016/j.jamcollsurg.2020.03.031. [Epub ahead of print].
- Mohr DC, Eaton JL, McPhaul KM, Hodgson MJ. Does employee safety matter for patients too? Employer safety climate and patient safety culture in health care. J Patient Saf 2018;14:181-185.
When the COVID-19 pandemic started, hospitals suddenly had to determine how to ration scarce critical care resources. Hospitals could not change the fact they were caught without enough personal protective equipment (PPE) and could not immediately obtain more of it. However, they could control whether they responded ethically. Some hospitals imposed gag orders on staff, barring them from voicing concerns about PPE publicly. Nurses and physicians have been disciplined or threatened with termination for reporting inadequate PPE on social media.
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