Operationalizing the role of the nurse ethicist: More than a job

Introduction

The idea of a role in nursing that includes expertise in ethics has been around for more than 30 years. ¹ Whether or not one subscribes to the idea that nursing ethics is separate and distinct from bioethics, professional nursing practice in the clinical setting has much to contribute to the increasingly complex and ethically challenged practice of healthcare. Nursing is inherently patient-focused and relationship centered, and in the acute, rehabilitative, and chronic care settings, nursing attends to the patient 24/7, thus holding direct knowledge of the patient’s illness experience and trajectory. The nurse can listen closely to the patient’s story and observe their response to illness and accompanying interventions, which provide crucial information for conversations with surrogates and health care team members. More than a paternalistic “best interests” approach and more than a consumeristic “patient wishes” approach, the art of nursing is to provide an on-going presence with the patient that elevates their authenticity, be they alert or silent, in their experience of serious illness. ² However, both because nurses are primarily at the bedside and due to the hierarchical nature of healthcare, nurses often find themselves “in the middle” of a complex web of patients, families, physicians, administrators, other nurses, and other members of the healthcare team.^3,4 Nurses encounter moral hazards, where they must endure the consequences of decisions made by others, and this reality can make it difficult for them to raise their voices when they perceive ethical challenges. ⁵

These experiences contribute to moral distress, a phenomenon that was first identified in nursing in 1984, ⁶ and has subsequently been the focus of empirical study ⁷ and conceptual debate.^8–10 Regardless of how moral distress is defined, decades of research has evidenced its prevalence in nursing, and its deleterious effects as moral distress contributes to burnout, compassion fatigue, and nurse turnover.^11,12 The concept of moral distress draws attention to the constrained nature of the nursing role and the unique ethical challenges nurses encounter. While there is continuing debate about how moral distress ought to be defined, we do not take a particular position in this paper. Regardless of the definition, nurse ethicists should be familiar with the history of the debate to inform their understanding of the concept.^8–10,13 Moral distress is an organizational ethics issue with negative consequences for nurses and patients, and while moral distress is not a phenomenon specific to nurses, much of what is understood about it comes from work with, and by, nurses, and nurses consistently report higher intensity and frequency of moral distress than other care providers.^14–16 This disproportionate impact means that attending to moral distress is, in and of itself an ethical issue, and one that might reasonably be the purview of the nurse ethicist.^17,18

Higher levels of moral distress and stressful work environments have been linked to nurses’ intention to leave high acuity areas and the profession.^19,20 Not only does this affect individual nurses but this also has huge implications for patient care.^16,21 Healthcare institutions have a moral responsibility not only for providing high quality patient care but also for the wellbeing of their employees. ¹² The US. Surgeon General 2022 ²² advisory underscores the need to provide healthcare workers with opportunities to discuss ethical challenges as a key strategy for addressing burnout. A dedicated role, such as a nurse ethicist may play a pivotal role in implementing strategies to mitigate moral distress. Others who may be positioned to lead some of these efforts, such as nurse leaders, understand the particular role and responsibilities of clinical nurses but few have the ethics expertise required to connect the ethical challenge to the distress expressed. Conversely, clinical ethics consultants possess ethics expertise but may not have the understanding of the nursing profession to connect the ethical issues to the nursing role.

In this paper, we draw upon our collective experiences in nurse ethicist roles (ranging from 4 to 25 years, and includes for each of us the opportunity to create the role in our institution) and the literature to inform discussion about how the particular role of a “nurse ethicist” in tertiary care settings can support the provision of ethical nursing practice, and ultimately add value to nursing, patient care, healthcare organizations, and bioethics teams. As the field of clinical ethics gains its professional footing, we believe it imperative to begin conversations regarding how to differentiate the “nurse ethicist” role in the field of clinical ethics. This paper (and special issue) was motivated by the emergence of job advertisements in the United States for a nurse ethicist.^23,24 This unusual occurrence sparked discomfort about the notion of the role being defined by healthcare administrators or other ethicists rather than nurse ethicists themselves. Undoubtedly, the distribution of job responsibilities will have different elements depending on the nature of the nurse ethicist’s home institution. Our focus is upon the essential elements that ought to be addressed in a job description for a nurse ethicist practicing in a primarily clinical, rather than academic, setting.

We first propose necessary training and education for a nurse ethicist. Next, we outline four areas of responsibility that we argue ought to be central to a nurse ethicist role and the ways in which the nurse ethicist adds value to that particular area of responsibility: ethics consultation, education, research and scholarship, and policy work. We hope that this explication contributes to scholarly and operational debate about the role, provides guidance to individuals who might want to create this role in their organization, and to healthcare leaders considering the value of the role.

