Addressing 21^st Century Nursing Ethics: Implications for Critical Care Nurses

Introduction

Ethical challenges are embedded into everyday nursing practice. Nurses in all specialties and roles confront ethical challenges as they strive to uphold their personal and professional values and balance their commitments to patients and their loved ones, inter-professional colleagues, the organizations where they practice and to the broader society. Many nurses demonstrate courageous advocacy by employing exquisite ethical reasoning skills, respectful communication, and compassionate actions. Unfortunately, too many others report feelings of despair and powerlessness after repeated experiences of moral distress while caring for patients and their families in systems where their voices are silenced or disregarded.

The impact and urgency of addressing ethical issues nurses face is intensified in the context of internal and external pressures that threaten the integrity of nurses, the profession and the people they serve. Disparities in access to health care, goals of care at the end of life, resource distribution and threats to respect, dignity, quality and safety are common issues that keep nurses up at night and contribute to a growing prevalence of moral distress. The effects of moral distress result in negative outcomes for nurses including coping strategies such as distancing oneself from the patient,^1-3 withdrawing from providing care,^2-4 and leaving positions or the profession.^4-7 These negative outcomes are particularly salient as the burgeoning needs for health care are outpacing the nursing workforce.

Yet many nurses are unprepared or lack confidence in their ability to recognize and address these ethical challenges. Our educational systems in nursing lack robust curricula in ethics, practice settings have an insufficient ethics infrastructure to support nurses to address ethical concerns, organizational and public policies may undermine ethical practice and the evidence base for ethical practice is inadequate to guide nurses. With the landmark Future of Nursing⁸ report largely silent about the ethical aspects of nursing and the convergence of complex professional, health care, and societal forces that challenge the ethical foundation of nursing, it is urgent that the profession pause to consider it's ethical foundations anew and commit to a robust agenda to strengthen the ethical core of the profession.

A National Nursing Ethics Summit

In August 2014, 50 nursing leaders including nurse ethicists and representatives from key nursing organizations, participated in a national summit on Nursing Ethics for the 21st Century, sponsored by the Johns Hopkins School of Nursing and Berman Institute of Bioethics. The goal of the Summit was to identify the strategic nursing ethics priorities for the profession and create a blueprint for the future. The intention was to engage key individuals, professional organizations and societies to adopt and implement the recommendations to build capacity within nursing and create and sustain a culture of ethical practice so that everyone is able to do the right thing, for the right reason, at the right time.

Despite the complexity and rapid change in health care and the nursing profession, nurses in all roles and specialties remain committed to serving patients and their loved ones and communities while fulfilling their professional responsibility to uphold nursing values. With the recent revision of the ANA Code of Ethics for Nurses,⁹ bringing the ethical foundation of the profession into everyday practice and integrating ethics into the strategic agendas of the leading nursing organizations is a vital step to secure nursing's future. These steps are vital to create a culture of ethical practice that keeps clinicians at the bedside and mitigates negative patient and clinician outcomes. Summit participants concentrated on ways nursing and ethics intersect in four critical domains: clinical practice, education, research, and public policy. They identified priorities in each of these domains and created a blueprint for the future in order to:

• Develop and sustain work environments that support ethical nursing practoce

• Promote excellence in nursing ethics education

• Create a research agenda that will lead to a culture of ethical practice in diverse care settings and

• Foster an ethical health environment by developing resources, policies, metrics (outcomes), education, training, and research.

As an outcome of the Summit, major nursing organizations representing more than 700,000 nurses and several other healthcare-related partners have already taken a leadership role by endorsing the vision statement created in spirit of the Summit and pledging their commitment to taking definitive steps to implement the recommendations outlined in the blueprint for action.

