Hospital leaders all are asking the same question: How can we retain nursing staff? “Nurses who are stressed, overworked, and understaffed do not provide optimal care. As we are seeing currently, they leave the profession in droves,” says Pamela J. Grace, RN, PhD, FAAN, associate professor emeritus at Boston College.
Understandably, administrators typically focus on offering nurses competitive pay and benefits packages or wellness programs. Yet there is mounting evidence suggesting ethics expertise is needed to alleviate the burnout, moral distress, and dissatisfaction that is driving the crisis. Prominent nursing leaders interviewed by Medical Ethics Advisor argued ethics education is a powerful tool to improve retention. “The ability to provide good care in spite of obstacles requires at least a basic grasp of ethical decision-making,” Grace explains.
Ethics consults might be called if serious conflicts arise during an individual patient’s care. However, staff nurses confront ethical issues daily, such as inadequate staffing that prevents good care. Those “everyday” ethical issues typically go unaddressed. For some nurses, this is the tipping point to cause them to leave the hospital, or even the profession altogether. “Nurse managers and leaders should be prepared to serve as ethics resources,” Grace asserts.
To hone these skills, nursing leaders can join ethics committees or participate in ethics consults. Armed with ethics expertise, nursing leaders can help frontline nurses avoid burnout and moral distress. Consider routinely hosting short meetings to discuss ethical problems that are arising before things reach a crisis level. “This encourages staff to express concerns using the tools of ethical decision-making,” Grace says.
For example, during these meetings, a nurse might state: “I am concerned that I am unable to fulfill my obligations to my patients.”
Georgina Morley, PhD, RN, HEC-C, views ethics expertise as a powerful retention tool and a way to mitigate moral distress. “Having the ability to think critically and problem-solve is intrinsic to ethics education. It can also be helpful for examining issues related to understaffing,” Morley says.
For instance, nurses face an ethical dilemma if they cannot provide good care to patients because the department is short-staffed. “Ethics expertise can help to reframe the conversation; instead of nurses feeling like they are failing, nurses can understand how to navigate ethical challenges and who to call to help them,” Morley says.
Recently, Morley and colleagues surveyed 49 nurses and interviewed seven nurses about ethical challenges during the COVID-19 pandemic.1 It turned out the ethical issues that came up were not unique to the pandemic. “Rather, the impact seemed to be amplified because of the repeated duration and occurrence,” reports Morley, director of the Cleveland Clinic Nursing Ethics Program, a collaboration between the Center for Bioethics and the Nursing Institute.
For instance, nurses struggled with questioning whether surrogates were making decisions that truly reflected a substituted judgment or best interest standard. Nurses also reported taking on added emotional burdens when caring for patients dying alone. “Nurses often struggle to disentangle their personal and professional values with the values of patients and families,” Morley notes.
Nurses can use ethics expertise to inform decision-making, preventing moral distress that can lead to turnover. Yet ethics education often is inconsistent at the undergraduate and postgraduate levels. “We would benefit from providing more ethics education in hospital settings to nurses,” Morley asserts.
The Cleveland Clinic’s recently launched program, Moral Spaces: Seeking Perspectives to Advance Clinical Ethics Skills, provides 42 hours of ethics education to 20 nurses over seven months. After participating, nurses offer ethics and moral distress support on their units. “Ethics education is a way to make nurses more morally resilient,” Morley says. “But we also need to pay attention to the ethical climate of healthcare institutions.”
Nurses with solid ethics expertise can improve it by confidently engaging in discussions with surrogate decision-makers regarding a patient’s values. “This helps to ensure that the care we provide aligns with the patient’s wishes, thereby mitigating the root cause of moral distress,” Morley adds.
Cynda Hylton Rushton, PhD, RN, FAAN, and colleagues have conducted several studies examining ethical challenges encountered by nurses during the pandemic.2,3 The findings shed light on how to improve retention of nursing staff, according to Rushton, a founding member of Johns Hopkins University Berman Institute of Bioethics. “Many of the ethical issues reflect threats or violations of nurses’ core professional values and their identities as a nurse,” Rushton reports.4
Rushton is leading a statewide initiative in Maryland to build greater resilience and ethical practice among nursing faculty, students, and novice nurses. “When nurses cannot uphold the values outlined in the American Nurses Association Code of Ethics for Nurses, such as respecting all persons, fairness, and equity in allocating harms and burdens, or preserving their own integrity, moral suffering is likely to ensue,” Rushton says.
At Johns Hopkins, Rushton created the Mindful Ethical Practice and Resilience Academy, an educational program for frontline nurses. The program improves ethical confidence and competence, resilience, and work engagement; and alleviates anger, depression, and intent to leave.5 “Cultivation of moral resilience offers a protective resource for nurses and others who are addressing complex ethical issues,” Rushton says.6
Ethics education alone will not convince nurses to stay. “But it does give them a vocabulary and framework for understanding their concerns — and, potentially, finding an integrity-preserving path forward,” Rushton adds.
As a clinical ethicist at the University of Rochester (NY) Medical Center, Marianne C. Chiafery, DNP, PNP-BC, routinely met with new nurses a few months after orientation to offer the opportunity to share ethical concerns. Chiafery came empty-handed to the meeting, without slides or handouts. The nurses drove the discussion. First, Chiafery asked the nurses how much ethics education they had received. Most stated they received little to none. Yet when Chiafery asked: “How many of you have faced ethically challenging cases that left you troubled?” almost all nurses raised their hands.
The nurses acknowledged many ethics knowledge gaps — the role of proxies and surrogates, capacity assessment and its role in informed consent and informed refusal, how to cope when personal values conflict with professional obligation, and providing treatment that seems to offer no benefit to the patient. “Adequate ethics education is lacking,” Chiafery says. “This has a profound effect on patient care, nurse satisfaction, and retention.”
This spurred Chiafery to provide a 30-hour ethics education program, conducted over nine months. Several experienced bedside nurses who participated in the program admitted they had been ready to quit the profession. “However, they had renewed energy — and became ethics educators and liaisons on their units,” Chiafery says.
REFERENCES
1. Morley G, Copley DJ, Field R, et al. RESPONDER: A qualitative study of ethical issues faced by critical care nurses during the COVID-19 pandemic. J Nurs Manag 2022;30:2403-2415.
2. Rushton CH, Thomas TA, Antonsdottir IM, et al. Moral injury and moral resilience in health care workers during COVID-19 pandemic. J Palliat Med 2022;25:712-719.
3. Rushton CH, Nelson KE, Antonsdottir I, et al. Perceived organizational effectiveness, moral injury, and moral resilience among nurses during the COVID-19 pandemic: Secondary analysis. Nurs Manage 2022;53:12-22.
4. Swavely D, Romig B, Weissinger G, et al. The impact of traumatic stress, resilience, and threats to core values on nurses during a pandemic. J Nurs Adm 2022;52:525-535.
5. Rushton CH, Swoboda SM, Reller N, et al. Mindful Ethical Practice and Resilience Academy: Equipping nurses to address ethical challenges. Am J Crit Care 2021;30:e1-e11.
6. Spilg EG, Rushton CH, Phillips JL, et al. The new frontline: Exploring the links between moral distress, moral resilience and mental health in healthcare workers during the COVID-19 pandemic. BMC Psychiatry 2022;22:19.
Armed with ethics expertise, nursing leaders can help frontline nurses avoid burnout and moral distress. Consider routinely hosting short meetings to discuss ethical problems that are arising before things reach a crisis level.
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