Clinical ethics consultation

There are increasing numbers of nurses conducting clinical ethics consultation—particularly in the United States (US)^32,33—and while the distinct role of the “nurse ethicist” was named in the literature as far back as 1998 (Mary Lund: RN, PhD Nurse Ethicist), the role or job title of “nurse ethicist” is relatively new. ³⁴ We note that while some authors ³⁵ use the terms nurse ethicist, clinical ethicist, healthcare ethics consultant, bioethics consultant interchangeably, we start from a position that there is a distinct difference in the role of the nurse ethicist and clinical ethicist and our aim is to delineate the areas of responsibility for a nurse ethicist. We direct readers to the paper authored by Grace and Milliken in this special issue to consider this debate further.

Specifically, we suggest that clinical ethics consultation ought to be integral to a nurse ethicist role. Nurses frequently encounter ethical challenges and in some healthcare systems are regular ethics consult requestors (second only to physicians). ³⁶ However, long-standing hierarchies in healthcare may inhibit a nurse from seeking assistance with an ethics concern, and further, there may be some important distinctions between nurses and other healthcare professionals’ reasons for consulting ethics consultation services. Friedrich et al. ³⁷ found that nurses described relational benefits to ethics consultation, with verbatim quotations indicating that ethics consultation helped to open up space for communication, whereas physicians described more normative benefits such as offering expertise and giving concrete guidance. Similarly, Milliken et al. ³⁸ report that nurses were significantly more likely than physicians to consult ethics for assistance with communication. In our experience, nurse ethicists approach ethics consultation from the hermeneutic of nursing—a relationship centered approach specific to the practice of nursing—blending nursing and ethics theories and concepts, an approach that is preferable to nurses. ³⁷ Applying Walker’s ³⁹ analogy of the ethics consultant as “architect” and “mediator” to the specific role of the nurse ethicist as ethics consultant allows us to explore ways in which the nurse ethicist can craft spaces to conduct ethics consultation and optimize the involvement of nurses in ethics consultation processes.

The nurse ethicist adds value to a team of ethics consultants or healthcare organization by integrating specific practices into an ethics consultation service that are nursing oriented. The nurse ethicist can share their understanding of the way in which ethical issues might impact differently situated nurses with clinical ethicist colleagues so that normative recommendations can be further refined. For a busy consultation service, while the ethics consultant can speak with the nurse caring for the patient on day one of the consult, it may not be practical to connect with the nurse every day. The nurse ethicist can spearhead practices that are sensitive to such constraints by routinizing the inclusion of ethics consult information into nurses’ handoffs to optimize the flow of information or send an email summary to the nurse who placed the consult request but is then not scheduled to work for several days. While these steps can be taken by all clinical ethics consultants they are unlikely to be common consultation practices without the insights of a nurse ethicist. Though the Core Competencies for Healthcare Ethics Consultation ⁴⁰ describes a number of key skills and process steps, there are no specific recommendations regarding engaging with nursing teams who are responsible for delivering the plan of care.

As architects of moral spaces, the nurse ethicist role is critically important to assist nurses in elevating both the nurses and patients’ experience in decision-making forums such as team or family meetings. These are meetings at which physicians often inhabit the discussion and many nurses feel unable to contribute equally. Comfort and understanding in one’s professional role in nursing and the ability to articulate the concerns from a nursing perspective are essential in the nurse ethicist’s role. This does not translate to automatically “siding with” the nurse or nursing team but rather, assisting the nurse to reflect upon their role and perspective and revise it as appropriate when hearing the perspectives of other disciplines. The nurse ethicist, by virtue of their nursing background can act as a coach, offering specific advice and recommendations about the provision of nursing care. As previously intimated, the point of care nurse’s voice may be absent or marginalized, and just as a Clinical Nurse Specialist would, the nurse ethicist assists the practicing nurse to bring forth the nursing perspective. In our experience, elevating the nursing perspective can be impactful for reconsidering the patient’s treatment plan. One example of this from our practice illustrates how the nurse ethicist can partner with the nursing team to elevate and address their ethical concerns. Members of the nursing team were intimidated by a senior surgeon and felt unable to initiate discussion regarding their concerns. The nurse ethicist validated the credibility and relevance of the concerns and worked with the nursing team to set up a meeting. The nurse ethicist facilitated the discussion amongst the nurses and attending surgeon, uncovering shared concerns about the patient’s obstacles to progress. The meeting allowed a space for collaboration and creative thinking about how to help the family appreciate limitations in the patient’s recovery and inability to meet their goals of care. Because the nurse ethicist was a trusted collaborator to both the nursing team and surgeon, they could support the nursing team to elevate their concerns.

