Abstract
Since the 1960s, it has been recognized that “medical ethics,” the area of inquiry about the obligations of practitioners of medicine, is inadequate for capturing and addressing the complexities associated with modern medicine, human health, and wellbeing. Subsequently, a new specialty emerged which involved scholars and professionals from a variety of disciplines who had an interest in healthcare ethics. The name adopted is variously biomedical ethics or bioethics. The practice of bioethics in clinical settings is clinical ethics and its primary aim is to resolve patient care issues and conflicts. Nurses are among these clinical ethicists. They are drawn to the study and practice of bioethics and its applications as way to address the problems encountered in practice. A significant number are among the ranks of clinical ethicists. However, in the role of bio- or clinical ethicist, some retained the title of their original profession, calling themselves nurse ethicists, and some did not. In this article, we explore under which conditions it is permissible or preferable that one retains one’s prior profession’s nomenclature as a prefix to “ethicist,” under which conditions it is not, and why. We emphasize the need for transparency of purpose related to titles and their possible influence on individual and social good.
Keywords
Introduction
Research has supported the ways in which one’s job or position title comprises an important aspect of one’s identity and sense of responsibility as well as what the title conveys to others about the person. 1 “(A) job title communicates the knowledge, skills, abilities, and other characteristics that employees who hold the job are likely to possess.” 1 (p1201) When position titles are determined by institutions, they can alter employees’ perceptions of their role and its responsibilities and this may limit creativity in resolving associated problems. In healthcare settings, they can further standardize expectations of the role by providing an associated job description. However, tightly delineated job descriptions tend to prioritize institutional interests over professional or service goals. 2 Alternatively, a worry with self-selected job titles is that they may be insufficient in fully identifying one’s role or may create an illusion of greater expertise than is warranted based on one’s training and skill set.
The main purpose of our paper is to highlight the position that in healthcare settings at least, the title one holds related to one’s work is important for furthering patient good and supporting quality patient care. Specifically, we examine possible distinctions between the title “clinical ethicist” and “nurse ethicist.” This is important because the way we are perceived and understood by those with whom we interact, how well our aims cohere with theirs, and how we perceive ourselves, our goals, and responsibilities can significantly impact our scope of influence and our ability to question the status quo. 2
An example of potential diminished ability to influence good care occurred in the US in the 1980s. A shortage of nurses led to the proposition that Registered Care Technologies (RCTs) could substitute for much of the task-oriented work of nurses. These RCTs would be educated by the institution to meet the needs of the institution and thus not answerable more broadly to the goals and purposes of the nursing profession related to individual and social good. 3
In healthcare systems, regardless of country, human power dynamics are inevitably at play and hierarchical models of interaction are the norm. It is critical that we keep the idea of power structures and imbalances at the forefront of our clinical decision-making and factor it into our actions. Forces associated with hierarchies and power imbalances can distract from the ultimate reason healthcare services exist—to attend to the “good” in terms of individual human flourishing and wellbeing. Moreover, such influences can deter us from questioning the origins of a current ethical conflict when these are deeply buried in societal injustices or misunderstandings.
While the experiences that inform this exploration stem mainly from healthcare settings in the US, the problem of the status of names, titles, and affiliations and in what ways they matter pertains regardless of setting or country of setting. They matter, for better or worse, in terms of influence on ethical decision-making to address patient care problems. Also important is an understanding of the focus and scope of responsibility accruing to the role assumed. When considering one’s obligations related to good patient care, responsibility cannot solely be to address current circumstances but also to inform policy change and work in concert with others toward ameliorating root causes of injustice or misinformation.
