The current state of nursing requires change.Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning. —Winston Churchill, 1942
From the earliest moments of the COVID-19 pandemic to today, the nation’s 5 million plus nurses have been at the forefront of America’s response to the crisis. The sustained crush of the pandemic, however, has resulted in serious consequences for the nursing workforce, including staffing shortages, compensation inequities, unrelieved moral suffering, burnout, and collective grief. Although the public initially applauded the “heroism” and sacrifice of nurses, sentiment later shifted to anger and violence, reflecting a deep societal divide about individual autonomy and collective responsibility. Nevertheless, the public, and by extension healthcare leaders and organizations, assumes that nurses will continue to serve—regardless of the circumstances—believing that their commitment to patients will take precedence over their own welfare and that they will continue to fill the gaps in stressed or dysfunctional systems.
Although the pandemic has powerfully demonstrated the essential role nurses play across the healthcare continuum, it also has exposed fractures in conceptions of nursing by the people they serve and by social systems and structures. The social contract between nurses and the public has frayed in ways dissonant with the values and commitments nurses adopt through their education and professional code of ethics. As we emerge from the worst global crisis in a century, we call for critical examination of the collective experience of nurses during this time and a re-evaluation of the profession’s relationship with the public.
The social contract
Nursing, a scientific discipline, encompasses a unique body of knowledge concerned with the human bio-psycho-social-spiritual interaction with, and response to, the environment and subsequent impact on well-being. Nursing grounds its knowledge and practice in the American Nurses Association Code of Ethics for Nurses with Interpretive Statements (the Code). In the United States, professional nursing is regulated through state licensure or registration. When a person becomes an RN, they agree to practice with integrity according to the rules of licensure and in concert with the goals, norms, and values of the profession as reflected in the Code. Historically, this commitment served as the basis for the social contract between nurses and the public.
A social contract serves as a metaphorical device that explains an understanding between people and society and about how society is organized, how benefits are distributed, and how shared responsibilities are defined. Social contract theory derives from philosophy, politics, and religion. Although not legally binding, the theory suggests that the rights and duties of the state and its citizens are reciprocal, creating a relationship analogous to a contract that relies on social cooperation, shared concepts of fairness and justice, and a common understanding of obligations owed to each party by the other. As society and its governance structures evolve, so too, does the social contract.
Initially hailed as heroes in the early phase of the pandemic, nurses now face threats and violence from patients, families, and co-workers. Evidence indicates that a significant number of nurses providing care for patients with COVID-19 have experienced physical violence and verbal abuse. Data collected by Byon and colleagues from February to May/June 2020 showed that 44.4% of nurses reported experiencing physical violence and 67.8% reported verbal abuse. In some instances, members of the public resistant to public health measures to contain and combat the virus perpetrated these actions, confirming Cohen’s admonition that “the codicils in the social contract with society are always at risk of unilateral modification by the public.” This leaves nursing without clear recourse or means for renegotiation of this contract.
The term “contract” suggests a transactional relationship between nurses and the public, which may foster adversarial interactions when expectations aren’t met. Nursing, however, is an inherently relational endeavor, resting on an ethical foundation, which makes nursing’s relationship with the public more akin to a moral covenant than a contract. A covenant is based on a mutual relationship where each party makes solemn, binding promises to the other to work together toward a common goal or outcome. It typically outlines the morally binding promises or commitments that each party is accountable for and emphasizes values and trust rather than transaction. Nurses enact their professional ethics through socially defined and sanctioned roles, authority, and accountability that depend on the integrity of the social conditions necessary for professionalism to thrive. These social conditions include reciprocal and respectful relationships with the public.
We argue that nursing’s complex relationship with the public requires re-evaluation to understand the needs, challenges, and opportunities inherent in this moment. It’s time to recalibrate nursing’s social contract with society and embrace a more robust notion of a morally grounded social covenant. At least three contextual factors (nurses as human beings, nursing as relational, and nurses as linchpins) inform why this shift is necessary.
Nurses as human beings
Nurses are human beings with their own personal values, beliefs, commitments, and moral framework. Each comes to the profession with unique motivations and innate and learned personal resiliency.
Nurses in all roles and specialties must uphold the nine provisions of the Code and adhere to laws and regulations that govern nursing practice. Their individual understanding and interpretation of the Code and the regulatory requirements that govern practice in crisis and non-crisis situations inform their consideration of professional responsibility and accountability. As outlined in Provision 2 of the Code, nurses’ primary commitment is to the people or groups they serve rather than primarily advancing their own personal views and perspectives. This doesn’t suggest that nurses abandon their own moral compass, but within their professional role constraints ensure that they treat everyone they serve (patients, families, colleagues, and the public) with respect and fairness.
