Working While Ill During COVID-19: Ethics, Guilt, and Moral Community

Colleen is a 5-year veteran critical care nurse working in a busy intensive care unit that has been filled to capacity with patients with suspected and confirmed COVID-19. She has diligently followed infection-control guidelines inside and outside the workplace. She has responded to pleas from her nurse manager to (1) cover additional shifts, (2) take on additional responsibilities, and (3) orient traveling and less experienced nurses to care for high-acuity patients with COVID-19 and/or related complications. Although she has supportive family and friends, she is physically, psychologically, and morally exhausted by the weight of the pandemic. Over the past 24 hours, she has felt more fatigued than usual despite additional sleep, has a worsening sore throat and dry cough, and feels febrile. She has tried all the usual remedies, but her symptoms have worsened. She is scheduled to work the night shift beginning at 7:00 PM. She wonders if she should call out ill or go to work, despite the risk she may be infected with COVID-19. What will the consequences be to her patients, colleagues, and herself? How will her manager respond? What will her colleagues think?The age-old question of whether nurses ought to work while ill has intensified as the prevalence of COVID-19 has rapidly threatened capacity of health care systems to respond to the volumes of patients requiring treatment. Guidance from health experts typically recommends nurses not come to work when they are experiencing symptoms of illness. Does, or should, this guidance change in the midst of a pandemic when there are legitimate constraints on resources, including staff? How might nurses weigh their options in such circumstances?In the context of a pandemic, many additional ethical questions become relevant. Health care systems struggle with staffing under ideal circumstances, but the pandemic has severely depleted human resources to buffer staff illness while meeting the intensified needs of patients in volumes that exceed capacity. How should the risks be weighed—for the nurse, patients, colleagues, and other hospital staff—when a nurse has symptoms of illness but comes to work anyway? How does it impact teamwork, patient care, and productivity? What are the physical, emotional, moral, and relational consequences?Presenteeism is defined as observed decreases in productivity when employees attend work despite feeling ill; it is a state between absenteeism and full productivity.1 This phenomenon tends to be more common in “helping” professions, such as nursing, whereby employees feel a sense of duty to care for others, particularly amid staffing shortages and public health emergencies.2 However, in the context of the COVID-19 pandemic, presenteeism can perpetuate occupational transmission of the virus if nurses continue working despite developing symptoms.3Guidelines regarding diagnostic testing and quarantining have fluctuated. The Centers for Disease Control and Prevention (CDC) guidelines have shifted from a recommended 14-day quarantine period to 10 days.4 Even still, health care systems acknowledge critical staffing shortages may require nurses to return to work sooner than is recommended by public health experts.2–4 The CDC has published contingency capacity strategies for health care facilities to consider, such as canceling nonessential procedures and rotating clinicians’ schedules to account for patient care needs.5 Officials acknowledge these strategies may not be enough and offer further suggestions for enabling symptomatic clinicians to provide patient care as safely as possible.5There are a number of individual and organizational factors that can influence decisions about returning to work when ill. Financial and/or job insecurity is the most common reason for presenteeism.2 A negative organizational culture can contribute to presenteeism by threatening job loss should employees take “unnecessary” time off. The threshold of what managers consider “sick enough” to avoid work varies greatly by occupation and organization.6Nurses, particularly in critical care, may experience pervasive feelings of guilt and shame when they perceive that they are unable to fulfill their job responsibilities. A strong commitment to patients and colleagues often leads nurses to sacrifice personal health and well-being in service of others. Nurses notoriously work while experiencing common cold symptoms, a habit that may make it difficult for them to determine whether their symptoms are COVID-19. They may reason that “I can’t abandon my patients and my colleagues,” or “I always have protective equipment on, so the risk to others is reduced.”In the shadow of this commitment to others is a culture where admitting illness or limits is often met with judgment, retaliation, and shame.7 The “suck it up” mentality is pervasive despite harmful consequences. The narrative in the break room may be one of judgment and resentment, as colleagues question whether illness is being used as a “cop out.” No one wants to be the topic of break room conversation or carry the stigma of being viewed as a “slacker.”Nurses express deep guilt associated with a decision to not work when assigned. They reason absenteeism, or staying away from work, will place additional burden on others or cause risk to their patients. One purpose of guilt is to recognize a gap in, or conflict between, personal values or core beliefs.8 Guilt can also warn an individual from taking an action that hurts others, or it can cause individuals to punish themselves for actions that cause harm. It can activate