From corridor to boardroom: An upstream-focused model of clinical ethics for organisational impact

Abstract

In this paper, we present a model of clinical ethics support that is focused on addressing clinicians’ ethical concerns in practical and meaningful ways, including at a systems level within the hospital by engaging institutional leadership. Our work highlights the importance of this approach as a focus in nascent service establishment. The ‘corridor-to-boardroom’ model that we put forward aims to amplify clinicians’ voices in order to motivate organisational change. The model evolved in our clinical ethics service (CES) in a public hospital in Melbourne, Australia, and reflects the specific context including changes in our state's healthcare landscape that created organisation-wide ethical challenges enabling the establishment of our service. Key features of the corridor-to-boardroom model include: 1) identifying patterns of clinician concern and articulating them as ethical issues; 2) amplifying clinicians’ concerns through organisation-level discussions and engagement with leadership; and 3) partnering with clinicians and organisational leaders to develop pragmatic and ethically robust responses at a systems level. To elucidate the key features of the model, we use the example of our recent clinical ethics work responding to occupational violence and aggression in the emergency department. Sharing features of an ‘Integrative Clinical Ethics Support’ model, our model applies similar principles at an institutional level. This approach also contributes to answering the call for CESs to more effectively link the clinical workforce with institutional leadership to address ethical issues in clinical practice at an organisational level.

Keywords

clinical ethics services organisational ethics systems thinking leadership occupational violence

Introduction: Systems thinking in clinical ethics work

Clinical ethics services (CESs) in a hospital setting generally engage in three key activities: policy development, education, and consultation for individual patient cases.¹ Clinical ethics consultation is often the most visible activity of a CES and, to date, has received the most scholarly attention.² Typically, in clinical ethics consultation, the focus is on addressing a question arising in an individual patient case. While responding to acute ethical issues is important and impactful work, it has been described as just ‘the tip of the iceberg’, with organisational processes and culture underlying these acute ethical issues.³

Over the past 20 years, there have been a growing number of calls for CESs to be better integrated across the organisation,^4,5 and to engage in systems thinking.^2,4,6 Adopted in healthcare more broadly since the 1980s, systems thinking shifts the focus from individual actions and behaviours to identifying and addressing the underlying causes of those behaviours.⁴ In the context of clinical ethics, this is about recognising how organisational factors can influence the ethics practices of individuals,³ and contributing to the continuous improvement of those organisational factors. Compared with the traditional approach of CESs, engaging at a systems level involves both consideration of different types of issues, and different ways of responding. It is about tackling broader issues within an organisation, such as the resource allocation questions that arise in various contexts, or practices related to patient privacy and confidentiality.³ It also involves a shift ‘upstream’ in ethical thinking and orientation,⁷ moving from or beyond acute ethical issues for individual patients to address the system-level factors that facilitate or inflame them.

A number of models or strategies have been proposed for applying systems thinking to clinical ethics work. MacRae and colleagues share 10 principles for achieving this, including being practical and useful; proactive rather than reactive; and understanding the needs of key stakeholders.⁴ Fox and colleagues have described in detail the ‘IntegratedEthics’ model, which they implemented across the Veterans Health Administration, the largest healthcare system in the United States.³ Recognising the importance of addressing ethical issues proactively, on a systems level, the IntegratedEthics model is a comprehensive program structured around three functions, each of which targets a different ‘level of ethics quality’: (1) ethics consultation, at the level of decisions and actions; (2) preventive ethics, at the level of systems and processes; and (3) ethical leadership, at the level of environment and culture.³ ^p.8 Hartman and colleagues describe an approach which they call ‘Integrative Clinical Ethics Support’.⁸ With the aim of increasing the impact of clinical ethics work, Hartman and colleagues adopt an approach that involves creating co-ownership of clinical ethics work with clinicians and better integrating clinical ethics support within existing structures.⁸