We have found repeatedly that when a nurse raises an ethical concern and is approached by a nurse ethicist, there is a natural connection based on the shared experience of nursing, which engenders trust in a powerful way. Similarly, when an organization places a nurse in a position to offer recommendations to a medical team (a key function of clinical ethics consultation practice), it conveys the message that ethics concerns transcend clinical hierarchies.

Education

Supported by provisions 4, 5, and 6 in the Code of Ethics for Nurses ⁴¹ and Code 1 in the International Council of Nurses Code of Ethics for Nurses ⁴² we argue that a key area of responsibility for nurse ethicists is to build the ethics capacity and capability of nurses in their institutions through ethics education. As the largest profession in the healthcare workforce and those most frequently at the bedside, nurses can play a pivotal role in preventative ethics work. However, evidence suggests that many nurses do not feel equipped to cope with the ethical issues that arise, exacerbating feelings of powerlessness and moral distress.^43,44 Indeed, a qualitative study revealed that nurses in the United Kingdom (UK) described feeling unprepared to manage ethical conflict. ¹⁹ A quote from this work exemplifies the lack of preparation many nurses face:

“I have not had a course in ethics, [and] I did not study philosophy I’m not sure if I’m equipped. And I think that’s really scary and there’s quite a lot of distress that comes out of that… I’m not sure if I’m really equipped to make these decisions or be part of the team that makes these decisions yet.” (p. 10) ¹⁹

Provided with the necessary training and skills for identifying ethical issues, nurses could enhance the ethical climate of healthcare organizations and in turn their own sense of ethics self-efficacy.^45–47 Nurses frequently recognize when a plan of care is not consistent with a patient’s expressed wishes or when the treatment plan raises ethical concerns. Equipped with knowledge and skills they can help the team avoid conflict by effectively communicating this to the medical team. However, not all nurses feel confident nor assured that this is within the remit of their expertise and responsibility. Indeed, despite a call for better integration of ethics into nursing school curriculum, ⁴⁸ little progress has been made toward consensus in ethics education for nurses. ⁴⁹ There has been some progress in identifying undergraduate curriculum content; ²⁵ however, this still requires support in practice integration. ⁵⁰ With the wide variation in ethics education in formal training programs, the gap must be made up in post licensure education. Fortunately, there is evidence to suggest that ethics education beyond formal training likely has the greatest impact on the moral development of nurses. ⁵¹

Grady et al. ⁵¹ surveyed nurses and social workers about the level of ethics education they had received, willingness to take moral action and access to ethics services such as ethics consultation services and ethics committees. Twenty-three percent of nurses reported receiving no ethics education and were less likely to use ethics resources because they did not feel authorized or qualified; whereas nurses who reported receiving ethics education—in continuing education or in-house—reported greater confidence in ethical preparedness, willingness to take moral action and to access ethics services when required. ⁵¹ This suggests that not only do nurses need ethics content in their pre-licensure education so they can identify ethical issues and take moral action, but that without additional education some nurses feel unprepared to utilize ethics consultation services. Ulrich ⁵² suggests that the goal of bioethics education in nursing is three-fold; to encourage nurses to critically reflect on the values, beliefs and assumptions that they bring to their practice; to engage in conversations that promote societal goods and patient advocacy; and to provide an intellectual foundation that will enable nurses to reason through the competing moral demands they face in practice. A nurse ethicist can readily support these goals by providing post licensure education and mentoring to nurses in clinical settings. The nurse ethicists’ expertise in nursing fosters connection with and promotes credibility to practicing nurses that they are valuable contributors to ethical treatment plans for patients. The nurse ethicist should consider both formal and informal education opportunities such as the provision of monthly didactic sessions or integrating ethics education into rounding activities.