Here, we discuss what matters related to the title and goals of the role assumed and in what ways a title affects one’s own and others’ perception of the role related to the title assumed. We were interested in exploring the ways in which a person’s professional title may advance or retard the ability to meet one’s role-associated goals (in so far as these are discernable) while also being cognizant of the originating seeds of an issue, conflict, or problem. It is self-evidently a mistake for any human service discipline, profession, or practice to ignore or discount the importance of understanding the root causes of recurring conflicts. A significant concern for both of us, as experienced nurses, and academic and clinical ethicists, is that regardless of title assumed or assigned, transparency is required. It is required to identify oneself and others with whom one is working or advising and clarify what the scope and limits of one’s role is within the setting or environment. Additionally, transparency is required about the scope and nature of obligations to engage in further actions when the origins of a presenting problem are locatable within a societal fabric that has caused disadvantage or injustice. A certain level of responsibility for both resolving clinical ethical problems specifically and addressing the root causes of recurring problems or injustices more generally is inevitably one function of any role concerned with clinical or professional ethics and this is not always recognized.
The purpose and context of role matters
Many years ago, during her philosophy/medical ethics studies (1990s), first author (PG) was challenged by a philosophy professor to explain why some nurses who were engaged in clinical ethics work called themselves nurse ethicists. At the time, she had not given it much thought and did not have an answer. After many years of reflection upon this question, she has what she considers a justifiable position. She argues that the term “nurse ethicist” renders nurses with ethics expertise visible, accessible, and approachable to the nurses who most frequently encounter ethical conflicts in their everyday work. It denotes an understanding of the everyday nature of problems in nursing work in a way that those from other professions frequently miss and thus allows a deeper digging into root causes of patient problems and other ethical issues as these arise in society and within healthcare institutions. Medical ethics, in turn, is an applied professional ethics of ancient origins that developed from philosophizing about the duties of physicians to their patients initially and eventually more broadly to society. 4 The term bioethics is a more recent addition as discussed shortly and pertains to a field of inquiry about the interactions of biological and technological advances on human health and illness as well as value conflicts that arise in providing healthcare. Thus, the use of the terms nurse ethicist, medical ethicist, bioethicist, and clinical ethicist may be distinguished by history, context, and purpose.
The second author (AM) emphasizes the importance of purpose in her discussion. She argues that nurses who are engaged in interdisciplinary clinical ethics work should, like professionals from other disciplines, adopt the name “clinical ethicist” and be aware of the role distinction between nurses as nurses and nurses engaged in clinical ethics consultation work apart from their professional nursing role. It is a tricky distinction as some have noted because all healthcare professionals should be aware of the ethical nature of their work5,6 and be concerned to identify and ward off emerging ethical issues that interfere with good patient care. The title, Clinical Ethicist or Clinical Ethics Consultant is more all-encompassing of this special role and references the broad scope and interdisciplinary nature of the expertise that is required. In the US, clinical ethicists are asked to explore and uncover underlying nuances of a difficult patient care situation and the perspectives of the various involved parties while keeping in mind the purpose are to advise what are “right” or “good” courses of action for a particular patient and why (this is the scope of clinical ethics at the bedside or in consultation). The goals of clinical ethics differ in this respect from the goals of a given healthcare profession. The ethical responsibilities of the given professional are to provide the “good” promised implicitly in the social contract between the profession and society. Roughly stated here, a social contract consists in public understanding of why a particular profession exists and subsequent privileges granted. The responsibilities may also be explicitly stated in Codes of Ethics adopted by the profession. In either case, they are based in the reason for existence of the profession and the needs it purportedly meets. 7
Clinical ethicists may also have a separate or primary role as a nurse, a physician, chaplain, or a multitude of other professional backgrounds. While working in their primary roles, it is expected that they know something of the ethical guidelines of their profession or discipline (in the case of a non-practice-oriented expertise). However, when working in the role of clinical ethics expert, their purpose, while obviously informed by their professional knowledge, is different than that of fulfilling their professional role obligations—as noted above. The skill set of a clinical ethicist should be consistent regardless of professional background. That is, a nurse who is a clinical ethicist and who conducts clinical ethics consultations as requested should possess the same consultation competencies as a physician, or chaplain, or philosopher who is also a clinical ethicist. 8 In other words, the skill set of a professional “clinical ethicist” should have an established standard that uniformly applies. We recognize that controversies remain both about what the essential skills and competencies should be and what are the proper goals of clinical ethics, and more work needs to be done. Ongoing knowledge development efforts both empirical and philosophical are required to resolve these questions. 6 It is beyond the scope of this paper to explore this concern in more depth.
