The practice of ethics

When staff nurses walk through the doors of their workplace, they step into a world of complex human interactions, science and technology, birth, death, and everything in between. And if those factors collide, nurses can face ethical dilemmas.

There are, however, some nurses in both unit-level and high-level ethics positions at healthcare organizations who can provide counseling and support to their colleagues who are confronted with ethical issues, such as family members insisting on care for their loved one that is no longer therapeutic.

And more nurses skilled in ethics are needed, because healthcare issues aren’t likely to become less complicated. This year, the American Nurses Association (ANA) cosponsored an ethics conference to give staff and other nurses more information around ethical issues and research, real-practice strategies, and ways to apply ANA’s Code of Ethics for Nurses with Interpretive Statements into their practice. During breakout sessions in which ethical scenarios were discussed, participants expressed encountering similar, if not the same, issues in their practice. Moreover, they didn’t necessarily agree on the best approach to solving the dilemmas they face.

“Nurses want to do the right thing, they want to be an ‘ideal nurse,’” says Lucia D. Wocial, PhD, RN, a nurse ethicist at the Charles Warren Fairbanks Center for Medical Ethics and Indiana University Health, an Indiana State Nurses Association member, and chair of the 2013 National Nursing Ethics Conference co­sponsored by ANA and the California-based nonprofit organization Ethics of Caring. “As a nurse ethicist, I can help nurses think about ethics and the issues they are grappling with.”

The nurse ethicist is in

Wocial has several roles as a nurse ethicist, from teaching ethics to healthcare professionals, to providing formal ethics consults on patient-care issues at Indiana University-affiliated facilities, to meeting with nurses informally to discuss challenges.

In both her formal consults and informal discussions, the number-one ethical challenge for staff nurses involves care at the end of life and, more specifically, futile care. “A nurse can have five people in the ICU who are clearly dying and know there are five people in the ER who need and could benefit from ICU care,” says Wocial of this care dilemma.

Barbara Bennett Jacobs, PhD, MPH, RN, agrees, saying. “A staff nurse often feels moral distress when, in her mind, she is providing care that is futile. She may think, ‘This patient’s vital organs have failed. He is unresponsive. What am I doing continuing care? Am I doing the right thing?’ If the families are demanding continued life support, she may feel complicit in something that is immoral.”

Part of the problem lies in an inadequate understanding of “medical futility,” says Jacobs, director of Clinical Ethics Consultation Service at Hartford Hospital, a large urban teaching hospital in Connecticut, a Connecticut Nurses Association member, and speaker at the spring 2011 ethics conference. “You need to look at the benefits, the burdens, and the effectiveness [of treatment], she says. “It is not just a subjective decision.”

Beyond futile care, physicians and nurses also frequently ask for Jacobs’ guidance on how to ethically deal with a next of kin disrespecting a loved one’s living will request regarding treatment; differing views on quality of life; decisional capacity questions; and increasingly, inability to transfer in a timely fashion a patient from acute care to a nonacute care facility, often because of a patient’s socioeconomic circumstances.

To a much lesser degree, Wocial and Jacobs field ethical questions about workplace issues, including
social networking concerns, such as some nurses being concerned that their coworkers are not appreciating boundary issues or are perhaps blogging about a patient load. Wocial says another ethical concern involves nurses or other providers who see errors or breaks in procedure and don’t speak up; for example, watching and not stopping someone walk into the room of a patient who has a methicillin-resistant Staphylococcus aureus infection without first gowning up.

Beyond these larger issues, she says nurses make little ethical decisions every day—even in determining which of their five or more patients deserves the most of their time. And sometimes there might not really be an ethical conflict present. “End-of-life decisions usually are very emotionally charged, particularly if families are divided over choosing aggressive treatment,” she says. “However, once everyone gets to hear one another, conflict often melts away. Good communication is at the root of ethics about 80% of the time.”

Additionally, Wocial and Jacobs expressed the belief that because they themselves are nurses, it allows other nurses to open up to them and work through their ethical questions and struggles more comfortably. “I’m going to cast this morally safe net, so frontline nurses have the freedom to talk about anything without consequences [unless there is some critical breach],” Wocial says.

Having nurses in high-level ethicist roles and having strong administrative support for ethics programs is crucial. “We’ve seen when things can go horribly wrong when nurses do the right thing, such as in Texas [where nurses faced criminal charges for reporting their concerns about a physician’s standard of care],” Wocial says.

Ethics support on the unit

When educational specialist and Magnet® Program Director Patricia Rackstein, MA (in Bioethics/Medical Humanities), BSN, RN-BC, began serving on a multidisciplinary ethics committee at Morton Plant Mease, BayCare Health System in Florida, she noticed a growing amount of moral distress among staff, and nurses in particular. Concerned about its effect on RNs as well as potentially on nurse retention, Rackstein received administrative approval in 2010 to develop a cadre of ethics resource nurses who could immediately step in and help other staff on their units navigate ethical challenges.

Currently 34 in number, the ethics resource nurses are direct-care nurses who have received additional education in ethics. That training includes knowing how to incorporate the Code of Ethics into daily practice, being able to help nurses tap into Morton Plant Mease’s ethics consult process and other key resources, and gaining greater communications skills.

“Anyone can request an ethics consult—the physician, patient, family member, nurse, or other caregiver,” says Rackstein, a Florida Nurses Association member and former ICU nurse. “But our goal with having these resource nurses in place is to be more proactive and address issues before a conflict occurs and a formal ethics consult is needed.”

Since becoming a critical care nurse 35 years ago, Karen DeSantis, RN, has always been interested in ensuring ethical and sound decisions at end of life. “I’ve always felt it’s important for nurses to treat the whole person—the physical, emotional, psychosocial, and spiritual—and that we always respect the wishes and rights of the patient,” DeSantis says. Because of her commitment to these long-held beliefs, she was one of the first nurses to sign on to become an ethics resource nurse, specifically for her CCU, and hopes that the program will grow and thrive. “As nurses, we’re with patients and their families 24/7,” DeSantis says. “So when I’m talking with nurses, I suggest that they find out as much as they can about what their patients were like before they were hospitalized, their family dynamics, and religious beliefs. That way nurses can know what is going into patients’ and families’ treatment decisions, or they can guide them better through decisions about care, especially at the end of life.”

She also urges nurses to be patient, tolerant, and accepting of others’ feelings and attitudes. “We all come with our own moral compass, and it can conflict with what our patients or their families may want,” DeSantis says. “And nurses go through a lot of grieving too. Things don’t always turn out the way we would like them to, such as when a younger person dies.

“Lots of nurses feel the need to be very stoic. So having an ethics resource nurse available to them on their unit allows them to have an outlet to express their feelings, and maybe get a referral to pastoral care, for example, if needed.”

Not an ethics expert overnight

All the nurses interviewed encourage staff nurses to get involved in ethics committees if they are interested, but with two important caveats: Get more formal ethics education to become competent and skilled, and know one’s own abilities and limits.

“All staff nurses have to have certain ethics-related competencies to practice,” Jacobs says. “Not all nurses can be clinical ethicists. But if you are a staff nurse who is curious and passionate about ethics, find out about what committees are in place at your facility and take the important steps to learn more about ethics so you can be effective. You also need to know your values, what is important to you, and how your values influence your practice.”
Wocial notes that Indiana University Health has been very supportive of giving nurses a voice at ethics tables. “We believe their involvement helps everyone.”

For more information on the Code of Ethics and ANA’s work on ethics and human rights, go to www.nursingworld.org/MainMenuCategories/EthicsStandards.aspx.

Susan Trossman is the senior reporter for ANA.

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