empathy for others and motivate the process of making amends.8 In terms of sickness presenteeism, the potential harms to patients and colleagues leads nurses to feel guilty, whereby staying home would entail abandoning a core value and their identity as a nurse.Guilt is an expected emotional response in the presence of conflict or threats to important values. Capacity to feel guilt is a signal of moral conscientiousness and can be used as means for deeper inquiry and reflection rather than reaction. The American Nurses Association (ANA) Code of Ethics, Provision 2, emphasizes that nurses’ primary obligation is to the patient; however, in this case, it can cut both ways.9 If a nurse works while ill and is not productive or efficient, it could cause harm to patients. Additionally, working while ill can increase the potential for infecting others. Some may interpret the ANA Code of Ethics as suggesting nurses should do whatever they can, including sacrificing personal health, to serve their patients. Recent guidance from the ANA suggests sacrificing personal health is incongruent with the interpretation of the Code of Ethics.9 Nurses must deeply respect themselves, inclusive of their boundaries, to fulfill their commitments to others; as the saying goes, “You cannot pour from an empty cup.”When guilt reaches an unhealthy limit, it turns to shame. Guilt can become insidious and self-destructive when it is disproportionate to a situation, gets misdirected, or is illogical. Anger and resentment can filter in as well, either self-directed or directed toward others. It is at this point where shame sneaks in, and nurses begin internalizing others’ appraisals of their actions and abilities. Like guilt, shame can have a devastating effect on a person’s ability to accurately appraise a situation or determine an appropriate course of action.Misplaced guilt, and in turn, shame, can occur when nurses attempt to overcompensate for problems beyond their scope of responsibility, because guilt and level of responsibility are directly correlated. Nurses are obligated to protect others’ welfare, and in cases where they are unable to fulfill that responsibility, guilt may be justified, particularly if any harm is caused. However, it is unhealthy for one individual to feel solely responsible for maintaining sufficient staffing and mitigating all other challenges brought about by the pandemic itself. Nurses are committed to providing patient care amid difficult circumstances, but heroic action is not required, nor should it be expected, when there are potential health risks to nurses, their patients, or any other hospital staff.Nurses, already feeling isolated from team members, may be worried about their own health and possibly infecting their patients if they come to work ill. Costs of misplaced guilt can be paralyzing and disabling and hold potential to erode cohesion of the health care team. In proportion, guilt can support group cohesion by re-enforcing shared norms, commitments, and responsibilities, but there must be boundaries. Research suggests engaging positive emotions rather than negative emotions, such as guilt or shame, can release energy and ingenuity.10 How can health care systems accommodate and adapt for critical situations, such as pandemics or other public health emergencies, in ways that do not erode the integrity of the team? How can nurses weigh their choices regarding coming to work while ill in ways that uphold their integrity, commitments to self and others, and professionalism (Figure)?Words and stories people tell about themselves matter. Noticing the pervasive narrative that is repeated over and over, in formal and informal conversations and discussions, is an important starting point. As the pandemic unfolded, financial concerns reinforced mantras such as “Keep beds open,” and “Do more with less.” Nurses and other clinicians were asked (and in some cases mandated) to work overtime, often without adequate supplies. Many were forced to acquire additional responsibilities and others were deployed to new and unfamiliar settings to accommodate staffing needs.11 In some cases, when nurses called their managers and leaders to inform them of COVID-19-like symptoms, some were met with anger, blame, and pointed questioning, as opposed to a nonjudgmental response acknowledging the sacrifices being made by nurses everywhere. These instances highlight the need to invest more in personal well-being. Extreme examples of nurses being required to report despite confirmed illness were also reported.12 The media was flooded with stories of hospitals being overrun with patients and not enough nurses to care for them all. Conscious or unconscious pressure from nurse leaders to come to work while ill can add to a wound of moral injury, whereby nurses begin to feel their employers view them as dispensable and are more concerned about maintaining expensive service lines than preserving the welfare of employees. For some nurses, this feels like a betrayal of trust by their organization to maintain a safe, healthy work environment. Nurse leaders may feel abandoned when staff nurses are unable to work and simultaneously feel pressure to produce resources when there are none. Both parties can wind up feeling betrayed in different ways.Frontline nurses and leaders in these demanding situations can benefit from developing constructive communication skills that can help (1) override fear-based responses, (2) engage empathy, and (3) create connection rather than alienation. Being mindful of tone and contents of communication and shifting to a narrative that reflects shared commitment and collaboration