Editorial

In November 2021, while the pandemic still featured large across the globe, the Children’s Bioethics Centre at The Royal Children’s Hospital (RCH) in Melbourne, Australia circumnavigated logistical difficulties with international networking to host a two-hour ‘Nursing Ethics Virtual Roundtable’. This meeting was part of a project to explore ways of increasing engagement of nurses at RCH in clinical ethics discussions. The roundtable participants were the Australian paediatric bioethics team and 10 invited nurses working in clinical ethics or what we assumed to be clinical ‘Nurse Ethicists’ from the United States (US). The primary aim of the roundtable was for the Australian service to learn from the US experience of supporting nurses in clinical ethics, given the value placed on nursing ethics in the American healthcare system is far in advance of Australia.

The roundtable explored a variety of topics beyond the engagement of nurses in clinical ethics, including governance and funding for ethics services, the misunderstandings of the role of an ethics consult, and the nature of nursing moral distress. To the host team’s surprise, though, arguably the most robust discussion surrounded the label of ‘Nurse Ethicist’. There was a variety of opinions in the virtual room about the ‘pros’ of using ‘Nurse Ethicist’ as a title versus ‘cons’ of such a label.

This roundtable discussion has now led to this – a special issue on the role of the nurse ethicist. The broader context for debate in this special issue needs to be kept in mind. It is impossible to fully appreciate the divergence of opinion, and the degree of thought and consideration given to the Nurse Ethicist title without revisiting the history of power and hierarchy in nursing ethics, and how this has translated to nurse clinical ethicists, as they weigh up whether calling themselves a ‘Nurse Ethicist’ is a help or a hindrance, relevant or irrelevant to their work.

This history is written into the academic literature. One example is in Fowler’s work in which she captures the history of nursing ethics. In 2017, Fowler conducted an informal review of bioethics texts and of the 18 included texts found that nursing was mentioned in only 2 books. Fowler (2017) details, ‘One book had 67 chapters and 88 contributing authors, four of whom were nurses. ¹ This guide to bioethics has one brief chapter on ethical issues in nursing practice written by two nurses. .... In the other book, there are three mentions of nurses in one chapter but nowhere else. Like a troubled marriage, where bioethics literature interacts with nursing, it is a one-sided relationship with nursing trying very hard to make the relationship work and to feel loved’. (p.294, emphasis ours). IIlhaam and Gaskin (2010) describe the birth of bioethics in the US as built largely from philosophical and legal collaborations on the Belmont Report, ² solidifying relationships between philosophers, lawyers and physicians but marginalising the integration of other healthcare professionals in bioethics. Recent shifts to carve out spaces and roles – such as the Nurse Ethicist role – need to be understood in this context.

The history is also experienced in an on-going way by nurses working in bioethics and clinical ethics. One of our editorial group (GM) recounts this recent experience.

At a national bioethics conference I was attending, there was a keynote session in which the speaker presented their research findings regarding physician ‘moral stress’ during the COVID-19 pandemic. I was disappointed from a conceptual perspective that the speaker did not describe how they had differentiated ‘moral stress’ from the various ways in which ‘moral distress’ might be understood. I was then further troubled when the speaker failed to make any clear reference to the decades of research conducted by nurses exploring moral distress in healthcare. The findings seemed to correlate substantially with nursing ethics theory and research that recommend morally distressed nurses need support at the individual, team/unit and organization/system level. One would assume that findings could be bolstered by highlighting similar supporting findings that were unfortunately omitted in this case. This begs the question whether they were omitted due to time constraints, an unfortunate oversight or because these findings from the nursing realm were regarded as insignificant.

Some authors in this special issue describe similar experiences of the marginalisation of nursing ethics, and even the questioning of how a nurse could have a legitimate place in philosophical ethics.