Importantly, our aim in this article is to provoke further discussion related to the roles of nurses, physicians, and other sorts of clinical ethicists in anticipating, addressing, and resolving complex and difficult patient care situations as they arise in healthcare settings. While acknowledging and valuing the importance of interdisciplinary discourse related to clinical ethics, we also recognize that nurses, either acting in a nursing role or advising about the obligations associated with nursing work, have ethical responsibilities to contribute their perspective where this constitutes important but otherwise missed data.
Traditional undervaluing of nurses’ perspective on patient care problems
Nursing perspectives have historically been undervalued, and their concerns downplayed or ignored.9–12 Among the reasons for this are the historical place of nursing in the medical hierarchy, its predominance as a female profession in many countries, and restrictions imposed by organizational interests. 10 Since nurses as members of the healthcare team are often closest to patients and their families, they are likely to be best situated to act as liaisons conveying preferences that would otherwise not be heard, or to communicate burgeoning worries to the interdisciplinary clinical team. If this perspective is unheard, it is problematic for patients and hinders the work of clinical ethics. We describe later how one role of a nurse ethicist is to help nurses develop confidence in their ability to articulate their perspective in interdisciplinary forums for the purpose of improving patient care or accounting for otherwise occult aspects of a situation.
In the next sections, we sketch the development of Bioethics as a new interdisciplinary body, practitioners of which have come to be identified as clinical ethicists. We differentiate the role of clinical ethicists qua clinical ethicist from that of a healthcare professional engaged in their profession’s field of inquiry about the scope and limits of professional obligations. Following that, an argument is presented for the circumspect use of the term “nurse ethicist” by first author (PG). Subsequently, second author (AM) argues in favor of using the term clinical ethicist for those engaged in clinical ethics consultation. Finally, we describe how confusion about roles and responsibilities for those with dual qualifications might be avoided in the interests of good patient care and societal good.
The emergence of bioethics
Since the 1960s, interdisciplinary and public input has been recognized as critical for resolving the ethical dilemmas and conflicts emerging from the use of biotechnological advances for the cure of or mitigation of disease.13,14 A new discipline slowly developed as a way to translate this developing body of knowledge and its impact on human health. Initially, the field of inquiry that explored problems associated with the conduct of physicians and medical practice was termed medical ethics 13 because of its historical association with the philosophy of medicine and medical practice. As the complexity of medical practice increased because of the burgeoning biological and technological advances since World War II and their impact on human health and wellbeing, both positive and negative, more philosophical analysis and input was seen as needed. The breadth of the field of inquiry around the ethics of healthcare expanded to encompass knotty social problems and dilemmas. The field is alternatively called “biomedical ethics” and more contemporarily “bioethics.” 13 Members of this new discipline of bioethics, as Kopelman 15 notes, almost all had a different discipline (field of inquiry) or profession (practice) prior. Thus, many of those who became involved in the practice of bioethics were members of other healthcare professions in addition to medicine, pastoral care, or philosophical and theological disciplines.
Not surprisingly, nurses who encountered ethical problems at the bedside saw both the discipline of bioethics and its application to care at the bedside as a way to mitigate the distress they often felt in being unable to meet the needs of patients. They hoped to gain the knowledge and skills to address and resolve the patient care obstacles of various kinds that they faced. As nurses took courses in “bioethics” or “medical ethics,” a significant number started to specialize in this area and gained the philosophical tools of ethical decision-making. In specializing in applied ethics or bioethics (broadly framed), some nurses retained the title of their original profession, and some did not. PG’s studies in philosophy with an additional concentration in medical ethics were undertaken because of seemingly unresolvable and frustrating nursing practice problems she faced. She hoped to gain remedial knowledge and skills from philosophy studies. However, she found the problems of nursing practice openly discounted as being not “juicy enough” (one faculty’s comments) and that a nurse’s hat (way of thinking) should be substituted for a philosophical one. The everyday practice problems of nurses were largely unaccounted for in the medical ethics concentration of her doctoral program or in associated clinical ethics practica. In the end, skills and knowledge gained about conflicts associated with human life and medical dilemmas had to be adapted for use in nursing education, knowledge development, and everyday practice as well as in clinical ethics settings. This background informs her perspective. Interestingly, while we started this paper thinking that our perspectives differed somewhat radically, we found they did not.