Nurse ethicists have designed highly innovative and robust programs to enhance nurses’ abilities to serve as ethics resources.^53–55 When curricula are relevant to nursing problems in practice, it promotes goals of the profession. With careful and considered on-going ethics education and mentoring, nurses can be equipped with the skills to engage more fruitfully in moral deliberation within their healthcare community, breaking down barriers between professions rather than contributing to silos. Strong mentorship from nurse leaders with ethics expertise can transform how direct care nurses engage with ethical challenges. Evaluation comments from participants in the Clinical Ethics Residency for Nurses program exemplify this point:

“Prior to participating in this program I reacted to ethical problems on a highly emotional level. When analyzing an ethical problem using my values as a backdrop, my reaction became very personal. … 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” (p.12). ⁵⁴

Research and scholarship

In addition to clinical contributions, nurse ethicists should consider building research programs to move the field of nursing ethics forward, and to mentor nurses in empirical research and scholarship. The aim of these activities is to better understand challenges in the delivery of healthcare, and to translate research into practice to enhance ethical care. In tracing the history of nursing ethics, Fowler ⁵⁶ suggests that the first research conducted in nursing ethics was an empirical ethics project in 1935 in which Vaughn explored the moral problems that nurses faced. Fowler ⁵⁶ describes how Vaughn asked nurses to keep diaries and then analyzed those for the number and nature of ethical issues that arose. One of the most prominent issues that arose was cooperation between physicians and nurses. More recently, the research and scholarship of nurse ethicists has contributed significantly to our understanding of moral distress and the impact of perceptions of the ethical work environment.^7,47,57,58 Nurse ethicists who are integrated into a hospital’s ethics consultation service can also engage in multidisciplinary descriptive and outcomes research related to consult themes which can then contribute to significant process and policy revisions as well as enhanced understanding of specific clinical disorders that can create ethical challenges such as substance use disorder.^59–61 As with all scholars and researchers, nurse ethicists have an obligation to disseminate their scholarship at academic and non-academic fora, at conferences and through writing. Dissemination is an essential way to influence practice. Disseminating work via peer review processes elevates awareness of the potential impact of the role of a nurse ethicist, enhances credibility of the work, and promotes meaningful change that enhances ethical patient care.

Health policy

Policy work, whether at the local or broader societal level is often politically fraught, complex, and value-laden. ⁶² Despite the potential or actual contributions of nurses to policy decisions, nurses still experience barriers preventing them from even obtaining a seat at the table and the opportunity to exert influence. ⁶³ In 2012, the failure to include nurses in national and international health policy-making was named a “global crisis.” ⁶⁴ It is deeply concerning that 10 years later during a global pandemic, nurses were still excluded from critical decision-making. Case in point, without the urging of nurse leaders, nurse participation in the COVID-19 advisory board would have been absent. ⁶⁵ The increasing prevalence of nurse ethicists is an opportunity to reverse this pattern, though of course will not be without its own challenges.

Nurse ethicists can bring a perspective to policy work that is sensitive to ethical challenges, practical realities, implementation issues, and risk to nurses, patients, and families. An innovative policy at Massachusetts General Hospital provides an example of how nurse ethicists can continue to uniquely influence policy work.^60,66,67 Informed by experiences of bedside nurses caring for imminently dying patients for whom a full code order was still in place due to surrogate disagreement, the hospital nurse ethicist catalogued data to make the case for Do Not Resuscitate (DNR) order in such situations. In her role as ethics committee co-chair, Robinson and a physician counterpart introduced and guided a policy statement for a “Do No Harm” medical order (DNR) through multiple hospital committees including but not limited to the critical care committee, medical policy committee and office of general counsel to achieve final approval. Application of the policy in clinically and ethically appropriate situations has been positive, allowing for natural death and preventing clinicians from violating their obligation to prevent harm. They disseminated their work through publication, influencing other organizations to evaluate their own policies related to code status.^60,66,67

Optimally, nurse ethicists would engage politically, embracing the social justice origins of the profession. ⁵⁶ Scully ⁶⁸ suggests a continuum of advocacy and activism for bioethicists, arguing that because bioethicists must make normative claims about certain acts or states being ethically preferable above others—a commitment to “how things should be”—this necessarily means “there cannot be a hard line between scholarly bioethics and being an advocate/activist” (p. 875). As an emerging role, one that is more informed, developed, and visible, nurse ethicists have an opportunity to advocate for the health and welfare of individuals, groups, and communities they serve. Even if there is disagreement about the extent to which nurse ethicists should engage in public political action they can, at minimum, work towards empowering and representing the voice of bedside nurses to the leaders of healthcare organizations so that unavoidable ethical challenges can be addressed and moral distress mitigated.