In this paper, we present the model of clinical ethics support that we have developed, and that continues to evolve, at the Clinical Ethics and Decision Support Unit at Austin Health, a tertiary, public hospital in Melbourne. The model comes out of our specific context in Australia where CES development is sporadic, rather than centrally co-ordinated or systematically professionalised. Regulatory bodies have expressed in-principle support for CESs to be broadly available throughout the Australian healthcare system (see for example Equip National Guidelines. Standard 15. Criterion 2. 15.6. The Australian Council on Healthcare Standards, pp16–17 (2012); and the Australian Health Ethics Committee of the National Health and Medical Research Council Consensus Statement on Clinical Ethics (https://www.nhmrc.gov.au/sites/default/files/documents/attachments/consensus-statement-clinical-ethics.pdf)). To date, however, their development has been ad hoc. CESs are not required for healthcare accreditation, there are no formal pathways for clinical ethics training, and there has not been a coordinated approach to implementation. Largely driven by enthusiastic clinicians and bioethics academics, who have been motivated to independently pursue training or experience in clinical ethics and contribute to a growing field, a key challenge in the development of CESs is securing sustained funding. In-principle support from healthcare leaders does not necessarily translate to financial support for CESs. Some additional driver – organisational crisis or perceived risk – is generally needed to prompt the establishment of CESs, which are then required to secure funding from external sources or otherwise make the case for continued organisational funding at regular intervals (This is our understanding of the pattern of development of CESs in Australia, based on conversations with our colleagues in this relatively small professional community.)

The catalysts for the development and growth of our CES at Austin Health were gaps in ethics support for organisational-level issues. It was significant changes in our state's healthcare landscape that created opportunities for development and funding of a CES. These changes included, firstly, implementation of several significant pieces of new legislation related to patient-centred treatment planning and voluntary assisted dying (VAD). Later, the COVID-19 pandemic created service planning and resource allocation issues at an organisation-wide level. These organisational ethics issues facilitated initial funding of the service and enabled it to be embedded in the hospital's functioning.

Our strategy from the outset was to demonstrate the value of clinical ethics to the health service. Advocacy within the organisation resulted in initial recognition of the importance of clinical ethics through the appointment of a Clinical Ethics Medical Lead – without dedicated funding but with institutional endorsement to engage with complex ethical issues arising from new legislation around treatment planning and consent. Clinicians from various areas of the hospital contributed their ethics expertise to this work within their existing roles and workloads. The new service drew on the ethics training of clinicians within the organisation, including senior clinicians with Masters-level qualifications in bioethics who supported the service through serving on various governance structures including a clinical ethics committee (CEC) and clinical ethics response group (described further below). Subsequently, the introduction of VAD in our state provided an opportunity for project-based funding to support both the Clinical Ethics Medical Lead and a Bioethicist, highlighting the tangible benefits of ethical input into sensitive and high-stakes areas of practice. During the pandemic, the growing visibility and impact of the service led to permanent hospital funding for the Clinical Ethics Medical Lead, along with additional project funding for bioethicist support, reflecting increasing recognition of the CES’ organisational value. Collaboration with the Department of Surgery at the University of Melbourne enabled further salaried funding for a bioethicist position and a part-time administrator role, enabling the expansion of our research and education activities, and consolidating the service's place within the institution.

The corporate structure of our CES was designed to maximise engagement and impact across the organisation, both among clinicians and hospital leadership. The service sits within the Chief Medical Officer's portfolio. The Clinical Ethics Medical Lead also meets quarterly with the hospital's Chief Executive Officer. A CEC was established, with senior representatives from key medical and surgical specialties as well as the Chief Nursing Officer and senior allied health clinicians. The committee also included bedside nurses and a nurse unit manager. As staff of the service, we report monthly to the CEC. CEC members also act as ethics champions within their areas, including raising concerns from their departments. The CEC is chaired by the Chief Medical Officer or Deputy Chief Medical Officer. We also established a Clinical Ethics Response Group, based on the corporate structure of the successful CES at the Royal Children's Hospital in Melbourne, Australia.⁹ The Clinical Ethics Response Group is a multidisciplinary group of clinicians with strong interest and additional training in clinical ethics, who are available to contribute to complex clinical ethics case consultations. They also function as a community of practice, to whom we provide additional educational and discussion opportunities to build connection and further capability.