When it comes to clinical ethics, this special issue affirms the legitimate place of nurses, demonstrating many ways in which nurses with ethics training not only contribute to but lead and enhance clinical ethics services (see Ford in Jones et al.). Metselaar and Molewijk, for example, describe moral case deliberation as a method used by nurse ethicists to foster moral resilience in the face of moral distress. However, the term ‘Nurse Ethicist’ itself remains vexed. Authors of some of the papers in this special issue (including Morley, Robinson and Wocial; Ulrich and Grady; and Pilkington and Giuliante) regard it as an essential title, denoting a unique role. They put forward several arguments in favour of using the term ‘nurse ethicist’ rather ‘clinical ethicist’ for a nurse working in a clinical ethics role. Some arguments are based on what might be called ‘internal reasons’, related to the nature of nursing as a discipline. Pilkington and Giuliante make the case strongly, arguing that nursing is unique, with a foundation and special focus on relationships, which makes it different from other health disciplines. Hence, the type of ethical expertise that the nurse ethicist brings is distinctive. Using the title of nurse ethicist also allows nursing identity to be retained, which may be important to the professional integrity of the person in that role. Others give reasons that are more “external”, relating to the message it sends to staff. Barnum notes that the title engenders trust, makes the nurse ethicist more approachable by nurses and enables solidarity to be forged. The title makes the nurse ethicist “visible” to nurses, who are the ones that the nurse ethicist role (at least in many institutions) is set up to serve. Barnum has pragmatically harnessed this visibility, implementing the ‘e-walk’ (a walk around patient care areas to do ethics rounds supporting staff in their ethical challenges). This as a tangible example of the shared nurse identity to foster acceptance of the ethicist physically in clinical areas. Morley, Robinson and Wocial describe the more nuanced visibility, in which their nursing knowledge and identity has been able to bridge gaps between nurses and clinical ethics services, translating process steps and the rationales to facilitate mutual understanding.

For others, the most important issue is what the ethicist with nursing training can bring. Wolfe paints a picture of the nurse ethicist expanding upon and addressing the contextual elements of a ‘case’, which add nuance and complexity to standard ethics questions, but also surfaces additional questions. Johnstone describes the nurse ethicist as a ‘moral facilitator’ whose role is to facilitate moral deliberation, starting with the moral knowledge and the lived moral experience of those facing a moral problem. Several papers (including Wolfe and Barnum) reference the idea of ‘moral space’, suggesting that nurses are particularly adept at creating this space. Jones gives a vivid practical account of her practice of creating moral space, but does not attribute this to nursing education at all.

One of the core contributions and skills of the clinical ethicist is the ability to promote a fair process. On this view, the ‘added value’ of the nurse ethicist (as argued by many in this special issue) is as an individual able not only to promote fair process but who also possesses a deep understanding of the nursing perspective which enables them to integrate nursing ethics expertise and often ignored ‘housekeeping’ concerns into decision-making. This perspective arguably greatly expands the scope of the problems and decisions that fall within the domain of clinical ethics; and in doing so contributes to the on-going thought about clinical ethics as a discipline.

Underlying all the papers in this special issue is the fundamental question of disciplinarity – both for nursing and for clinical ethics. Questions about the role of nurse ethicists and uniqueness of nursing ethics may be most suitably answered by comparative reference to the broader role of bioethics and the nature of clinical ethics as a discipline or practice. By virtue of the nature of bioethics, it is a diverse discipline. Bioethics is constructed of the various healthcare professions, lawyers, philosophers, and theologians. The question is to what extent each individual ought to bring this specific background and expertise to their ethics practice. In the perspective piece to which Birchley contributes (Jones et al.,), Birchley argues that we ought to strive for an egalitarian approach to clinical ethics in which we come to ethical discussion as an individual, not as an individual from a distinct profession. This, however, requires that we can separate ourselves from our disciplinary background and to some extent, also requires that we put that background aside as if it is a hindrance rather than a help. One approach might be to embrace a transdiscplinary approach. IIlhaam and Gaskin (2010) distinguish transdisciplinary from multidisciplinary and interdisciplinary approaches. ² Multidisciplinary models invite individuals to contribute to the team from their own discipline, interdisciplinary models invite three or more representatives to contribute collaboratively but still reinforce hierarchy, whereas a transdisciplinary approach urges individuals to come together from a ‘shared philosophical perspective’ (p. 92, quoting Anderson et al. 2000). This approach, it is argued, has the greatest potential to disturb hierarchical power dynamics because team members are considered equal and work jointly to make decisions that are directed toward a shared perspective. This enables individuals to bring the expertise of their discipline but without hierarchy and, arguably, while also minimising bias (since the goal is shared). In light of this understanding, it might be suggested that nurse ethicists might be engaged, with others of different disciplines, in the transdisciplinary practice of clinical ethics.

From practical strategies used by nurse ethicists, to reflection on the nature of nursing ethics and clinical ethics, this special issue offers much food for thought. We hope that readers of this issue will find it by turns informative and useful, challenging and thought-provoking.