One potential avenue for this is for nurse ethicists to conduct research that has potential for shaping policy. ⁶⁹ For example, Morley et al. ⁷⁰ highlighted how funding cuts increase the avoidable ethical challenges faced by nurses and thereby exacerbates moral distress. Others have argued that healthcare professionals in the UK are currently being morally exploited because of the structural injustices forcing them to bear avoidable moral burdens which would be relieved if the political climate and system were different. ⁷¹ Another opportunity to impact policy is by elevating concerns about the widespread creation of policies that are founded on an incomplete understanding of the issue. For example, research about the impact of resilience on moral distress is inconclusive and yet it is promoted as a strategy for addressing moral distress.^11,12 Promoting resilience in this way may subvert the nursing workforce by placing the onus on individuals rather than holding organizations accountable for addressing systematic issues that cause ethical challenges.^72–74

Challenges and limitations of the nurse ethicist role

Nurse ethicists are called upon by clinical nurses, allied health professionals, and physicians who are seeking a pathway to navigate the thorniest of ethical, and often, political-ethical challenges. To say that this role is one of ease would be disingenuous. The ability to work effectively within challenging environments and ethically complex situations requires steadfast commitment, courage, knowledge, and excellent communication skills. In short, being a nurse ethicist requires ingenuity, innovation, and bravery. They must develop relationships in the organization that are genuine, be a role model in character, approachable, and recognized as a problem solver. The role must be recognized as having expert authority that can influence ethical action in a positive way on behalf of patients, families, practicing nurses, allied health professionals, and physicians. This role often requires “speaking truth to power” yet doing so in such a way that educates rather than alienates. In many ways, they serve as change agents. Promoting positive change depends on sharing disagreements in a way that invites the discussion of different perspectives, rather than discrediting them. To this end, continuous cultivation of self-awareness, reflection, and self-care are highly recommended. We describe these characteristics not from a place of feeling secure that we have reached these lofty goals but rather as aspirational for the nurse ethicist.

A significant limitation of delineating the role of the “nurse ethicist” is the potential for contributing to silos between the various disciplines within bioethics and perceived hierarchies. Some individuals within bioethics and clinical ethics also refer to themselves as “physician-ethicists,” ⁷⁹ “philosopher-ethicists,” ⁸⁰ and “lawyer-ethicists” ⁸¹ and one could imagine consult requestors and stakeholders assuming a hierarchy between these roles. However, these delineations demarcate areas of specialty not power. For example, during ethics consultation if there is a particularly legally complex case one might first reach out to their “lawyer-ethicist” colleague before then speaking with colleagues in the legal department. These demarcations do not mean that the lawyer-ethicist should then take the consult as their case because it is important that ethicists have understanding of each of these areas but rather these role titles flag a deeper level of expertise in that particular subject area. As we have described, expertise in nursing and ethics provides a number of opportunities to contribute to the ethical climate of healthcare organizations and the practice of bioethics teams, nurses and other healthcare professionals.

Conclusion

In 2001, Singer et al. ⁸² stated that “Clinical ethics is not founded in philosophy, law, or theology but, instead, is a sub-discipline of medicine, centering upon the doctor-patient relationship” (p. 7). Nurses, philosophers, social workers, theologians, lawyers (and many other disciplines) working in bioethics have done much to counter this rhetoric in clinical ethics and the field is now celebrated for its disciplinary diversity. Our aim in delineating the role of the nurse ethicist has not been to alienate or express a lack of respect for the expertise of clinical ethicists with non-nursing backgrounds but rather to highlight the value of a nurse ethicist to multiple stakeholders.

It is our contention that for a nurse ethicist working in a clinical setting, the primary spheres of responsibility ought to be: the provision of ethics education for nurses that engenders critical reflection; supporting and optimizing the conditions for nurses to deliver patient care that aligns with the patient’s goals and preferences, supports good medical practice, and enables the promotion of excellent nursing care; contributing to rigorous empirical research that generates new knowledge about how to navigate the ethical challenges that nurses face; and collaborating on policy work that positively impacts medical practice and patient care, incorporating the nursing perspective, and promoting social justice. This requires a sensitive approach where the nurse ethicist influences not just the acquisition of ethics knowledge but the practical wisdom that comes from applying that knowledge to everyday ethical challenges. Optimally, the nurse ethicist can stimulate moral imagination, deepen moral understanding, and create moral spaces where nurses’ ethical practice can thrive.

One might ask, can a non-nurse do what we are describing? The legitimacy of our position is difficult to quantify, yet qualitatively it is clear. In our experience, our non-nurse ethics colleagues have engaged us in discussions that suggest we add value to ethics analyses by illuminating the nursing perspective. Our nurse colleagues consistently express gratitude for supporting them in unpacking the ethical complexities, with a focus on the impact on nursing practice. Each of us has been asked, “What do I need to do to be qualified for your role?” We hope that this manuscript provides some direction to those pondering this question, or those operationalizing such a role.