However, the Code also calls on nurses to promote and maintain their own health and well-being, and places responsibility on the individual nurse to cultivate personal resiliency and integrity within a workplace culture that supports ethical practice. Provision 5 of the Code specifically outlines these obligations as non-negotiable. A 12-month media investigation by Kaiser Health News estimated that more than 3,600 U.S. healthcare workers died during the first year of the pandemic—32% of them nurses (more than any other healthcare occupational group). In addition, early studies, such as one by Rushton and colleagues, reveal the immense and unprecedented impact that the pandemic has had on nurses’ psychological and moral well-being.
Other researchers, including Guttormson and colleagues and Cohen and associates, have documented relationships between COVID‐19–related moral distress and post-traumatic stress disorder, burnout, work and interpersonal difficulties, and moral injury associated with organizational factors. In April 2023, the National Council of State Boards of Nursing unveiled research that revealed approximately 100,000 RNs left the workforce during the pandemic due to stress, burnout, and retirements; another 610,388 reported an “intent to leave” the workforce by 2027. Nationally, about one-fifth of RNs are projected to leave the healthcare workforce.
Nursing as relational
As a relational endeavor, nurses work in tandem with patients, families, and other providers and personnel to deliver care in various settings. Maintaining trusting relationships with each of them enables nurses to provide safe, high-quality care. When the glue that holds a team together erodes, desired patient and organizational outcomes are compromised, and may even become unattainable.
Unprofessional and toxic behavior among nurses and other providers predates the pandemic. Many nurses report increased collaboration and teamwork in response to the pandemic, but workplace bullying persists in both plain and less obvious ways. For example, throughout the pandemic, especially when resources became scarce, nurses were expected to bear greater risk by providing direct care to patients suspected or confirmed to be infected with the COVID-19 virus. Nurses account for the most known healthcare worker deaths in the United States (32%), compared to physicians (17%), healthcare support personnel (20%), and all other roles (<10%). The inequity in risk and burden of exposure by nurses has undermined trust and confidence among healthcare team members.
This reality, which was animated by re-deployment to unfamiliar settings and nurses leaving hospital employment to accept travel assignments, frequently degraded relationships among healthcare teams. Conditions of extreme exhaustion depleted everyone’s capacity for empathy, generosity, and kindness and further eroded relationships among patients, families, colleagues, and the public. In addition, as Grace noted, misinformation spread by some nurses, who used their credentials as evidence of knowledge and reliability, contributed to a loss of trust and forced colleagues to address the effects of these ethical lapses.
Nurses as a linchpin
As the largest segment of the healthcare workforce, nurses are the primary providers of hospital patient care—the linchpins within the healthcare system. Appropriate nurse staffing ensures safe and effective patient care; however, chronic understaffing has persisted for years throughout the United States. For decades, healthcare facilities have exploited “cost-saving” just-in-time staffing models. While minimizing investment in the nursing workforce, organizations have relied on overtime (including mandatory overtime) or staff reassignment (floating) as daily management tools to address staffing shortages, frequently without making efforts to understand and mitigate the reasons behind shortages.
Predictably, in response to the pandemic, organizations depended on the same strategies but within a context of inadequate protective measures and cross-training. Even so, nurses continued to show up day after day despite chronic understaffing, overtime, demands of rapid “upskilling” or “reskilling” (for example, acute care nurses learning to function as ICU nurses), unresolved ethical issues, intensified workplace hazards, and incivility within and outside of the workplace. Not surprisingly, nurses have been lauded as heroes and angels, reinforcing tired tropes embraced and promoted by the healthcare industry, which legitimize expectations of self-sacrifice and prioritize perceived courage over knowledge, skill, competence, and commitment to professional and ethical practice.
NBC News reported that during the height of the pandemic, as the demand for nurses soared, hospitals experienced a “mass exodus”—nurses leaving staff positions to become travel nurses to make as much as $5,000 to $10,000 per week, well beyond the compensation and benefits paid to nurses employed by health systems, which revealed the economic perversities that underly the financing of nursing staff.
Reliance on temporary contract nurses and “short staffing” has profound consequences for safe, quality care. Recent pandemic era data from the National Healthcare Safety Network showed significant increases in rates of central line–associated bloodstream infections, catheter-associated urinary tract infections, and ventilator-associated events. Before the pandemic, Cimiotti and colleagues showed the relationship between these nursing-sensitive quality indicators and nurse staffing. Willingness to make costly investments in travel contracts and temporary measures provides evidence that healthcare organizations can re-allocate funds and realign priorities to increase nursing budgets when needed, which has led Berwick and others to challenge the basic financial foundation of American healthcare.
These three factors create the context for understanding the fragmentation of nurse’s relationship with those they serve—the public.
Societal responsibility and public breach of contract
For most nurses, their relationship with the those they serve (individuals, families, groups, communities, or populations) provides motivation and meaning. Generally, patients express gratitude for nurses’ knowledge, expertise, advice, and skillful care. According to Gallup, the public consistently rates nurses highest among professions for honesty and ethics.
