Ethical dilemmas faced by Community Health Nurses in the COVID 19 pandemic
This blog post by Ruth Schofield, Michelle Johnson and Shona Lalonde is the second of two that describe the work of Community Health Nurses (CHNs) as they respond to the COVID-19 pandemic. These blogs reflect the voices of CHN across Canada — their experiences, challenges and innovations, as well as ethical dilemmas they face.
In March 2020, an e-mail survey asked Canadian community health nurses (CHNs) in home health and public health from several provinces to share their current reality in the midst of the COVID-19 pandemic. Four questions were circulated by email and included:
- What has been your experience of COVID 19 pandemic response?
- What are the challenges?
- What are the successes? and
- What are the ethical dilemmas you have faced?
The first blog post of this two-part series features highlights from the responses to the first three questions.
In this second blog post, we explore responses to the question about the ethical dilemmas CHNs have encountered during COVID-19. We use these responses to delve into the 2017 Canadian Nurses Association (CNA) Code of Ethics,  including its relationship with the 2019 Canadian Community Health Nursing Standards of Practice.  We also offer a hypothetical case study that applies the former.
CHNs described ethical dilemmas that arose as they made clinical decisions about prioritization of client services and programs. These occurred in the context of preserving the limited supply of Personal Protective Equipment (PPE).
Debates ensued about protecting staff or clients, including the distribution of supplies and equipment to First Nations. CHNs struggled with supporting families whose loved ones were in hospice or long-term care and strict limitations on visitation.
They also talked about the moral distress they experienced as they worked with clients and families who were at increased risk of COVID-19 infection due to them experiencing mental illness, homelessness, poverty, food insecurity and reduced access to health and social services.
Ethical issues and challenges are common in CHN practice. However, during the COVID-19 pandemic, new ethical challenges arose. How can CHNs face these challenges and reconcile practice within an ethical framework? The CNA Code of Ethics  can provide assistance.
The CNA Code of Ethics contains two components:
- Nursing values and ethical responsibility
- Ethical endeavours related to broad societal issues
Seven core nursing values are cited:
- Provision of care
- Informed decision-making
- Accountability 
The 2019 Canadian Community Health Nursing Standards of Practice  includes an expectation that CHNs use of the CNA Code of Ethics.
CNA Code of Ethics and CHNC CHN Standards of practice
CNA Code of Ethics 
This graphic [1(p3)] illustrates the two parts of the CNA Code of Ethics.
Canadian Community Health Nursing Standards of Practice 
The Canadian Community Health Nursing Standards of Practice document covers eight expected areas of practice:
The CNA Code of Ethics includes the Oberle and Raffin model of ethical decision-making. This comprehensive model describes the following aspects of ethical decision-making:
- Assess the ethical situation — relationships, goals, beliefs and values
- Consider possible actions or choices
- Select an action
- Carry out the ethical action
- Reflect on the action taken 
The following hypothetical scenario demonstrates how the model can be applied.
Hypothetical case story
Davis Caron is an experienced CHN in a rural community health practice and is leading an interprofessional team around COVID-19 testing to be completed in both the town and the nearby First Nations community.
As planning for the response is initiated, the team quickly realizes there are insufficient testing supplies for both the town and the nearby Indigenous community. More test kits cannot be supplied until the next week. Davis struggles with how to proceed as both communities need testing and have community members with symptoms of possible infection. Community leaders in both areas are eager to have a testing clinic in their community. Davis refers to the CNA Code of Ethics and decides to use the Oberle and Raffin model to assist the team and himself to work through this ethical challenge.
1. Assess the ethics of the situation – the relationships, goals, beliefs and values
The team listed important relationships such as those with community leaders, community members and other public health leaders. Davis knows the goal of testing is to assess the number of people infected with the virus to show the extent of community transmission and to identify those needing to self isolate or quarantine to slow transmission of COVID-19.
Davis and the team identify that providing protection to those most vulnerable to severe disease is an important intent of the testing effort.
He identifies the CNA Code of Ethics' values of providing competent care, promoting health and well-being, promoting justice and being accountable, as values that are of particular relevance to this issue. 
2. Consider and review potential options
The CHN knows each community expects testing as a priority but knows the people who live in the First Nation are a more vulnerable population and experience a number of significant health inequities. Put simply, the people who live in this community could gain greater benefit from testing and resulting actions.
Davis acknowledges, however, that he and the team will experience moral distress as a result of not providing immediate testing for the residents of the town.
3. Select an ethical action
To select an ethical action, Davis and the team ask themselves a number of questions:
- Which action do they believe is best?
- How can they support the needs of both communities?
- Does the team have the information and knowledge they require?
Davis and the team decide to prioritize testing of those people with symptoms of COVID-19 living in the First Nation, as well as symptomatic members of the town who have underlying conditions putting them at greater risk.
4. Carry out the action
While working to complete the planning, Davis reflects on the following key questions:
- Is he practicing as a prudent nurse would?
- Is he is acting with care and compassion?
- Are professional and system expectations being met?
5. Reflect on the action
Once their plan is implemented, Davis and team stepped back and reflected on the following important ethical decision-making consideration:
- Were the outcomes acceptable?
- Did all involved feel respected and valued?
- Was harm minimized and benefit maximized?
- What was done well and what could have been done better or differently in the future?
CHNs like Davis Caron are and will play a critical role in the COVID-19 pandemic response and recovery. They are in a unique position to reach populations, families and individuals in homes and other community settings. They are also trusted by and intimately involved with the populations and communities with whom they work. Their skill and capacity to communicate and work together with other partners and the community is invaluable in emergency situations. In addition, their voices articulate a constantly changing and complex environment, adversity and amazing innovation juxtaposed with moral distress.
The Canadian Community Health Nursing Standard of Practice define their practice and the use of ethical decision-making tools are critical to resolve ethical dilemmas. Moreover, they direct CHNs to promote health equity for all who live in Canada.
About the authors
Ruth Schofield, RN, MSc(T), is an assistant clinical professor at McMaster University in Hamilton, Ontario. She is also the former president of Community Health Nurses of Canada.
Michelle Johnson, RN, BN, MSc (Inf Dis) is a public health nurse with the Public Health Branch of Manitoba Health, Seniors and Active Living in Winnipeg, Manitoba.
Shona LaLonde, RN, MN, is a nurse tutor at Camosun College in Victoria, BC.
 Canadian Nurses Association. Code of ethics for registered nurses [Internet]. Ottawa (ON): CNA; 2017 [cited 2020 May 6]. 49 p. Available from: https://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/code-of-ethics-2017-edition-secure-interactive
 Community Health Nurses of Canada. Canadian community health nursing practice model and standards of practice [Internet]. Toronto (ON); CHNC; 2019 [cited 2020 May 6]. 59 p. Available from: https://www.chnc.ca/en/standards-of-practice
 Oberle K, Raffin Bouchal S. Ethics in Canadian nursing practice: navigating the Journey 1st ed [Internet]. Toronto (ON): Pearson Education Canada; c2009.