Hence, the characteristics of our clinical ethics model reflect an active and deliberate strategy to engage with and address ethics issues at a systems level from the outset, aligning with the organisation's expectations of our newly established service. While in hospital settings, tensions can arise between the priorities of institutional leadership and individual clinicians’ aims in providing care, our approach has been successful in both supporting frontline clinicians and engaging hospital leadership. Key to building trust in our service has been a pragmatic and responsive approach, and a commitment to partnering with clinicians to ensure that ethics work meets their needs. We have consistently focused on staff support and wellbeing, precluding any perception of the service as a mechanism for oversight or control. The CES has been embraced by bedside staff for individual patient care issues, receiving 30–60 case referrals annually since 2021. Each year, the number of unique medical specialties referring cases to the CES has increased, demonstrating broad acceptance of the service across the institution. In response to calls for CESs to engage in systems thinking and link with institutional leadership to contribute to broader organisational impact,⁶ we share our reflections and insights on this model so far, for others to draw from in the establishment or ongoing functioning of their own CESs. Our experience suggests that an organisational focus is particularly important in nascent service development.

The corridor to boardroom model: Organisation-focused clinical ethics

MacRae and colleagues describe a systems approach to clinical ethics as:
using the original functions associated with clinical ethics – consultation, education, policy development, and scholarly work – for the purpose of improving the overall culture and system of care delivery, including but moving beyond, care of the individual patient.,⁴ ^p.320

Outlined in Figure 1, our model aims to achieve this by firstly identifying patterns of clinician concern and articulating them as ethical issues. This takes the form of noticing (or being engaged in) the corridor conversations that indicate clinician distress about a patient or issue. Sometimes clinicians themselves clearly identify issues as ethical and engage with our service. On other occasions in contrast, clinicians perceive decision complexity and experience discomfort but do not specifically categorise the issue as an ethical one. Noticing clinician distress or listening to clinicians’ reflections about an issue can be followed up with specific ethics conversations to identify systematically the ethical components of the issue together and, where sought by clinicians, formal case consultations or other sessions to assist staff to further articulate their ethical questions and concerns and generate a way forward for individual patients.

Figure 1.
The corridor to boardroom model of clinical ethics.

Where there is a pattern of these conversations and consults – i.e. a recurring issue – it is the role of the CES to amplify clinicians’ concerns through organisational discussions and engagement with leadership. The CES can amplify clinicians’ voices by aligning their ethical concerns with known organisational priorities. Identifying and joining relevant organisational committees is one very practical way of achieving this. The aim of this phase is to alert organisational leaders to clinicians’ ethical experiences and insights.

The final phase is an institutional response to the ethical issue. The CES's role here is to ensure the organisation's response takes into account the relevant substantive and procedural values, and in association with this, to build the ethics capabilities of the organisation. This is likely to involve the CES partnering with clinicians and organisational leaders to develop pragmatic strategies for responding to the ethical issue at a systems level. These system-level responses in turn contribute to building further ethical sensitivity at the micro level, fostering a robust ethical environment at all levels.

The model in action: Responding to occupational violence in the emergency department

To further explicate these steps, we describe below our clinical ethics work on the issue of occupational violence and aggression (OVA), which took place across 2023–2025. We link this model with existing discussions of clinical ethics models and the role of CESs in organisational issues, to highlight connections and the distinct contribution of our corridor-to-boardroom approach.

Identifying patterns of clinician concern and articulating them as ethical issues

Staff across the hospital experienced a spike in OVA that was unprecedented in intensity and frequency during the COVID-19 pandemic, with implementation of visitor restrictions and other infection control measures. Despite the return to more usual hospital processes as the acute phase of the pandemic passed, many staff were noticing that OVA incidence had not abated and was now occurring in a much wider range of circumstances. Staff felt that this increase in OVA had become an entrenched problem. In our CES in 2023, we noted an increased number of referrals for ethics consultation related to concerns around OVA and how best to respond to it. Simultaneous with this increase in referrals, OVA was often being raised in discussion at all-staff events, such as grand rounds, as well as in ethics-led education sessions for particular units and craft groups on different topics, and in informal conversations in the corridors and other contexts. Distress and disquiet were permeating the hospital about this issue.