Despite public esteem for nurses, negative perceptions persist, especially gendered and sexist stereotypes as recounted by Summers and Summers. Continued misunderstanding of the educational preparation of nurses persists, which fosters disrespect for nurses’ unique knowledge and independent decision-making skills, at all licensure levels. For example, how many nurses pursuing a research or clinical doctorate in nursing have been asked, “Why don’t you just get a medical degree?” Such comments reflect ignorance of or bias about the scope and significance of nursing preparation and practice and devalue nurses’ central contributions to patient and organizational outcomes and scientific inquiry.
In addition, workplace violence against nurses has been increasing for decades. According to data from the Centers for Disease Control and Prevention, as the primary providers of care in most settings, nurses face a greater risk of workplace violence compared to most other professions, with the primary source of violence being patients and visitors. Gender-based biases, cultural norms, and power relations also increase the risk of discrimination against, harassment of, and physical attack on healthcare workers who are women. One wonders if Alex Wubbels, the Utah nurse wrongfully arrested and handcuffed for correctly refusing to allow a police officer to take blood from her unconscious patient in 2017, would have been treated differently had she been a man or a member of a different profession.
As pandemic sequelae linger, social discontent and defiance of public health requirements and institutional policies governing visitation, masking, and physical distancing have intensified. News outlets such CNN, Kaiser Health News, Forbes, and others report that nurses have become the lightning rod for disrespectful and abusive language and escalating physical and psychological violence, including extremist animosity shared via social media. According to the Associated Press, nurses’ commitments to their patients have been challenged, and they’ve been accused of dishonesty regarding a patient’s diagnosis and of participating in conspiracies. Moreover, nurse “social influencers” engaging in misinformation and disinformation weaken nursing’s standing as a scientific discipline and ethical profession in the eyes of the public.
Trust, foundational to establishing and maintaining a patient–nurse therapeutic relationship, remains necessary to fuel nurses’ continued commitment to those they serve. Despite being repeatedly viewed as the “most trusted profession,” the confluence of factors prior to and during the pandemic has fostered bidirectional erosion of trust between nurses and society.
Reimagining nursing’s social contract with the public
The pandemic has amplified the essential role of nursing and the financial, psychological, and moral costs of providing care during a protracted crisis. Complex factors and interactions impact the delivery of nursing care, from individuals to systems, and multilevel interventions would sustain nursing in the present and build for the future. We need a more balanced and reciprocal relationship, one in which nurses receive what they need to perform at the highest levels of their education and practice.
Nurses’ psychological and moral integrity and well-being must be enabled by structural changes in healthcare systems. New care delivery models should fully engage the public in the delivery of healthcare and reinforce the bidirectional responsibility for health. Nurses, as individuals within a profession, must not be viewed as responsible for fixing a broken healthcare system but rather as full partners in system redesign. Nursing continues to hold high esteem by most of the public, but what does that mean for the future? How does nursing leverage this moment?
How to build a social covenant
The language and concepts we, as nurses and as a society, use to describe the relationship between nurses and the public matter. Collectively, we must move away from relying on a transactional framework—a social contract—and instead, amplify the deeply personal relationship between nursing and the public rooted in ancient human moral values and commitments. We must rebrand the profession and move beyond identifying as the “most trusted” profession to honoring the unique contributions nurses make to health, healing, and societal well-being. We must recast nursing’s image to reflect an identity of education, competence, and ethics. In addition, nurses’ unique knowledge, skills, and qualities demand full understanding, appreciation, and equitable compensation.
Nurses must create a new narrative about their work and the profession and engage in intentional strategies to shift the disempowering elements of the current narrative. Post-pandemic, we must re-introduce our profession to the public and reset the expectations, ethos, and image of nursing. Any concerted effort to re-imagine a new relationship with the public—a covenant—will require the engagement of all stakeholders. We must involve communities in understanding and enacting their reciprocal role, including their personal responsibility in managing their health and supporting the delivery of healthcare. We must leverage policy, with the support of organizations and their leadership, to support this recalibration.
Kazuaki Tanahashi, a Japanese translator, artist, and social advocate, suggests four principles of social transformation to approach a complex issue: No situation is impossible to change. A communal vision, outstanding strategy, and sustainable effort can lead to positive change. Everyone can make a difference. No one is free of responsibility. If we embrace these principles, everyone can participate in transforming the nursing contract into a social covenant. (See Proposed interventions.)
Be a catalyst
With a clearer understanding of the historical and contemporary notions of nursing’s social contract with the public and the characteristics of nurses and nursing practice, especially within the context of the pandemic, we can consider whether that framing aligns with current realities. Let this discussion serve as a catalyst for raising awareness, engaging in principled discernment, and invoking action to dismantle the disempowering structures that undermine nursing’s ability to fulfill its commitments to society and the profession.
Eileen Fry-Bowers is a professor and dean of the University of San Francisco School of Nursing and Health Professions in San Francisco, California. Cynda H. Rushton is the Anne and George L. Bunting Professor of Clinical Ethics and Nursing at John Hopkins University Berman Institute of Bioethics & School of Nursing in Baltimore, Maryland.
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Key words: social contract, ethics, public, relationship, re-design