Perspectives on the role of the nurse ethicist

Jenny Jones

How much does a name matter? My name is Jenny Jones. My vocational experiences include hospital-trained Registered Nurse, Primary Care Giver, Early Childhood Educator, University Student, Doctoral Graduate and Clinical Ethics Coordinator; I am now retired. Prior to retirement I was employed in the role of Clinical Ethics Coordinator situated in the nursing practice development unit of a large tertiary hospital in a major city in Australia. Despite my nursing background, I did not identify as a Nurse Ethicist. Nor did I identify as a Clinical Ethicist. Did that matter? To answer this question, we need to first situate Clinical/Nursing Ethics within the contemporary healthcare setting and then explore the work I did.

There have been many changes since I began my nursing training in the early 1970s: at that time, training was hospital-based, whereas it is now university-based; paternalism no longer reigns supreme; there has been a significant increase in medical specialities and sub-specialities. Science and technology are now intrinsically linked to healthcare. The rapid development of new technologies has exponentially increased treatment options. However, at the core of all healthcare is a person who is suffering and professionals who wish to alleviate that suffering. These people coexist within the ‘social practice’ of healthcare; when a person becomes ill or is injured, they enter into a relationship with others who are themselves embedded in broader domains such as professional practice and organizational culture. Each person’s personal and shared values guide and drive the relationship; ‘values permeate every aspect of our lives, shaping individual actions and giving meaning direction and scope to our work environment and organizational cultures’. ¹ At times, however, there can be competing and conflicting demands which impact our ability to move forward, and which ultimately cause distress. As the Clinical Ethics Coordinator, I was predominantly tasked with (a) assisting staff build their ethics capacity and (b) provide practical support through consultations related to complex case situations.

In seeking to build capacity, I facilitated small and large group education sessions across all disciplines: I contributed to staff on-boarding orientation sessions; I facilitated small and large group education sessions such as Ethics Seminars and Ethics/Compassion Cafés. ² These cafés were built on the concept of the Café Philosophique first established by Marc Sautet in France in 1992: ³ a safe space was provided for staff to build capacity by assisting them to identity and make sense of the ethical challenges they encountered.

The second aspect of my role was to provide practical support to staff particularly with respect to difficult or challenging case situations. At times, this involved a one-on-one discussion; other times a Clinical Ethics Committee ¹ Consultation meeting was held whereby multiple perspectives could be presented. There was no magic ethical wand that could be waved for the ‘right’ answer to be produced. Rather, my role involved providing staff with a reassurance that the discussions would be within a framework of safety: no judgements would be made; all staff would be given the opportunity to contribute; the complexity of the situation would be acknowledged; with several possible responses likely to be identified. Staff would not be told what they ought to do; rather they would be guided to an appropriate ethical response. How was this guidance enacted in the consultation process? I believe Ethics Consultation involves (a) opening a space for ethical deliberation as distinct from a focus on disease/illness/injury of the person who is suffering (b) asking the right questions at the right time within the consultation process. ⁴ This second task is much harder than the first. Each person – staff involved in the situation and committee members – comes with their own unconscious bias: they bring, mostly unknowingly, their own values which, as noted, permeate, and define our personal and professional lives. I found that in the process of outlining and discussing the ethical challenges, varying personal and professional values were implicitly identified. However, the power differential embedded in the ‘social practice’ of healthcare was also often explicitly identified. With awareness of the values and power at play in each specific context, practitioners were drawn to an appropriate ethical response – a response that aligned with the deeply entrenched values of ‘care, trust, and reciprocity’ which define healthcare as a moral, value-laden practice. ¹

So back to my original question: Did it matter that I didn’t identify as either a Nurse Ethicist or Clinical Ethicist? No, I do not think it mattered. As the title I held implied, the facilitation of an ethical culture required a coordinator – one who was able to draw practitioners together for the common good.

