Developing a moral compass: Themes from the Clinical Ethics Residency for Nurses’ final essays

Abstract

Background:

The Clinical Ethics Residency for Nurses was offered selectively to nurses affiliated with two academic medical centers to increase confidence in ethical decision-making.

Research Question/Aim:

To discover how effective the participants perceived the program and if their goals of participation had been met.

Research design:

A total of 65 end-of-course essays (from three cohorts) were analyzed using modified directed content analysis. In-depth and recursive readings of the essays by faculty were guided by six questions that had been posed to graduates.

Ethical considerations:

Institutional review board approval was granted for the duration of the program and its reporting period. Confidentiality was maintained via the use of codes for all evaluations including the essays and potentially identifying content redacted.

Findings:

An umbrella theme emerged: participants had developed ethical knowledge and skills that provided a “moral compass to navigate the many gray areas of decision-making that confront them in daily practice.” Six major themes corresponding to questions posed to the participants included the ability to advocate for good patient care; to support and empower colleagues, patients, and families; they experienced personal and professional transformation; they valued the multimodal nature of the program; and were using their new knowledge and skills in practice. However, they also recognized that their development as moral agents was an ongoing process.

Discussion:

Findings support that enhancing nurse confidence in their moral agency with a multimodal educational approach that includes mentored practice in ethical decision-making, enhancing communication skills and role-play can mitigate moral distress. A majority found the program personally and professionally transformative. However, they recognized that ongoing ethics discussion involvement and supportive environments would be important in their continued development of ethical agency.

Conclusion:

Multimodal ethics education programs have potential to be transformative and enhance nurse confidence in their ethical decision-making.

Keywords

Decision-making developing a moral compass ethical moral distress multimodal ethics education nurse moral agency nurse personal transformation nurse professional transformation

Introduction and background

The various environments in which contemporary nurses practice are complex, multilayered, and demanding regardless of setting. This complexity contributes to the difficulties of nursing work and can present obstacles to practicing well. Evidence is mounting that when nurses are hindered from providing what they see as needed care for patients, or when they are unsuccessful in advocating for a patient’s needs to be met, they can experience moral distress. Moral distress is a temporary or persistent feeling of disequilibrium that can have psychological and physical sequela. Over time, and when unrecognized or unaddressed, moral distress can have an anesthetizing effect that leads to nurses distancing themselves from patients. Alternatively, nurses may leave the profession due to feelings of impotence or dissatisfaction. In either case, unaddressed moral distress is a problem for nurses but even more importantly, perhaps, for patients and the public served.^1
–3

The authors of this article collaborated on developing a grant-funded multimodal educational program, the Clinical Ethics Residency for Nurses (CERN). The program was designed to develop nurse confidence in their ethical decision-making and moral agency. Nurse moral agency is the ability to address practice issues that impinge on good patient care. Elsewhere, we proposed that moral agency provides a defense against the experience of moral distress.⁴ Here, we describe our qualitative content analysis of the end-of-program essays written by participants of the CERN. For each year of this 3-year funded program,⁵ a cohort of nurses participated in the program over 10 months. Program graduates were asked to answer several questions in their essays and then present a verbal synopsis of them during a final “synthesis day.” Of the 67 participants, 65 provided essays. The findings of the analysis are discussed along with implications for nursing education and institutional administrators.

As a point of clarification, along with other authors,^6,7 we view ethical and moral as equivalent concepts when related to healthcare professional responsibility. Both terms are derived from the parent discipline of moral philosophy but have their roots in different languages (Greek and Latin, respectively). For consistency, we use “moral agency” to talk about nurses’ ability and motivation to act to meet nursing goals and “ethical” when talking about decision-making and individual actions.

The Clinical Ethics Residency for Nurses

Details of the CERN project are published in three prior articles.^4,7,8 In summary, CERN was a US Health Resources and Services Administration (HRSA)-funded project (HRSA D11HP18974) to create and offer an ethics education model that aimed to increase nurse confidence in ethical decision-making and action and prepare bedside and supervisory nurses to serve as local and institutional ethics resources. The program used a multimodal educational curriculum of one 8-h day for each of 10 months and a 16-h mentored practicum providing an opportunity to use their skills to develop unit or institutional ethics initiatives. Practica were started during the program but not, for the most part, completed until after program end. There were three separate cohorts of nurses over the 3 years of the program (2010–2013). The total number of participants was 67. Participants were drawn from a wide variety of practice settings as discussed shortly. They were asked to reflect upon how the CERN experience had impacted them using their application essays as an anchor and a set of six questions, reflecting the course objectives, as a guide. Acceptance into the program was selective and prospective participants had been asked to describe why they were interested. Analyses of these application essays are published elsewhere.⁸