is essential in rebuilding trust when it has been broken. Noticing the storyline that gets repeated to peers, among leaders, and across disciplines can create an opportunity to shift from a mindset of scarcity to one of possibility.Moral community begins with leadership and structures that help people do the right thing consistently, fairly, and without undue burden. Trust is built when promises made are kept, when communication is transparent, and when self-knowledge of needs and limits is honored. Frontline nurses must co-create norms with their leaders during these challenging times by listening to others’ intentions, commitments, and limitations. The WikiWisdom Forum suggested 3 ways that health care organizations could respond to address issues revealed by the pandemic: listen, protect, and empower nurses.13 Perhaps the most difficult is to really listen, particularly as feelings of fear and exhaustion are in overdrive. Further, instead of promising a fix, offering an invitation and commitment to figuring things out together may be more useful. These solutions could help nurses realize that although there are many issues at play, many of them are temporary, and others can be managed by breaking tasks down into smaller, actionable steps. Both frontline nurses and leaders have shared accountability to create an environment where mutually agreed-upon norms are well integrated into practice, which can guide decisions about coming to work with diagnosed or undiagnosed illnesses and/or exhaustion.Karanika-Murray and colleagues14 developed a conceptual framework proposing presenteeism as a potential avenue for adapting to extenuating circumstances, such as the COVID-19 pandemic. There are 4 types of presenteeism: functional, dysfunctional, therapeutic, and overachieving, each of which renders subsequent behaviors in the face of ill health (Table). These ideas operate under the presumption that nurses are able to accurately assess their own health status and be aware of their motivations, fears, and patterns of responses. This novel framework may provide nurses and leaders with a model for assessing their own patterns of decision-making about coming to work when symptoms of illness are present. There is a delicate balance between functional presenteeism, whereby a nurse is able to successfully balance ill health while safely performing their duties, and dysfunctional presenteeism, which is the exact opposite.14 Similarly, when motivations to come to work while ill arise from a competitive stance fueled by fear of failure, shame, or exceptionalism, nurses may take unnecessary and harmful risks to their health and well-being (overachieving presenteeism). In other cases, nurses show up to find refuge at work through mingling with like-minded colleagues, but this can have a detrimental impact on overall productivity of the team and lead to poor morale (therapeutic presenteeism). Therefore, individual and organizational factors must work in tandem to achieve functional presenteeism while simultaneously bolstering a moral community.Having clear and consistent policies regarding expectations of nurses to work when they are ill helps everyone to navigate when crises arise. Additionally, there should be a clear process for determining what threshold warrants coming to work when symptoms are present. It should be clear whether nurses are mandated to work with symptoms or if that decision should be made on individual assessment. Outlining the degrees of freedom in personal decision-making regarding the severity of illness and being clear on processes are necessary steps to reduce guilt and shame. During the COVID-19 pandemic, some organizations created command centers that fielded calls from staff who were concerned about coming to work with possible symptoms.15 After conferring with their manager, nurses were referred for anonymous, confidential exploration of their symptoms with trained call center staff. On the basis of information provided, a recommendation was made about whether to report to work, get tested, or seek medical care.15 Such processes relieve the burden of individual decision-making and shift the focus on what is needed to care for employee health without shame, guilt, or retribution.Given the uncertainty and demands created during the pandemic for both health care systems and nurses, the limitations on both sides have to be acknowledged. From an ethical perspective, having individual choice guide the decision about when (or whether at all) to work when ill acknowledges that different people will weigh the risks differently. Organizations can support good decision-making by creating the parameters or degrees of freedom people have in making this decision. Examples of this support can include adhering to published public health guidelines; transparently revising them as new information is available; creating a standard process for reporting pandemic-related illness and returning to work; and allocating employee health and human resource capital to assure access to rapid testing, diagnosis, and treatment. Financial impact of the COVID-19 pandemic is severe in some locations, but now is not the time to balance the budget on the backs of those who have sacrificed so much. Nurse leaders responsible for staffing must be adequately resourced to adapt and respond to the reality that staff will, for a variety of reasons, be unable to work when assigned at one point or another. These complex and challenging times offer a continuous reminder to align efforts, offer others a measure of grace, and assume that everyone is doing the best they can under extreme, volatile circumstances.