Nurse ethicist versus clinical ethicist: An argument for the title nurse ethicist
The title nurse ethicist denotes a person who has both nursing and ethics expertise and sees these as in some ways inseparable from the work in which they are engaged. In many settings, the title nurse ethicist is helpful in highlighting for others one’s breadth of knowledge. So the two questions to be answered are (1) “in what ways does using the dual title help or hinder the identification and resolution of patient care issues?” and (2) are there circumstances in which using the dual title could be detrimental to the person’s work? An objection might be that if we successfully argue for the dual title, then logically we would accept others using their dual titles, for example, physician ethicist, philosopher ethicist, and theological ethicist. This possible objection is answered both here and in AM’s discussion.
Wocial and colleagues 16 define the nurse ethicist as someone who “is charged with creating and sustaining programs in ethics and nursing ethics education with the goal of improving the capacity of nurses to manage the ethical issues inherent in the care of patients in a contemporary, technology-driven health care system.” 16 (p287) While one could argue that a physician ethicist would therefore be a person who has a similar charge related to medical education and medical practice, the equivalence does not hold. One reason it does not hold is that medical practice in institutions such as hospitals has become so complex that when problems actually surface, they often present as dilemmas on first face seeming to have no identifiable preferable route of action. Different perspectives and intense data-gathering may be needed to uncover important nuances of a situation. Additionally, an attending physician is not bound by the advice offered by the ethics service or consultant, at least this is true in the US.
A profession’s ethical responsibilities are derived from the discipline’s historical insights about its purpose. In this sense, nursing ethics is a field of study and results in normative criteria for how that discipline’s members should practice and facilitates critical appraisal of how they do practice.7,11 For either of these facets, there has, of course, to be the possibility of choice among actions. It is a well-understood philosophical tenet that when an action is obliged by context and conditions, an ethical appraisal of the action is redundant. In other words, choices must be present for an action to be subject to evaluation. This is not the same as saying no other route of action is actually possible—it may be but at a different time and level of address. As examples, a policy change, educational initiatives, or contributions to public discussions may be needed.
The nursing profession has, arguably and from the large body of available literature, been much more self-reflective about its responsibilities than many other human service professions including medicine. There are good reasons for this that are irretrievably intertwined in the history of its development as a largely female occupation that was subservient to medicine among others. 11 Nurse philosophers and theorists have worked diligently to describe the nature and responsibilities of nursing work. Their work has been important for the profession’s development over the decades since the time of Florence Nightingale and other, less well-recognized, pioneers of nursing. Contemporary nursing education in many countries aims to develop highly skilled and knowledgeable nurses. A significant number possess baccalaureate and higher degrees requiring a lengthy period of study. Nevertheless, hierarchies persist in hospitals and clinics across the globe and nurses at the bedside often feel unheard. This is one reason why nursing ethics is not equivalent to medical ethics as an applied professional ethics. 17 Nurses may find themselves hindered from doing what their clinical judgment evaluates as required to optimize a patient’s good. Evidence supports that repeated obstructions can result in the phenomenon of moral distress further impairing ethically warranted actions. Note this is not the same as saying that all nurse clinical judgments are impeccable, they are not. 18 A role for nursing ethics education is to help nurses be reflective about the limits of their knowledge and when to access resources and advice. While controversy remains about essential aspects of moral distress, ample research supports that there can be physical and psychological effects that harm nurses and ultimately affect patient care. 19
Problems persist despite the recognition that nursing perspectives are critical to ethical decision-making involving patients and patterns of patient care that are unethical or ineffective.7,20–23 Evidence also exists that nurses do not always have the confidence to articulate their concerns or are not effective in articulating their concerns to the healthcare team, 24 and this is in part a problem for nursing education to resolve.