Aims

The fundamental aim of this educational evaluation was to discover how the participants perceived the program and whether and in what senses their expectation of participation had been met. By asking them to provide an essay or narrative with examples, we hoped to discern which parts of the program were most successful in developing their confidence in ethical decision-making and moral agency. A secondary aim was the opportunity for them to reflect on their learning and consider how they would use it in practice.

Methods and rigor

Study design

After consideration by the authors, the qualitative method of directed content analysis⁷ was determined as most appropriate to address study aims and permitted analysis of the 65 resulting essays, augmented by faculty observations and field notes that had been taken during the Integration Day (final course day) presentations. The essays were to address six questions and be supported with examples where pertinent. These questions, listed below, reflected the program objectives and the usefulness of the curricula modes.

Questions

How have you changed the way you approach and analyze an ethical problem?

How have you changed the way you communicate with health professional colleagues about ethical problems?

Identify areas of personal growth that are the result of CERN.

What aspects of the CERN teaching methods resonated with you?

To what extent did the CERN program meet your expectations?

Describe the impact (if any) that CERN has had on you/your practice?

Participants

Participants were selected by the program faculty from a pool of applicants at, or affiliated with, two academic medical centers in the North East USA, as described in a prior paper.⁴ Each year, there were more applicants than could be accepted to the program. The criteria for selection included strength of desire as detailed in the application essay, clear articulation of projected application of the knowledge and skills gained, and support from supervisor or overseeing administrative executive. In the second and third years of the program, additional consideration was given to applicants from units or clinics where there was a prior CERN graduate.

Data analysis

The CERN program, and resulting curriculum, had used a synthesized theoretical framework to structure educational components and content. However, this framework was not a good fit for the data analysis task of this study or for the prior published study,⁸ which consisted in an analysis of their essays detailing why they wanted to be accepted into the program. For the current educational evaluation, we used an inductive approach via modified directed content analysis, a qualitative descriptive method. In qualitative descriptive methodologies, “one interprets common themes, moving beyond what individual participants reported, clustering together common ideas from multiple individuals to re-present the data.”⁹ The essays of the three cohorts (2010–2011; 2011–2012; 2012–2013) were analyzed as a unit (N-65) rather than separated into cohorts.

While directed content analysis can be framed by a theoretical model,¹⁰ we used the six questions noted above to frame our analysis. After preliminary reading of the essays by all faculty, three faculty members were engaged in a deeper iterative process of reading and rereading, identifying units of information and clustering these under a label or code. We met periodically, to compare our individual analyses and agree on labels, themes, and their relationship to the questions. These were then shared with the group and evaluated for coherence with field notes and observations that had been made during the three Integration Days of the program. One challenge was the inevitable overlap among some of the labels and their subsequent themes. This was not surprising in light of the integrated nature of the program. That is, the programmatic didactic content, skill-building and practice components on each educational day, along with reflection periods (self-reflection and reflection on actualization of learning in practice), addressed common content and aims. This was in-line with the ultimate aims of the program to increase nurse confidence and skill in ethical decision-making and action. In addition, we wanted to prepare them to serve as ethics resources for colleagues and/or the institution depending on participant education level, role, and position.

Trustworthiness (credibility, dependability, confirmability, and transferability)

Relying on Lincoln and Guba’s⁸ criteria, the trustworthiness of the study derives from the competence and experience of the researchers, several of whom are experts in qualitative research. In addition, observations shared with the team by project advisors and institutional administrators on each of the Integration Days related to the participants’ verbal reports of aspects of their essays strengthened the soundness of the findings. We maintained an audit trail of all aspects of the data analysis including important decisions. Researchers were also self-reflective and challenging of their own and each other’s potential biases.

Ethical issues

Institutional review board (IRB) for human subjects’ research approval at the institution housing the grant was received. This included analysis and reporting of data gathered throughout the life of the program. Applicants had been informed that their data’s confidentiality would be maintained. To facilitate this, demographic data were delinked from narrative information and essays were coded with a number as noted above. The principal investigator (PI), program evaluator, and PI’s assistant were the only ones with access to the codes, which are kept in a secured area in the institution. However, for the readability purpose of this article, pseudonyms have been substituted for numbers. Where individual applicant essays might be identifiable to the faculty of the program related to the cases or examples reported we have eliminated data that would render them identifiable to anyone else.