Paul J. Ford

Healthcare centres are full of professional cultures through which a clinical ethicist must navigate. Being invited into a context as a guest or an adopted member provides opportunities to engage and help in novel ways. However, this is not the same as being from a specific culture. Belonging to a culture provides both insider knowledge as well as a different kind of acceptance from peers in ways that can be particularly helpful for individual ethicists and ethics programs. For more than a decade at the beginning of my career, I practiced in an individual professional ethics model without having a fulltime ethics colleague with a nursing background. For part of this time, I had an amazing colleague who was working full time in the Neonatal Intensive Care Unit as a CNS. She was a trained ethicist and contributed ethics support in addition to her fulltime responsibilities. In collaborating with her on cases and in education, I recognized that I could tap into nursing culture in ways that allowed me to be a more effective ethics consultant. However, there was built-in tacit knowledge and credibility that my CNS colleague always had because of her nursing experience. I often did not know what I might be missing because of natural gaps in my lived experience of having never practiced nursing and having never been fully enculturated. Recognizing that there are far more nurses than physicians and that a specific hospital patient spend much more of their time interacting with nurses than any other healthcare provider, it was clear that that nursing had been under-supported in addressing ethical dilemmas as well in responding to the distress that results from those dilemmas. When there was an opportunity to fill the nursing ethics gap with a special ethics fellowship, we collaborated with our Nursing Institute to recruit a highly qualified PhD with bedside ICU nursing experience. This fellowship demonstrated to the institution that there was an opportunity to enhance ethics work by filling gaps in our ethics consultation services. These gaps could be best identified and filled by someone with nursing experience and training in addition to clinical ethics expertise. This demonstration over an 18-month period made the value of a nursing ethicist plain enough that my institution created a new fulltime position to recruit and retain that nurse ethicist. Part of the value of having a nurse ethicist is that she can identify needs and solutions with an eye from the inside while still maintaining a professional role on the outside as an ethicist. Of course, inherent in the strength of being within a culture are the assumptions from others about role, advocacy, and understanding. A nurse ethicist needs to be able to contribute generally within an ethics service to serve a broad population of patients, families, and healthcare providers and she should not be constrained as being only relevant to nursing. Although a nurse ethicist is well position to advocate for nursing issues, she should also not be viewed as a singular voice for nursing in a way that replaces other types of intuitional representation for nursing. Finally, nursing includes a wide variety of jobs ranging from critical care, operating room, infusion centres, public health, and outpatient settings. A nurse ethicist may be enculturated and have experience in some of these but should keep in mind the diversity that still exists beyond her experience. In clinical ethics, we have found a nurse ethicist enriches our service both in the clinical ethics consultation work as well as in develop programs that empower nurses to address ethical challenges themselves.

Giles Birchley

A background in nursing is one of a number of subjective experiences an individual can bring to a role in academic and clinical ethics. Yet I suggest that any distinctiveness in nursing ethicists is entirely down to distinctive individual experiences rather than a distinctive professional role. The prevalent narrative accentuates the differences between healthcare professions. I argue such a narrative speaks directly against an egalitarian ambition to make hospitals and clinics places where healthcare professionals and patients meet as equals with a shared goal of promoting health and treating disease.

The ontology of clinical ethics consultation is contested, with ethicists such as Agich characterizing it as an activity that is about removing blocks to clinical processes, ⁵ while others argue it is about bearing witness to the inevitable dilemmas of clinical practice. ⁶ We could follow Agich’s characterization and argue that clinical ethics consultation is about bringing ethical knowledge that can be objectively applied to clinical cases. That both approaches tacitly form a commonplace in clinical ethics was captured by Frolic’s ethnography of clinical ethics consultants. Frolic observed ‘…some told stories of difficult consults… they were absent from these narratives, as if they were not agents in the drama but rather a Greek chorus standing in the wings, narrating the unfolding of fate’. ⁷ What Frolic is saying is that the clinical ethicists she observed apparently believed that taking an objective position was essential to their role. Yet if clinical ethics involves an objective viewpoint – in other words, detaching oneself from the subjective parts of one’s experience – objectivity will include detaching oneself from the subjective conditions of one’s background. I suggest that ethical knowledge is neither emotionally nor socially neutral (although there is not space to develop an argument on this point there is plenty of evidence that ethical judgement is linked to our circumstances and sensations as much as it is to reason). ² There is thus something going wrong with any account that suggests clinical ethicists can or should seek complete objective detachment. Given an assumption of non-neutrality, we might ask specifically what our clinical background as nurses brings, qualitatively, to clinical or academic ethics – and, by implication, in what way this experience differs from others working professionally in a clinical setting.