An additional concern for the health of individuals and society in the increasingly complex healthcare environment is that the discipline of bioethics has been slow to recognize the importance of nursing knowledge and perspectives and of the more everyday issues of practice, including sociopolitical injustices that affect health.25,26 Bioethics as a multidisciplinary endeavor developed specifically to address dilemmas, or complexly conflictual issues, and this focus persists, although over time, there has been movement toward broader foci.27,28 As AM argues shortly, in order to provide bioethical guidance, ethicists must be facile in providing recommendations that apply to the interdisciplinary team and not solely to members of their original discipline.
Recognition of the limited power of nurses to articulate their concerns, among other reasons, such as lack of understanding of their professional responsibilities or inadequate ethics education, motivated and continues to motivate sets of nurses to develop their philosophy, ethics or bioethics knowledge and skills.26,29,30 As nurses working in nursing practice, research, leadership, or educational roles, these experts in nursing ethics, both as a field of inquiry and appraisal of nursing actions, see themselves as doing nursing ethics and furthering ethical practice. Thus, the term nurse ethicist is explanatory of their work even when their work includes understanding difficulties in the interface among allied professions whose perspective on good care may differ in significant ways.
While recognizing the need for interdisciplinary collaboration in resolving ethical problems and conflicts as they arise both within institutions and from environmental conditions and structural injustices, 31 experts in nursing ethics are also concerned that the nursing perspective is accounted for in conflictual practice situations. Among their tasks is to raise consciousness, within both nursing and bioethics discourse, about how the issues of daily practice along with root causes of health problems in sociopolitical conditions are of equal importance as attending to dilemmas or conflicts. 26 Indeed, it is sometimes the case that lack of attention to these aspects results in unnecessary conflict.
An example witnessed by PG is that of a question brought to the ethics committee of a university hospital where she was completing a practicum related to the medical ethics concentration of her philosophy studies. The question was whether it was ethical to place a gastric feeding tube in a cognitively impaired patient admitted frequently from a nursing home with aspiration pneumonias but who passed a “swallow test.” PG coincidentally as part of her nursing faculty role had been supervising nursing students in that nursing home and was aware of poor staffing and the rushed nature of orally feeding those patients who could not feed themselves. Thus, the ethics question was misinterpreted solely as one related to individual patient care and missed the more fundamental one of societal origins. The clinical ethics question is what to do now in this situation to benefit this patient. The broader nursing, bioethics, and even clinical ethics question should be “what is our responsibility to highlight ethical quandaries caused by societal inequities?” This is a question that nursing ethics answers, but it is not clear how clinical ethicists in general account for the socially rooted problems they face (when these are even recognized) in the clinical ethics role.
In summary, when nurses are working in a context where both their nursing expertise and ethics knowledge and skills together comprise the reason for their role or their position, then nurses are justified in calling themselves nurse ethicists. For those nurses who are employed as clinical ethicists solely because of their ethics expertise, I believe they are also justified in including any qualifications on their name badges that inform their work as a clinical ethicist especially if that work is what led them to study moral philosophy, applied ethics, or bioethics. Significantly, for those holding a nursing qualification, knowledge of their background may make them a more visible resource for point-of-care nurses, although there are other ways of making oneself accessible.
While debate continues within nursing about what knowledge and skills are needed for ethics expertise, as also occurs in clinical ethics, that discussion is beyond the scope of the current manuscript. The next section addresses the second question posed earlier in this section, “are there circumstances in which using the dual title ‘nurse ethicist’ could be detrimental to the person’s work?”
An argument for the title “Clinical Ethicist”
“I’m not looking for a nursing consult, I’m looking for a medical ethics consult. I want to speak to a physician.”