Findings

Demographics

As reported elsewhere,^4
–6 participants were “predominantly female (92%), White (95%), non-Hispanic (100%), staff nurses (68%), educated at the baccalaureate to graduate levels (83%), and with an average of 20 years of experience. Almost one-third were APNs or nurse leaders” and “were employed in one of two academic medical centers in the northeastern United States or their affiliates” (p.447).⁷ Their areas of practice were various and included a range of critical care units, neonatal to adult; a range of acute care units including psychiatry; and a range of outpatient departments including oncology and gerontology, a clinical research unit, and case management. Some participants worked in supervisory or administrative capacities. The report of findings below describes an overarching theme and six major themes. We used participants’ own words to label the six themes and illustrate themes with epitomizing quotes from their essays. For the purposes of describing findings, we have assigned each participant a pseudonym rather than a number.

Themes

Besides the major themes that reflect response to the six questions asked, an encompassing theme emerged from the data analysis. The participants had developed ethical knowledge and skills that provided a “moral compass: to navigate the many gray areas of decision-making” that confront them in daily practice. They were enabled to advocate for good patient care and to support and empower others, peers, colleagues, patients and families. They found the program to be personally and professionally transformative. While overwhelmingly the participants had gained knowledge and skills to navigate the many gray areas, they saw this as a beginning, realizing there was much more to learn and that ongoing skill-building in supportive environments would be needed.

A clinical nurse specialist (CNS) wrote,

I had no idea that it would provide me with so many opportunities to reflect on my values…I am shocked how much I have learned, and overwhelmed by how much more there is to know about integrating this knowledge into my practice. I have begun to look at almost every situation in an ethical light. (Alisa)

Oona, a staff nurse, describes her ability to support and empower a nurse whose patient took a “turn for the worse and who (the nurse) was very unsettled” by this. She was able to “work with the nurse, and encourage her to talk with the family, the attending, etc.” Marco wrote, “when my journey started nine months ago it was impossible for me to foresee the transformation that was about to take place in me both personally and professionally.” Many recognized that developing their capacities was an ongoing process requiring mindfulness, practice in ethical decision-making, and support from colleagues and administration.

Six major themes

The six themes that correspond and capture the essence of the questions posed (listed above) follow and are illustrated with participant quotes that epitomize the theme.

Question 1

Themed response: They use a moral compass of nursing goals and ethical principles and tools to separate reason from emotion, systematically unpack situations, and direct actions.

The participants described how being equipped with frameworks for decision-making, understanding the centrality of nursing goals and obligations and learning the nuances of ethical principles and language permitted them to step back from their immediate emotional response and systematically think through difficult situations:

The CERN program provided me with insight into strategies to better address ethical issues on a daily basis…(a) systematic approach to an issue in collecting the facts…defining the ethical issue, posing possible solutions, and deciding on a workable solution serves us well time and time again. (Aggie)

“I have begun to recognize less obvious ethical problems and issues that arise daily in my nursing practice” (Bea). Lena, a clinical nurse, exemplifies the perspective of the majority of the participants stating, “I have learned a set of tools that allow me to analyze ethical problems in a meaningful, productive way.”

Many recognized that while in the past their own tendency to approach problems from an emotional level could permit bias and prejudgment to influence their responses, their perspective had changed. Awareness of the role of emotion in how one approaches decision-making was a sentinel learning event for many. They attributed this change to the program’s emphasis on self-reflection, group reflection on action, and modules on effective communication techniques. “It seems as though prior to the CERN course I would walk into ethics rounds or meetings with a set of pre-formed opinions or views” (Ariel). Bea wrote, “by using the skills I have learned over the past 9 months, I am now better able to separate my feelings and values from the problem and look more objectively at the views of all parties involved.”

Ethical issues did not necessarily become easier to handle but nurse participants were able to be more efficient and confident in their approach to the issues. Lee wrote, “I was able to gain a greater understanding of how to find my way through challenging situations in nursing and develop new skills to use when faced with ethical challenges.” Another benefit to the use of ethical analysis for complex problems included the increased sense of credibility they perceived from others in the team. As Marco reported, “I take the time to ask myself, what ethical principle is applicable in this case?…people are more inclined to listen or go the extra mile when I explain myself using ethical principles…my message carries more weight(and) allows me to better advocate for my patients.”

