At Cleveland Clinic Akron General, a nursing ethics champion program has helped nurses feel more confident identifying ethical issues and moral distress.1 A nurse on the ethics committee proposed the idea.
“The nurse stated that she had learned so much through her work on the ethics committee and wished there was a way for other nurses throughout the hospital to have similarly impactful learning opportunities, even if they weren’t serving on the ethics committee,” reports Hilary Mabel, JD, HEC-C, who previously supported the ethics program at Cleveland Clinic Akron General. Mabel is currently a clinical ethicist at Wellstar Health System.
Several nurses served on the ethics committee, all highly engaged. Thus, a planning group decided to implement a nurse-focused ethics champion program to capitalize on the nurses’ knowledge and enthusiasm. The planning group, which consisted of Mabel, a clinical ethics fellow, and eight ethics committee members, designed the curriculum for the program with the needs of bedside nurses in mind. “A number of nurses who were part of the planning group provided great insight into the kinds of ethical issues that nurses most often encounter,” Mabel says.
Thirteen critical care and medical/surgical nurses participated. The curriculum covered decision-making, advance directives, Do Not Resuscitate orders, and end-of-life issues. One session focused on how to address various ethical pressures that arise in daily nursing practice. “A lot of people conceive of ethical issues as grand and dramatic events that occur infrequently. In reality, they happen all the time,” Mabel says.
For example, patients occasionally refuse wound dressing changes. This is an ethical dilemma because the nurse wants to help the patient and knows the care is necessary to prevent infection. “But the patient is telling you no. And their individual autonomy starts butting up against your responsibility to help your patient,” Mabel notes.
The program provided education on moral distress stemming from situations like that. Nurses learned what moral distress is, how to identify it, and how to navigate it. “Part of the goal was to empower the nurse participants to become resources for their colleagues,” Mabel explains.
After completing the program’s educational component, the planning group surveyed participating nurses. “We saw statistically significant increases in confidence among participants in identifying when they or a colleague are experiencing moral distress,” Mabel reports.
Overall, nurses felt better equipped to identify and address ethical issues and moral distress in their work. Nurses were more willing to speak up about ethical issues encountered in daily practice. Additionally, nurses could identify institutional resources to assist with ethical issues and moral distress.
The ethics champion program did present some logistical challenges. “You need the bandwidth and person-power to support a program like this, in terms of planning, recruitment, and carrying out the program,” Mabel says.
First, the planning group secured buy-in from the leadership at two ICUs and two medical/surgical floors. Next, the group posted informational flyers, discussed the opportunity during daily huddles on each unit, and directly approached nurses who expressed interest in learning more about ethics.
Hospital leadership agreed to pay nurses for their participation. They were paid their regular wage for time spent attending all the sessions and meetings.
“Without that kind of support, I could imagine that getting nurses to join and stay in the program might be harder,” Mabel offers.
Leaders paused the program in 2021, mainly due to turnover. Several participants left to take jobs as nurse practitioners, travel nursing assignments, or inpatient nursing roles. “We continue to provide support to our remaining champions, and all nursing units, through structured ethics rounding,” says Julia Gorecki, MBA, BSN, RN, associate chief nursing officer at Cleveland Clinic Akron General.
Gorecki rounds with clinical ethicists on all inpatient clinical areas and invites staff to discuss challenging ethics issues. “One emphasis of these rounds is the nurse’s role in ethics conflicts at the bedside,” Gorecki says.
The nurse ethics champion program is expanding to an interdisciplinary ethics champion program. “The Cleveland Clinic’s Center for Bioethics is supporting our hospital to develop ethics ambassadors by educating clinicians to develop skills surrounding ethical issues,” Gorecki reports.
At Children’s Minnesota, ethicists launched an integrated ethics program in 2022. Participants attend rounds in the units, conduct case reviews, and serve as “ethics liaisons.” Currently, three nurses, three physicians, and one surgeon act as liaisons. All have served, or are serving currently, on the hospital’s ethics committee. The liaisons facilitate unit-based ethics forums on their respective units. “They provide peer-to-peer ethics support and are a link to the clinical ethics department in identifying educational, policy, or consult needs,” reports Ian Wolfe, PhD, MA, RN, HEC-C, a senior clinical ethicist at Children’s Minnesota.
The ethics service’s goal is for every unit to host some type of ethics forum. “These ethics forums provide multidisciplinary ethics discussions, facilitated by the ethics liaison and a member of the ethics consult service,” Wolfe explains.
Recent topics have included infants at the edge of viability, infants with complex genetic disorders, and resuscitation. Ethicists and liaisons encourage multidisciplinary discussion among nurses, physicians, nurse practitioners, respiratory therapists, chaplains, and social workers.
“Nurse ethics champions bring ethics to the frontlines, where ethical issues are not always the big, ‘macro’ ethical questions. Often, it’s the everyday ‘microethical’ questions that can be equally, if not more, impactful on practice,” Wolfe offers.
Moral distress can occur in basic, everyday nursing practice. Nurses question the right thing to do and debate disagreements on benefits and burdens of treatment (e.g., painful medical interventions in chronically ill patients). “These issues, if not addressed, can lead to more harmful moral injury, moral distress, and moral residue,” Wolfe says.
Often, no one is doing anything wrong. The problem is nurses need some help understanding the ethical issues. An ethics champion can help nurses determine if an ethics consult is needed. “A nurse ethics champion can help provide colleagues with real-time assistance in how to process tragic circumstances or complex cases,” Wolfe offers.
Hospitals can implement a nurse ethics champion role in a variety of ways. “But in its most simplistic interpretation, someone in this role is attuned to the issues and needs of a particular unit or system,” says Aimee Milliken, PhD, RN, HEC-C, an associate professor of the practice at the Connell School of Nursing at Boston College.
Nurses in this role can ensure ethical care based on the specific needs of the patient population cared for (e.g., ICU patients, pediatric patients, or patients with cancer or stroke). “Nurses with ethics expertise are well-positioned to identify recurring ethics challenges and design subsequent preventive ethics-focused strategies for mitigating them,” Milliken suggests.
For example, there might be recurring communication issues that lead to misunderstandings about the goals of care for patients at the end of life. “Nurses in this role can also be attentive to related contextual factors giving rise to moral distress in order to proactively address these challenges from an ethical standpoint,” Milliken adds.
REFERENCE
1. Mabel H, Myers G, Gorecki J, et al. The ethics resource caregiver program: Equipping nurses as ethics champions. J Clin Ethics 2023;34:27-39.
With the right training and advocacy, nurses can identify and address ethical issues, along with moral distress. They might be more willing to speak up about ethical issues encountered in daily practice and identify institutional resources to assist.
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