Early on in her postdoctoral training in clinical ethics, the second author (AM) heard this statement after introducing herself as the nurse ethicist on call. The physician she was speaking to was anxious, overwhelmed, and in need of advice. He was also clearly confused about her role and the scope of guidance she was capable of providing. Despite her training in both nursing ethics and clinical ethics, she was perceived as an expert in only the former. This experience prompted her to examine her title in greater depth and to reconsider the way she introduced herself to members of the care team.
In order to clarify the scope of expertise of a clinical ethicist, several terms require defining. As we have explained, both professional ethics and bioethics are disciplines that fall into the category of applied ethics; that is, they involve the practical application of moral theory. 8 They are related, but distinct fields of study. Professional ethics involves answering questions about the nature of a profession’s services. 7 Professional ethics include the fields of nursing ethics and medical ethics. Bioethics, as defined by the Hastings Center which was instrumental in creating the discipline in the 1960s, “is the interdisciplinary study of ethical issues arising in the life sciences, health care, and health and science policy.” 32 Clinical ethics can be viewed as the practical application of the tools and skills of bioethics inquiry brought to bear on ethical issues as these arise in clinical settings. The main goals of clinical ethics are to answer questions about what is “right” or “good” for a particular patient in a particular clinical situation where there is conflict or uncertainty. Seigler argues that the goal of clinical ethics is “to assist the patient, family, and primary physician by offering suggestions that improve the process and outcomes of patients’ care.” 6 (p110) Clinical ethics deliberations typically involve the application of a structured approach to data-gathering, analysis, and ethical decision-making to resolve difficult patient care situations. Using this approach and associated tools, it is hoped that “reasoned conclusions” about what ought to be done can be reached and enacted. 33
The goals of clinical ethics consultation, a service typically provided by hospital-based clinical ethicists, are to identify and analyze the nature of the value uncertainty or conflict and to facilitate the resolution of that conflict. 8 As noted earlier, clinical ethicists come from a wide range of backgrounds with a wide range of training. In the US, for this reason, the American Society for Bioethics and the Humanities (ASBH) over several years developed a set of core competencies, a code of ethics, and a certification exam in the hopes of achieving consistency in the qualifications of clinical ethicists regardless of background. 8 Internationally, the existence and nature of clinical consultation services varies significantly among countries, but such services are seen as important in resolving difficult patient care situations. 34 The qualifications needed to do clinical ethics also vary. However, some countries or regions are following the lead of the ASBH in striving for some consistency.
To further distinguish these fields of study, professional ethics or clinical ethics, one can examine questions that apply in each area. Examples of questions specific to professional ethics might include what are the goals of nursing, and how ought we achieve them? What are nurses’ obligations to society, beyond the level of the individual patient? How are advanced practice nurses’ professional aims distinct from physicians’ professional aims, and where do they overlap?
In contrast, examples of clinical ethics questions might include what does good care look like for this patient? How can we provide goal-concordant care to a patient who is dying but whose family is having difficulty acknowledging this fact? How can we advise about the fair distribution of scarce resources when the demand outstrips the supply as occurred during the COVID-19 pandemic?
In examining these quandaries, it becomes evident that the answers to clinical ethics questions extend beyond considerations of the obligations of an individual professional or discipline. These questions are messy, complex, and inextricably linked to the context where care is being provided: typically, in the setting of a multidisciplinary team with a variety of professional perspectives.
If a physician (or any non-nurse) calls for an ethics consult, they need guidance that can be applied to the particular clinical situation at hand and an acknowledgment of the obligations of all of the interested parties. The clinician is implicitly or explicitly asking, “what should we do here?” They are asking about what is “right” or “good” for their patient. These questions invoke obligations of all the members of the care team, physicians and nurses included. As such, the ethicist must be adept at addressing the scope of obligations of each member of the interdisciplinary team and must also be able to provide an ethical framework to inform the multidisciplinary team’s approach to their quandary. If the ethicist is only perceived as an expert in a subset of these questions, their impact and ability to help may be hampered. While this clarification can be explicated and it is likely that any misconceptions about preparation or scope of expertise could be resolved, individuals still can arrive at snap judgments, particularly in a crisis. Therefore, for clarity, the second author (AM) now introduces herself by saying, “I am a nurse and a clinical ethicist.”