Question 2

Themed response: They use communication techniques and active listening to step into the shoes of others and see the issues in broader terms with the assistance of ethical vocabulary and decision-making tools.

Almost all of the nurse participants alluded to the communication modules and ongoing focus on being able to articulate a problem or position clearly as invaluable tools in facilitating good patient care. That is, not to assume meaning from “body language” or prior interactions with a person. I now never challenge a person verbally, I ‘inquire’” (Larna). “One of my new favorite phrases is ‘help me to understand what your concerns are’” (Matt).

An important insight from the essays is that improving communication skills is an ongoing process and that this needs to be recognized and supported. The formal communication modules were led by experts in the SAVI^® method.¹⁰ SAVI stands for system for analyzing verbal interactions. Our inclusion of experts in SAVI, in addition to ongoing role-play, simulation, and discussion were all cited in the essays as important in improving their ability to gain personal knowledge, hold their emotions in check, and clearly and concisely articulate the essence and nuances of a problem or situation using ethics language as pertinent. Couching communications with the healthcare team in ethical terms and mutual goals of good care, they saw, could defuse tensions and lead to effective action. As a clinical nurse participant (Caron) wrote, “the SAVI communication…along with role-playing helped me to appreciate that the way we communicate can impact a potentially difficult situation either positively or negatively.”

Cora, recounting the issue of a patient who was irreversibly brain damaged and whose family was struggling with what to do, noted that the resident physician was uncomfortable talking with the immigrant family about prognosis:

I (had) gained a voice…I decided to intervene…so unlike me. I asked the family if they have seen the magnetic resonance imaging (MRI)…what it means to have no brain function…after talking them through the situation and its implications they explained to me that it was very helpful for them to see the image.

A case manager, Dulcie, told of a pregnant non-English speaking woman whose fetus was diagnosed with a genetic problem where the physician did not know how to communicate the problem. “I suggested they have a family meeting with an interpreter…and that the patient should have family members of her choosing present. Prior to being in CERN, I may not have spoken up.” Harriet, an oncology clinical nurse, reported that for a patient with an inoperable brain tumor who could not tolerate the treatment she “approached the physician team and suggested maybe a simpler radiation plan with an easier to tolerate mask would accomplish Ms. X’s primary goals” and they agreed.

Marco, in talking about the usefulness of ethics terminology wrote, it “allows me to better communicate with my colleagues about ethical problems we face as a team.” A relatively new nurse, Micaela, recounted how the skills developed in CERN helped her to get a Vietnamese family the help they needed to resolve a misunderstanding about the patient’s prognosis, the team was moving forward with aggressive interventions. “I…felt so strongly about the principle of non-maleficence that I spoke up and made my point…I was heard.” Nadia wrote, “I have assumed the lead in several meetings as others have been hesitant to have the tough conversations. Without my CERN background I would have sat back and waited for someone else to take the lead.” Commenting on the critical importance of good communication skills for good care, Oona wrote, “I may have the lingo, the methods, and the empathy but if I can’t convey them in a meaningful way, they (these skills) are useless.”

Many talked about the importance of trying to understand the perspective of others, as exemplified by Alisa,

The role-playing we have done in this course forced me to look at things through a different lens…the importance of listening to what everyone literally brings to the table has helped me to come to a more informed decision…if I remove myself and step in another’s place for a moment, I am better able to understand the current situation.

Question 3

Themed Response: They experienced personal and professional transformation reflecting broadened thought horizons, deeper inquiry, an appreciation of nuance, and the courage to advocate and support others.

As noted earlier, we named the final day of the course each year “Integration day” and invited the nurse participants to share the essence of their essays and anecdotes about how they had used what they learned. Faculty and invited observers were struck by the question how many of the participants who talked about the personal transformation they had experienced over the year. This is exemplified in Marco’s essay, “When my journey started nine months ago it was impossible for me to foresee the transformation that was about to take place in me both personally and professionally” throughout the year:

I could not help but notice my own ways of seeing things. I discovered that my own biases, my personal and spiritual values, life experiences influence my decisions daily and am (now) empowered to not just see from where I stand but broaden my horizons.