As Fox and colleagues have noted, patterns in requests for ethics consultations and clinician concerns can reveal that there are organisational systems and processes (or a lack thereof) that are driving experiences and decision-making.³ It has also been observed that clinical ethicists can be ‘uniquely poised’ to recognise, and therefore to respond to, these patterns.,¹⁰ ^p.257 This is because CESs might interact with a broad range of teams across an institution, allowing them to see patterns of ethical concerns for particular patient groups, craft groups, and departments, or issues that traverse the whole organisation.¹⁰ As well as engaging with a broad range of departments and craft groups through education sessions and case consultation work, our service's ability to recognise patterns of clinician concern is enhanced through Author DK’s specific position, with various roles within the hospital that cut across departments as a member of the quality and safety team and a senior palliative care clinician. Having a member of the CES with other roles within the organisation is an important element of our model. However, it is important to note that multiple simultaneous roles within an organisation also bring the potential for confusion among colleagues and unconscious bias in the provision of ethics advice. DK's various roles require critical reflection and shared clarity with colleagues in terms of ‘which hat’ is being worn in a given situation, noting the potential for blurred boundaries.¹¹ Inclusion of the bioethicist and/or members of the Clinical Ethics Response Group are key strategies implemented in our service to ensure the rigour of the ethics advice provided.

As well as recognising patterns of concerns, an important contribution of our ethics service is to articulate relevant concerns as ethical in nature, which provides a distinct avenue for responding. For us, building a CES based on collaboration between a senior clinician and an academic bioethicist has been fundamental to the service's ability to identify patterns of clinician concern and articulate them as ethical issues. Bioethics expertise ensured our work was deeply informed by ethical theory and current bioethics research. RM's training and position outside biomedicine enabled recognition and questioning of clinicians’ ingrained assumptions, stimulating productive reflection and discussion.

The CES was not alone in recognising OVA as a cause for concern; it was a front of mind issue for many in the organisation. However, OVA had not yet been broadly conceptualised as an ethics challenge within our institution or the healthcare sector, and there is only a very small ethics literature to date on this topic.^12–15 One of the first actions taken by our CES on this issue was to lead an all-staff forum organised by the hospital's OVA committee. This forum centred around the question of what zero tolerance to OVA means at our institution (a stated policy position at that time). Our team facilitated a multidisciplinary discussion and highlighted the values in tension for clinicians making decisions in this context, including the duty to care for patients in need of medical attention, staff members’ own safety and wellbeing, and that of their colleagues.

Beyond identifying these relevant values, what this conversation revealed was that there were varied perspectives among hospital staff about how these values should be prioritised, and what would constitute an effective and ethically justified approach to OVA. These differing judgements about an appropriate response to OVA seemed to be based on clinicians’ own sense of professionalism, their past experiences, and specific vulnerabilities. The CES was able to recognise and name the ethical diversity within the organisation.

These values-based aspects of clinician decision-making had not yet been explicitly considered in discussions about appropriate responses to OVA. By framing the conversation in ethical terms, we began to offer new ways of looking at the challenge. We learned from colleagues that understanding OVA as a value conflict helped to explain why it was such a challenging issue to address and why team members views on appropriate responses sometimes differed, which was helpful in itself. These conversations also indicated the high level of staff anger, fear, and moral distress around this issue. The urgent need to improve approaches at an institutional level was clear.

Amplifying clinicians’ concerns through organisational discussions and engagement with leadership

Amplifying clinicians’ ethical concerns via relationships in the organisation was a feature of our work on OVA. After noting the increase in referrals for distress around OVA, we sought a place on the hospital's OVA Committee with the aim of contributing ethical frameworks and thinking to the strategic work being done at a systems level to address this complex and pervasive phenomenon. This included contributing ethical components to discussions within meetings and highlighting to leadership the moral injury risks to which staff were currently exposed. In addition, our service was involved in formalising a smaller working group to facilitate a better flow of information between frontline clinicians and executive. This increased shared understanding and promoted a pathway for more timely and effective organisational responses.