Discussion
The semantics or meanings of terms matter as they relate to the fitness for the purpose of their use. In conflictual situations involving patients, a broad understanding, including the nuances of a situation, must be grasped and the meaning for those involved must be clear in order to develop the most beneficial solution for the patient and others who will be affected.
A further important factor to keep in mind for professional ethics scholars, practitioners, and clinical ethicists are the constraints of the institutions within which they work. In the US, clinical ethics, for the most part, takes place within institutions and are sanctioned and largely funded by those institutions. While there are some independent clinical ethics consultation services, these are not the norm. Not all appropriate decisions result in action in the moment for the simple reason that policies of the institution may give rise to barriers, or resources needed to resolve a problem not available. This relationship (between the ethicist and their employer) may give rise to circumstances where the optimal option is unpalatable to the institution due to, for example, bad press. In this instance, the ethicist is conflicted, and this dynamic may interfere with achieving the “best” outcome for the patient.
This brings us full cycle back to the question of what if anything does adopting a particular title help us accomplish in the way of the goals or purposes of our role. In either case, professional ethics or clinical ethics, a major purpose of the role is optimizing good patient care and its outcomes. While we do not have a definitive answer to this question as there may be perspectives we have not considered, we do agree that context and transparency about our knowledge and expertise related to the project at hand matter, albeit perhaps not in the way that some have assumed.
Thus, the titles used to denote expertise of various kinds should be easily recognizable to those for whom we are serving as a resource, whether this is advisory or educational. Essentially, this is important for developing trust, which in turn is important for relating to stakeholders, gathering information, and uncovering important nuances of a situation that might otherwise remain invisible. One’s relevant credentials can also be displayed on name badges as explanatory of associated and helpful expertise possessed.
For example, when working in a point-of-care nursing role what is most important is one’s registered nurse credential. As an advanced practice nurse, one’s additional qualifications inform colleagues and patients that one has achieved the basic credentials to assume this role. It is an expectation of these roles that one understands the limits of one’s knowledge and skills and seeks resources as necessary. Having said this, evidence supports that the disparate healthcare and healthcare-associated professions do not always understand the knowledge, perspectives, and responsibilities of their colleagues.24,35 More efforts are required to help the various disciplines understand and respect the role and concerns of each other—a role, perhaps for the clinical ethicist as mediator.
While some may take this discussion as unimportant, an informal poll of a few colleagues in nursing ethics interest groups reveals feelings about preferences can be strong. Some nurses who are also clinical ethicists clearly believe that using the term nurse in their title emphasizes the critical importance of the nursing perspective related to patient situations. It is unethical for others to discount this because it can lead to untoward effects upon patients whose wishes were ignored or not sought.
The context in which ethics is being “practiced” is a critical consideration in the method one chooses to identify oneself. Not all nurse ethicists are experts in clinical ethics, and not all clinical ethicists who are nurses are experts in nursing ethics, viewed as a field of inquiry about the profession and its responsibilities. Nor are clinical ethicists from other professions and disciplines necessarily knowledgeable about the ethics of their profession. Inquiry about roles and how a stakeholder perceives their role would be part of the clinical ethicists’ exploration of a situation. One’s scope of expertise may need to be clarified in order to gain trust and be most effective in gathering information, in clarifying underlying assumptions, and in providing helpful recommendations that apply to all members of a healthcare team.
In using the “nurse” prefix, a person’s professional clinical background is evident upon introduction, and their role as a nurse is highlighted, perhaps garnering additional trust from the interdisciplinary team. However, as described by AM, emphasizing one’s first-order discipline—in this case nursing—may actually hamper the situation when colleagues do not understand the role distinction. It also immediately situates the person within the profession of nursing’s goals and perspectives, especially to colleagues and the public; this sort of framework is not as immediately obvious when introducing oneself as a “clinical ethicist.”