We had built into the program opportunities for self-reflection and reflection on practice, and this resulted in shared insights about personal and professional growth. Many nurses explicitly or implicitly noted that they had changed the ways in which they think about and approach practice and their personal lives. They had become more thoughtful and wiser in approaching issues in both their personal and professional lives. As Cate recounted, “some self-insights I had along the way…I realized now that I am more thoughtful in my approach” to problems. Evident in both the essays and their presentations was that the program had given them more than they could have anticipated. In talking about role-play where she had to take the part of a consultant a participant, wrote that “it was not until after class when I got home that I realized how much I learned about myself and changed the way (I) feel and think about things (Lucia). Another wrote, “the most surprising effect (CERN) has had on me is the new understanding and knowledge I have of myself and the improved confidence I have as a nurse and a person” (Larna). Noelle wrote of “Insights (that were) gained about how other people are thinking and what it is like for them and this adds a “greater comfort level” in interacting…my CERN experience helped me to be present with this patient (who had received bad news) in a meaningful way and with a greater comfort level.” The self-awareness and reflection components of the program enhanced the nurses’ abilities to tolerate uncomfortable emotions in clinical–ethical situations and recognized those emotions as part of the situation that then they could respond to therapeutically.

Participants talked about how elements of the program worked together to develop their courage to address problems carefully and directly when they previously would have stayed silent. The “program has given me a new found courage that I didn’t have before…through knowledge gained, through the communication skills class, the role-play and discussions…” (Cora). Carla described, “My entire thought process has matured around all things clinical and non-clinical…I am more apt to be less judgmental…I think longer and harder before providing insights. I approach situations with confidence and clarity.”

Alisa’s words capture the essence of the essays related to personal and professional growth. “I cannot express how much I have appreciated the opportunity to learn, reflect and grow…I am shocked at how much I have learned and overwhelmed by how much more there is to know.”

Question 4

Themed response. The integration of disparate methods, the critical importance of SAVI^© communication training, role-play, simulation, lectures, readings, interactions with colleagues, and faculty guidance in an open moral space, all resonated.

We built the CERN program based on the state of the science in adult learning, in addition to what is in the literature about developing moral agency. The curriculum used James Rest’s⁹ four cognitive processes of moral agency to structure learning as described in prior publications^4
–6 and multimodal methods of instruction that included seminal and contemporary readings, didactic, self-reflection, reflection on practice, simulation, role-play case analyses, and a practicum experience. By asking participants to address this question, we wanted to know what they perceived as working best for them. Not surprisingly given their various, education and experience levels, different aspects were more helpful to some than to others. Overwhelmingly, however, participants attributed their growth in knowledge, confidence, and agency to the opportunity to engage in diverse learning activities and learn from their peers and the expertise of the faculty in a “safe” learning environment as exemplified in the words of Abby:

The communication skills I have learned and begun to integrate into my own professional practice are also of great value to me. The role-play and SAVI training have been especially helpful…overall this has been one of the richest educational opportunities of my nursing career. By learning through didactic I better understand ethical concepts, through role play and simulation lab I was able to practice working with these concepts.

Some of the participants related that they found the role-play and simulation intimidating, taking them out of their comfort zone as it did, but it proved important in helping them understand another’s perspective and in developing confidence. “I have always found role playing very uncomfortable and I usually avoid it at all costs but these practice sessions were an invaluable part of the program” (Cate). Bonnie, a nurse educator, described “using the framework and methodologies learned during the CERN program, including SAVI^© communication techniques…simulation both in lab and low-fidelity, the extensive library of articles, and networking of colleagues” in her work orienting new nurses. Cate, a clinical trials nurse, captures the thoughts of the majority of participants related to the multimodal nature of the program:

As I review the many presentations, readings and role-play activities from the past nine months…I am amazed at the depth and variety of the experience…I am more comfortable having a framework and language to discuss ethical problems. I continue to rely on my notes and some of the readings to think about the four models for ethical analysis. Many of the case studies and in-class discussions taught me how to approach cases with an eye toward collaboration within the interdisciplinary team. Through assuming different roles in the safe environment of the classroom, I experienced the freedom to really feel what it might be like for other team members.

Question 5

Themed Response: An unimaginably valuable base on which to build and influence others, no longer living from hand to mouth, a truly expanded vision of what ethics means.