Engagement with leadership, MacRae and colleagues write, means ‘sitting at the senior tables and clinical tables and offering useful and effective tools and resources to help them to manage the real problems they face’.,⁴ ^p.320 Notably, securing a seat at these tables may be something that takes significant time for a new CES, if they are able to do this at all. In this regard, our service has again benefited from the ‘insider’ position of the medical lead already occupying senior and clinical spaces (We note the debate in the literature, which is beyond the scope of this paper, as to whether ‘insider’ or ‘outsider’ status is preferable for clinical ethicists. See White, Bruce D., Wayne N. Shelton, and Cassandra J. Rivais. ‘Were the ‘Pioneer’ Clinical Ethics Consultants ‘Outsiders’? For Them, Was ‘Critical Distance’ That Critical?’ The American Journal of Bioethics 18, no. 6 (June 3, 2018): 34–44. https://doi.org/10.1080/15265161.2018.1459935.). The possibility and effectiveness of these amplifying conversations relies on existing relationships, receptive colleagues, and trust built over time; these conditions may not be easily created or sustained in every context.

We had extensive conversations with leaders in the hospital's staff wellbeing team and in the Emergency Department where OVA was particularly prevalent. With these leaders, we developed the idea of conducting a collaborative research project with ED clinicians to enable a better understanding of their experiences and the values-based aspects of their decision-making in relation to OVA. The ultimate aim of the project was to develop a tool to support ED clinicians’ ethical decision-making, based on their team's shared values. We took this project concept to executive to seek their views and ensure that it was aligned with existing initiatives and plans. In bringing this project idea (and, later, results) to executive, we were also amplifying clinicians’ ethical experiences and concerns. Highlighting the moral distress, and in some cases anger, of staff added urgency to the institutional response.

Partnering with clinicians and organisational leaders to develop pragmatic and ethically robust responses at a systems level

In developing and delivering this project, we worked within existing structures, ensuring that the project team included leaders in all of the relevant organisational groups necessary to enable successful completion of the proposed work. This included members of the hospital's OVA Committee, the Emergency Department Aggression Management Committee, and the CEC. This allowed us to draw on clinicians’ lived experience of OVA, relevant expertise and institutional memory, avoid re-inventing the wheel, be alert and sensitive to challenges and current events within a broad range of clinical groups, and maximise uptake of the ethics resources generated by the project.

The aim of this project was to design a decision-making framework based on emergency clinicians’ own professional values. In the Integrative Clinical Ethics Support Model, Hartman and colleagues highlight the importance of partnership or co-ownership with clinicians to ensure that clinical ethics work meets clinician needs and is impactful.⁸ We conducted interviews and department-wide consultation sessions to develop and refine a values-based decision-making framework. (The results of this project will be reported in detail elsewhere.) Partnering with clinicians to develop tools or responses to ethical challenges involves bridging ethical theory and methods and clinical practice. In the OVA project, we first identified and articulated to clinicians the values that they already held, conceptualised in the context of the existing bioethics literature. We highlighted the ethical aspects of everyday clinical experiences, examining decision-making practices and reflecting back to clinicians the ethical values that were embedded in those practices.

We delivered these resources back to the ED staff group, using their feedback to iteratively improve the relevance and utility of the tools. We also fed the results up into various organisational bodies including leadership, based on the feedback from clinicians about the unintended harms of the organisation's response and processes. During this project, clinicians told us about various systemic issues and aspects of the organisation's approach to OVA that were difficult for them. Because of the nature of the project and team involved, these findings reached relevant organisational leaders at the highest levels.

Including leaders within our CES corporate structure enables opportunities for our service to contribute at a systems level. The then-director of the emergency department was a member of our CEC. A conversation about OVA at a CEC meeting resulted in the director requesting ethics input on a draft policy setting out the circumstances in which a patient will be evicted from the ED for violent or aggressive behaviours. This enabled integration of the relevant substantive and procedural values into the policy, informed by staff concerns and ethical theory. Having key leaders embedded within our CEC and Clinical Ethics Response Group both enables clinical ethics input and further builds ethics capabilities of these leaders.