My own experience is that the phenomenology of nursing is to care, or to touch, and this seems to relate to the academic explorations of the phenomenology of nursing.^8,9 This may be necessary to good bedside nursing, but it is not clear that these factors are sufficient conditions to distinguish nurses from other healthcare professionals. Taking doctors as paradigmic examples, while uncaring doctors certainly exist, it would be hard to argue that their practice was not defective. Similarly, it seems hard to argue that therapeutic touch is not something common to all healthcare professionals, even if its use is quantitatively different between different professionals and different settings. Similarly, most nurses, myself included, have experiences of injustice due to their place in clinical hierarchies, and this is also a well-documented area in the literature.^10,11 Yet although it is clear that in clinical practice doctors delegate tasks to nurses, so too do nurses further up the hierarchy delegate to those lower down. So it is not just the case that nurses are subjected to an alien authority. The intensely hierarchical organization of healthcare owes much to Florence Nightingale’s intentional reproduction of military distinctions between enlisted men and officers, yet these hierarchies are reproduced in all healthcare professions. It is frightfully clear that doctors near the foot of these hierarchies are as disempowered by them as are nurses who are similarly placed.^12,13 This difficulty ascertaining clear distinctions that are unique to each profession should tell us something important about the practice of healthcare. There is – and I suggest, there should be – something uniquely democratic in the treatment of the sick, that unites patients and professionals alike. As WH Auden observed: ‘The hospitals alone remind us of the equality of man’. ¹⁴ Health, illness, and death demonstrates our universal humanity. While nurses (and other professionals) bring our own unique and subjective experiences, motivations, and perspectives to a clinical ethics consultation, distinctions between professionals are largely artificial, symptoms of healthcare system built on authoritarian distinctions between persons. While the leaders of healthcare professions, who sit at the top of these hierarchies, have a vested interest in accentuating professional distinctions, it is hard to think what benefit they provide anyone else, besides the possibility of looking down others still further below them. Professional distinctions are a roadblock to creating a truly egalitarian healthcare system that values patients, nurses, doctors as human beings. As nurse ethicists we can take a first step towards such a vision is to relinquish narrow and partisan divisions in describing our own practice.

Settimio Monteverde

Clinical ethics consultation (CEC) has been established in many countries as a possible answer to the increasing complexities of healthcare. With some delay, this process also took place in Switzerland, initially with the intention to foster ethical accountability in the context of breakthrough achievements in medicine like the procurement of organs in donors declared dead by neurological criteria. ¹⁵ Since then, a series of regular surveys shows both an increasing number and variety of CEC services in healthcare facilities, although formal certification is still missing. In ensuring a common understanding of their scope, methods, and structures, the guidelines of the Swiss Academy of Medical Sciences ¹⁶ have been instrumental. Their core assumption is that clinical ethics consultation must be interprofessional, that is, with protagonists of CEC sharing diverse professional/clinical backgrounds and a common base of knowledge and skills relevant for understanding and processing ethical issues. ¹⁷ This is usually evidenced with a degree in bioethics (Master- or PhD-level) and concomitant clinical experience.

Although the dimension of nursing is explicitly addressed in national and institutional CEC guidelines, the Coronavirus pandemic has shown that nurses experiencing ethical challenges might not always have access to CEC structures within due time ¹⁸ or that CEC structures might not always be able to grasp and address the specific ethical concerns of nurses, among them the experience of moral distress. ¹⁹ From the author’s practical experience as clinical ethicist, three reasons can be listed for this:

1. Institutions with formal CEC structures can still maintain a strong hierarchical culture that does not encourage ‘questioning’ procedures, internal processes, or treatment decisions.

Situations like these can give an occasion to discuss the possible role of a nurse ethicist. Their role can be understood in a twofold way: first, as a facilitator who enables the nursing team to understand and tackle the specific ethical issues perceived by nurses, provide orientation and elucidate understanding to address them. Second, as member of the clinical ethics team, the nurse ethicist helps the organization to overcome potential ‘monoprofessional’ biases by claiming its profoundly interprofessional nature. ¹⁶ Until now, this discussion is not visible in Switzerland. Nevertheless, it is hoped that, in the context of discussions on the accreditation of clinical ethics and clinical ethicists, also the growing number of nurse scientists having academic degrees in bioethics will be addressed. Given the paucity of institutions actually funding specific clinical ethics positions until now (preferring to rely on professionals working primarily in clinical settings, and additionally having an ethics background), the figure of the nurse ethicist will probably remain an exception. On the way to raise the visibility of nursing and nursing ethics within the provision of CEC and meet its claim to interprofessionality, the three reasons raised above (hierarchy, devaluation of ‘housekeeping issues’ and the ability and courage to raise ethical concerns) must be addressed by beginning within formal education and training of nurses, ensuring the low-threshold accessibility of CEC structures for the whole healthcare team including nurses.