The overwhelming majority of participants (N = 61) explicitly or implicitly stated that the program exceeded their expectations or that they did not know what to expect but that the program exceeded anything they could have imagined. Aggie wrote,

In re-reading my CERN application, my goals were to increase my knowledge, broaden my perspective, on ethical issues, participate in discussions, share experiences and develop a strong foundation for the present and future ethics consultations. Little could I appreciate then how much I would learn and be able to incorporate into my nursing practice.

Jan, a staff nurse, wrote,

In all of my exposure to nursing in highly regarded academic medical centers and ranked nursing programs I have never had the exposure to ethics which is really the bedrock of nursing practice. I did not realize what I had been missing.

Abby wrote,

Overall when I think about a proposed ethical problem, my thought process differs now. Previously I found that I would often blend my emotions or experiences in with the actual facts surrounding the case. Now, I am consciously aware of how my own bias can obscure the facts. I now appreciate the powerful effect of emotions in distracting true ethical concerns. This course has challenged me to identify my own core values and begin to develop a moral compass.

For some, the program refreshed and added to prior knowledge and understandings of professional responsibilities to patients and colleagues. Arlie writes, “through this Clinical Ethics Residency I have become re-acquainted with the vastness and depth of the clinical ethics landscape (including) social justice. I feel a deep sense of responsibility to share what I have and am learning with others.” Alisa, a CNS reported how being in CERN had equipped her to serve as a resource for colleagues:

When I look back at the essay I wrote for my application to this program, it amazes me to see how far I’ve come, and surprises me to realize how many other things I would now like to do. My initial plan was to conduct ethics rounds with the nursing staff on my unit. I hoped to provide a space for nurses to discuss cases that presented ethical issues. The residency program has really expanded my goals. I now hope to involve all members of the health care team in discussions around ethical issues as they arise. I hope that this open communication will increase the respect between team members and decrease some of the distress that is often felt. When people ask me about this program I find myself at a loss for words. I cannot express how much I have appreciated the opportunity to learn, reflect and grow.

Question 6

Themed Response: They are questioning assumptions, separating reason from emotion, seeking to be aware of biases and their influence, finding their voices, and more confidently, advocating for patients and families, and are serving as ethics resources.

In their essays, as well as in their ‘Integration Day” presentations, participants described the various ways in which their practice had changed as a result of CERN but also recognized they had to continue to be involved, evolve, and have support. Many provided examples to support their perceptions. They had started questioning the assumptions that they and the team were making. They did this self-reflectively but also had found the confidence and language to question colleagues and the team. Larna, noted that her communication, “improved my discussions with my fellow nurses, doctors, members of the healthcare team, family members and most importantly, the patient.”

Joan, a staff nurse on a psychiatric unit, talked about the many ethical quagmires in psychiatric practice that can leave nurses feeling helpless, but that she is now seen by peers as someone with whom to discuss ethical concerns, writing that “they have begun to see me as a resource.” Gina, a neonatal intensive care unit (ICU) nurse spoke of questioning why concerned relatives of a dying baby were not allowed into the unit to hold the baby who was the victim of abuse and now in Department of Children and Families (DCF) custody. “After speaking to the baby’s aunt,” who was distraught that the baby might die alone, worked to have them allowed in. As a result “the aunt was able to hold him, pictures were taken, and he passed away.” An action of nurse advocacy in a situation like this can have a deep and lasting impact in a family member’s bereavement, especially given the challenging underlying circumstances.

A number reported engaging in patient care improvements, fostering patient autonomy as well as patient-centered family decision-making. Many termed this as the ability and courage to advocate for a patient’s needs when they might have stayed silent prior to CERN. Harriet, a radiation oncology nurse, exemplifies this in talking about a patient with end-stage disease who was being pressured by her daughter and the physician to accept more interventions. “I spoke to her daughter, who hoped to try everything but respect mom’s decision to stop treatment…I approached the physician team (again) and this time suggested a simpler radiation plan…which would accomplish (the patient’s) primary goals,” finally the team agreed. While Harriet felt her awareness of the profundity of ethical issues in her setting had grown, and she was more able to speak up and articulate the problem, she also recognized that the healthcare has “a long way to go before we are able to treat such patients in an ethical way.” Hazel, a psychiatric clinical nurse noted, “I truly do see changes in my clinical practice. My evaluations have a broader focus (and) both new nurses and some who have worked a while are willing and excited to discuss whether or not something is an ethical concern.”