Conclusion

A system-level focus has characterised our CES from its outset. In this paper, we have described key features of our approach to clinical ethics support – the corridor to boardroom model – with specific reference to our work addressing OVA as an ethical issue within our institution. Notably, the upstream-focussed approach reflected in our OVA work is one that we have taken more broadly from the inception of our CES, and one that has provided opportunities for the growth and development of the service through the visible impact that it achieves.

The corridor to boardroom model shares some features of the ‘Integrative Clinical Ethics Support’ model described by Hartman and colleagues, including the importance of co-ownership or partnership with clinicians, working within existing structures, and being responsive to changing clinical contexts and needs.⁸ Whereas Hartman and colleagues approach is based on an experience embedding ethics support within a specific team, here we offer an example of an approach that similarly prioritises clinician-centredness and a system-level focus for maximum impact, but on an institutional scale. We also demonstrate the application of systems thinking principles in clinical ethics work at a more granular level, which we hope will be informative to others looking to adopt a similar approach.

Footnotes

Acknowledgments

We gratefully acknowledge our CEADS colleagues past and present, and clinicians and leaders at our institution who have enabled and contributed to the development and success of the service. We particularly acknowledge Prof Vijayaragavan Muralidharan for his support, and Kat Hall, CEADS Unit coordinator, for her work establishing the processes and databases that keep our service running smoothly. We also wish to acknowledge the team involved in the ED OVA project: Meaghan Storey, Jerry Luo, Michael Geluk, Will Halpin and Jess Simionato.

ORCID iDs

Sharon Feldman

Rosalind McDougall

Ethical considerations and informed consent statements

Not applicable.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Strategic Grants for Outstanding Women scheme at the Melbourne Medical School. The ED OVA project was funded by the Avant Foundation.

Declaration of conflicting interests

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

Data availability statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

References

1.
Singer PA Pellegrino ED Siegler M . Ethics committees and consultants. J Clin Ethics 1990; 1: 263–267.

2.
New South Wales Ministry of Health, & NSW Health. Clinical ethics support: Literature review, https://nla.gov.au/nla.obj-2879888225 (2015).

3.
Fox E Bottrell MM Berkowitz KA , et al. Integratedethics. Innov J 2010; 15: 1–36.

4.
MacRae SK Fox E Slowther A . Clinical ethics and systems thinking. In: Singer PA Viens AM (eds) The Cambridge Textbook of Bioethics. 1st ed. Cambridge, UK: Cambridge University Press, 2008, pp.313–321.

5.
Singer PA Pellegrino ED Siegler M . Clinical ethics revisited. BMC Med Ethics 2001; 2: 1.

6.
Hoon E Edwards J Harvey G , et al. Establishing a clinical ethics support service: lessons from the first 18 months of a new Australian service – a case study. BMC Med Ethics 2023; 24: 62.

7.
Blake DC . Reinventing the healthcare ethics committee. HEC Forum 2000; 12: 8–32.

8.
Hartman L Inguaggiato G Widdershoven G , et al. Theory and practice of integrative clinical ethics support: a joint experience within gender affirmative care. BMC Med Ethics 2020; 21: 79.

9.
McDougall RJ Notini L . What kinds of cases do paediatricians refer to clinical ethics? Insights from 184 case referrals at an Australian paediatric hospital. J Med Ethics 2016; 42: 586–591.

10.
Guidry-Grimes L Warren M Lipman HI , et al. Clarifying a clinical ethics service’s value, the visible and the hidden. J Clin Ethics 2019; 30: 251–261.

11.
Carter BS Wocial LD . Ethics and palliative care: which consultant and when? Am J Hosp Palliat Care 2011; 29: 146–150.

12.
Delany C Hingalagoda A Gillam L , et al. Managing aggression in hospitals: a role for clinical ethicists. Clin Ethics 2020; 16: 252–258.

13.
Copeland D Arnold S . The moral dilemma of interpreting workplace violence. Nurs Inq 2021; 28: e12406.

14.
Dunsford J . Nursing violent patients: vulnerability and the limits of the duty to provide care. Nurs Inq 2022; 29: e12453.

15.
Basu S Preisz A . Family conflict and aggression in the paediatric intensive care unit: responding to challenges in practice. Clin Ethics 2022; 18: 410–417.