While our individual viewpoints stem from our histories and work environments (PG as primarily a nurse scholar/ethics educator and AM as primarily a clinical ethicist and bioethics educator), our perspectives are not as radically opposed as we had anticipated. Ideally, one’s official title should not change either how one approaches the task at hand or how one is regarded given appropriate knowledge and skills and knowledge of how to access resources. Unfortunately, as encountered by AM, nurses sometimes still face a certain amount of prejudice that can interfere with trust as well as collaboration.
Clinical ethicist is an appropriate title to use when working in the broader role of interdisciplinary ethics consultation and problem-solving as it indicates someone who holds the necessary skills to provide ethical decision-making assistance, guidance, and advice. Using the “clinical ethicist” title creates less of a need to explicate one’s scope of expertise related to bioethics broadly and clinical ethics specifically and may also render one more credible in the realm of ethics in particularly hierarchical environments. However, this title also erases the nursing professional identity from immediate introduction thus rendering it less visible. It may also, conversely, be harder to gain credibility with members of the clinical team as an ethicist without an immediately obvious clinical background and professional knowledge base to draw from.
In the clinical setting, both perspectives (professional nursing ethics and clinical ethics) work synergistically. However, nurse ethicist is also a permissible title if the individual is known as someone who is both a nurse (as their first order discipline) and knowledgeable about ethical problem-solving involving interdisciplinary teams. We believe this argument holds for other sorts of professionals as well. If functioning primarily in the role of clinical ethicist, individuals of all backgrounds may refer to themselves as such, assuming they possess the necessary competencies and skill set, as AM argues. It would follow, then, as PG argues, that individuals who are functioning in a dual capacity (i.e., physician and ethicist or chaplain and ethicist) could also choose to identify themselves in this way: physician ethicist or chaplain ethicist. It should not be the case however that nurses are the only ethicists who use such a prefix, and this may be an argument in favor of using the “clinical ethicist” title when in the hospital setting and actively engaged in the work of clinical ethics. When involved in nursing scholarship, education and nursing-focused research, the distinction may be less critically important. One’s nursing background and experience permits the application of ethical decision-making knowledge and skills to the everyday problems nurses face in providing good care. In clinical care, however, it must be clear to those requesting ethics support that the “nurse ethicist” is both an expert in nursing ethics and clinical ethics, assuming this is the case.
Conclusion
The meaning of titles matter for those who need to access, or benefit from, the services of the title holder. Thus, clarity about the scope and role of someone who is focused on developing the field of inquiry that is nursing ethics is rightly called a nurse ethicist, or nurse philosopher. Nurse ethicist is an appropriate title for those who are nurses, have extensive further education in philosophy, bioethics, and applied ethics, and are involved in developing the ethical expertise and confidence of nursing students and in addressing knowledge development that furthers the ability of the profession to meet its goals.
For ethics knowledge involving value-laden conflicts related to patient care and issues in institutional settings that involve multiple disciplines and stakeholders, either title nurse ethicist or clinical ethicist may be used, though individuals may have strong preferences about which is used depending on the context. The title used sometimes depends on the institution, sometimes on the original discipline of the person who started or directs an institutional ethics service, and sometimes on the necessity of avoiding prejudice against, or mitigating ignorance of, the important contributions that nurses can and should make in interdisciplinary problem-solving. Over the past few decades, respect for the knowledge and skills of nurses who do ethics has grown, largely due to the efforts of these experts and their ability to work across disciplines. What is important is that the ethicist is knowledgeable about both the disparate interdisciplinary interests at play in any given issue and how to enable interdisciplinary discourse and elicit stakeholder perspectives in order to arrive at a principled resolution to the conflict. As long as the title holder is respected for the position they hold, both are viable titles for nurses with knowledge and skills in the area of applied ethics.
Footnotes
Authors’ note
This paper was developed equally by the authors. First author and second author are purely an alphabetical convention.
Declaration of conflicting interests
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.