Several nurses had started formal and informal ethics rounds and conversations on their units, and others had become active or more active in institutional ethics forums. Lee, an infection control specialist, described how she had become a member of the ethics committee (the sole nurse on the committee) and is “holding educational sessions with nurses on how to have difficult conversations with patients or families and when to request and ethics consult.” Donna, an ICU staff nurse, described how she gained the tools to facilitate (ethics) team meetings, stressing clarity of purpose, respect for different points of view, and safety for honest discussion.

Becoming aware of one’s own biases and intentionally reflecting on the possibility of unconscious bias in self and others was perceived by many as another benefit of the program as it allowed a clearer grasp of the nuances of situations. Abby writes, “now I am consciously aware of how my own bias can obscure the facts.” Moreover, a significant number of participants related how the knowledge and skills they gained permitted them to identify emerging ethical issues and address them. “I have begun to recognize less obvious ethical problems and issues that arise in in my daily nursing practice” (Bee).

Summary

The findings reflect the complex learning and perceived personal and professional transformation that the participants experienced. The multimodal nature of the program was perceived as important and instrumental to their development of confidence in approaching difficult ethical situations as well as daily practice. While they saw themselves as “developing a moral compass: to navigate the many gray areas of decision-making,” they also realized that this was an ongoing process. Many of them had articulated plans for next steps and moving forward with their roles as institutional or unit ethics resources.

Limitations

As a qualitative study conducted in two academic medical centers in the northeastern United States, this study is subject to the critique that results may not reflect how effective a program like CERN would be in other settings. In addition, the faculty for the program were either clinical or academic ethics experts, a factor which contributed to the rich content of the program. Moreover, the results were startling for the lack of constructive or negative comments about the program. While this lack of critique could be attributable to our responsiveness to participant requests throughout the program, it could also be that we did not specifically ask in this assignment for what could be improved.

Discussion

Clinical nurses and nurses in leadership positions bear responsibility and accountability for good patient care and patient advocacy.^11,12 Yet, as an extensive body of literature reveals, this responsibility can be very difficult to fulfill in contemporary healthcare environments,⁶ leading to feelings of moral distress, distancing from patient problems and even attrition from the profession.¹³ Ultimately, lack of confidence in ethical decision-making and ability to “do the right thing” affects patient care. Nurses in all settings, but perhaps particularly clinical nurses in inpatient settings, tend to have sustained and intimate contact with patients and their families. They are often the first in the health care team to notice, respond to, and articulate the patient’s response to their disease and treatment or a family’s concerns.¹⁴ The extent to which they can effectively communicate these issues that may be unrecognized by attending physician and consultants can mean the difference between patient preferences and values being considered and honored or neglected.

Moreover, nurses in leadership roles have the responsibility of creating a milieu that recognizes the needs of patients and promote a mechanism for addressing difficult ethical problems that impact good patient care. This is both an ethical responsibility and in some countries such as the United States a regulatory imperative.¹⁵ Clinical ethics education for nurses who are practicing in the field is essential. While ethics education is also critically important in all levels of educational curricula,¹⁶ it is not sufficient to sustain nurse confidence in their ethical decision-making especially when so many barriers to this exist in practice.

The end-of-course essays of participants in this grant-supported program provide empirical evidence that such programs can be transformative, enhance the confidence of nurses in their ethical decision-making, and facilitate nurse contributions to the ethical environment of a healthcare institution. As members of the interprofessional healthcare team, they have an important perspective on patient and family desires and need. The possession of ethics knowledge and decision-making skills coupled with effective communication skills permits patient advocacy, support of peers and colleagues, and the development of ethical care environments.

The narratives of nurse participants in our program provide evidence of their self-assessed increase in ‘ethical practice effectiveness’—gaining knowledge, discernment, confidence, and agency in the enactment of their professional roles. Our analysis yields stories of moral agency enacted with a sense of greater comfort, skill, and confidence—factors that we believe mitigate moral distress through appropriate nurse action. We believe that this multimodal, temporal approach to ethics education has demonstrated a unique and powerful way to address moral distress and enhance moral agency and thus is an effective educational strategy for nurses to fulfill the full extent of their intended roles. While these insights contribute to the body of knowledge related to what contributes to nurse ethical decision-making skills and moral agency, more research is needed related to what should be included both in formal nursing curricula and continuing education.

Footnotes

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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