A Clinical Ethics Residency for Nurses has been developed at two large northeastern academic medical centers. One goal is to teach nurses how to be effective advocates for patients whose circumstances, problems, and treatments are ethically complex.
The program is funded by the Health Resources and Services Administration, and serves nurses at Massachusetts General Hospital and Brigham and Women’s Hospital, both in Boston.
“The ethical aspects of nursing practice are weighty. Nurses see some of the saddest, most tragic kinds of circumstances,” says Ellen Robinson, PhD, RN, the program director and nurse ethicist at Massachusetts General.
In addition to classroom lectures on ethics, the program incorporates the opportunity to explore one’s personal bias and its impact in highly emotional, complex ethical situations, communication techniques, role-play and simulation, and clinical mentorship.
“Big and little ethical questions arise daily for nurses,” says Susan M. Lee, PhD, RN, a senior nurse scientist at Brigham & Women’s Hospital’s Center for Nursing Excellence. Nurses often remain silent; if they do speak up, sometimes they do so in ways that are not effective.
“Sometimes, speaking up causes a backlash that may lead to silence in the future,” says Lee. “Nurses are often without forums for reflection, support, and mentorship.”
The program succeeded in reducing nurses’ levels of moral distress and increasing their self-confidence in handling emerging ethical situations, according to a 2014 report, which included feedback from 67 participants over three years of the program.1
“Nurses were given many opportunities to debrief with peers and mentors, while gaining support, new perspectives, and more effective language,” says Lee.
The group used the American Society for Bioethics and Humanities’ “Improving Competencies in Clinical Ethics Consultation: An Education Guide” as the foundation for the program, along with nursing’s professional code of ethics and other discipline-specific resources.
Ethics work is often interdisciplinary; different disciplines bring different strengths to ethical reflections, says Rev. Angelika A. Zollfrank, coordinator of pastoral education at Yale New Haven (CT) Hospital. “It is key to draw on the resources and skills of several professions, and create interdisciplinary programs that intentionally take advantage of these skills and strengths,” she says.
Nurses’ moral distress
Nurses are often in the best position to intervene and prevent emerging ethical dilemmas. “There are times when even prevention or early detection are not sufficient,” adds Robinson. “Nurses must take up the task of stepping into the ethical difficulty.”
In difficult cases, nurses may need to initiate ethics consultations. Not all are comfortable doing so. “Nurses need the tools to do this work,” says Robinson. “Cases that are fraught with controversy and indecision require more skills than knowledge alone.”
Historically, hierarchical structures in hospitals typically meant that physicians’ decisions reigned. “Today, we do see much greater collaboration,” says Robinson. “But at times, when there is nurse-physician conflict, it surely helps for nurses to have good communication tools to work with.” According to Robinson, “a more frequent ethical problem in patient care today is family members’ difficulty in accepting that their loved one is dying.”
Utilizing the techniques of role play and taped simulation allowed nurses to take on roles of other healthcare professionals and various family members, while applying newly acquired communication strategies. “They were able to see how they responded and communicated in real time, and allowed a space for debriefing about how they could then respond differently,” says Robinson.
Moral distress over end-of-life care
Nurses are often the ones who notice that the patient is suffering, that life-sustaining treatments are no longer conferring benefit and may be harming the patient, that conflict exists in the family structure/dynamics, or that healthcare teams are not in agreement. “Advances in medicine, surgery, and technology have brought us to uncharted waters, particularly in academic medical centers, where aggressive treatments are the norm,” says Lee.
Nurses witness a lot of what Lee calls “misalignment.” They see physicians giving prognoses that are not aligned with the patient’s declining condition, and care that is not aligned with the patient’s wishes, she says.
For example, it is not unusual that families request that pain medication be withheld so that their loved one is not sedated. “However, nurses cannot withhold medication in the face of suffering beyond what the patient is willing to tolerate,” says Lee. “Pain relief is a patient’s right, not a family decision.”
Organizations need to re-think their approach to ongoing education of nurses, says Lee, and address their moral and professional development in addition to skills and technology. “Ethics education is not a one-shot deal,” she says.
Nurses became more confident
Nurses are often first to notice emerging ethical dilemmas, but may not know how to articulate the problem. Many simply don’t feel comfortable speaking up.
“Many, though not all, dilemmas could probably be headed off with consistently good communication between and among the team, family members, and the patient,” says Pamela J. Grace, RN PhD, FAAN, associate professor of nursing and ethics at Boston College’s William F. Connell School of Nursing in Chestnut Hill, MA.
At times, nurses are discounted by others as not having important things to say. “We have long realized that nurses could be powerful forces in fortifying the ethical climate in an institution,” says Grace.
“Before and after” narratives completed by the participants were in sharp contrast. Initially, nurses often expressed powerlessness in trying to get what was needed for patients accomplished. Several months later, after the clinical ethics program was completed, nurses were more confident.
“They were much more willing to engage the team in discussion, or to put into place preventive initiatives such as ethics rounds or unit education offerings,” says Grace.
The program’s results demonstrated that a comprehensive approach is necessary. “It is a mistake to think that one can teach bioethics in a purely didactic fashion,” says Grace. “Healthcare professionals need to understand the ethical nature of all of their professional actions.”
Robinson EM, Lee SM, Zollfrank A, et al. Enhancing moral agency: Clinical ethics residency for nurses. Hastings Center Report 2014; 44(5):12-20.
Pamela J. Grace, RN, PhD, FAAN, Associate Professor of Nursing and Ethics, William F. Connell School of Nursing, Boston College, Chestnut Hill, MA. Phone: (617) 552-1246. Email: email@example.com.
Susan M. Lee, PhD, RN, Senior Nurse Scientist, Center for Nursing Excellence, Brigham & Women’s Hospital, Boston. Phone: (617) 525-9564. Fax: (617) 277-0383. Email: firstname.lastname@example.org.
Ellen Robinson, PhD, RN, Massachusetts General Hospital, Boston. Email: email@example.com.
Rev. Angelika A. Zollfrank, Coordinator, Pastoral Education, Yale New Haven (CT) Hospital. Phone: (203) 688-7036. Email: Angelika.Zollfrank@ynhh.org.