Implications for Critical Care Nurses

The “Blueprint” offers critical care nurses a broad agenda for engagement, advocacy and principled action. Critical care nurses are ideally situated to lead and contribute to developing and implementing a new paradigm for ethical practice in health care. Efforts to improve the ethical environment for nurses have a direct impact on the quality of care provided to patients and families and the sustainability of the health care system. We are at a critical juncture in health care as the needs of aging people, people with acute illness and injury, chronic conditions and highly contagious infections are expected to exceed the available workforce. Keeping trained critical care nurses at the bedside is vital for the sustainability of the health care system. Moreover, moral distress is a pervasive reality for nurses when they are unable to translate their moral choices into action because barriers prevent them from practicing in accord with their values. Critical care nurses know first hand the impact of moral distress on individual nurses, teams, patients/families and organizations. They are uniquely poised to work together to develop innovative solutions that support resilience and ethical competence.

There are significant gaps in nursing ethics education across the continuum from pre-licensure, advanced degrees, and continuing education. Critical care nurses at the bedside can be leaders in designing ethics curricula for orientation and continuing education. Ethics curricula that can be customized for specific critical care settings such as medicine, surgery or pediatrics that can be delivered in user -friendly formats hold great promise.

Policy development holds great promise to understand norms, practices, and drivers of health care to identify the root causes of nurses and other health care professionals’ inability to practice ethically. This will take a concerted effort to identify, compile and categorize existing policies, standards, guidelines, codes of conduct and best practices that contribute to a culture of ethical practice. Building on the American Association of Critical-Care Nurses (AACN) standards for a healthy work environment,¹⁰ AACN members are poised to lead and contribute to a new vision for critical care that is grounded in an ethical culture.

Research about the ethical issues that nurses face, especially in critical care is insufficient to design evidence-based solutions to some of the most complex ethical challenges. Focused programs of research are needed to begin to expand our philosophical, theoretical and empirical understanding and guide the development of innovative interventions to support nurses to practice ethically. This will require creative funding strategies, development of cross disciplinary tools and metrics to measure outcomes of ethics focused research and collaborative inter-professional initiatives.

These are only a few opportunities contained in the Summit report.¹¹ All critical care nurses are invited to review the report to identify areas that are aligned with their specific concerns and leverage the vision and contents of the Summit report for innovative and sustainable change.

Be an Ethics Ambassador: Be the Change You Want to See in Your Practice

One of the intentions of the National Nursing Ethics Summit is to be a catalyst to raise awareness and demonstrate principled action. Leverage the Blueprint to engage yourself and others in exploring what keeps them up at night and identifying innovative, out of the box solutions to address issues. There is great room for creativity – the recommendations are not the end point; rather they are the beginning of a dialogue, and you can lead it!

10 Ways for Critical Care Nurses to Commit to Action Right Now

1. Sign the pledge and invite others to do the same: http://www.bioethicsinstitute.org/nursing-ethics-summit-report/sign-the-pledge-2

   1. Commitments you can make include:

      1. Communicate the vision to other nurses and inter-professional colleagues
      2. Courageously advocate when there is an ethical concern
      3. Speak up to strengthen a culture of ethical practice
2. Leverage the Summit and its recommendations for change. Partner with AACN members and chapters, health care organizations, universities, policy makers and researchers to explore how you might build on the Nursing Summit recommendations to create your own local blueprint for ethical practice.

   1. Share the vision with your unit and encourage your colleagues to sign on
   2. Share the Blueprint and the vision with nursing leadership at your organization
   3. Disseminate to other nursing units / specialties
   4. Contact local AACN chapter leaders and enlist their support for disseminating the pledge and the summit recommendations

In the Next Month

• 3Systematically document the situations and cases that cause ethical concerns and moral distress. Use the Summit review of the literature as a starting point for developing an evidence base to support your concerns.
• 4
  Develop mechanisms in your practice area to discuss ethical concerns such as ethics rounds or facilitated ethical conversations.¹²

  • Embed ethical practice questions in daily patient care rounds. Ask questions such as:

    • ○ Are there ethical questions that need to be addressed? Is the plan of care, diagnosis and prognosis clear?
    • ○ Has adequate communication occurred with the patient and family?
    • ○ Are the patient's pain and other symptoms being managed optimally?
    • ○ Has the patient's resuscitation status been addressed?
    • ○ Does the patient have decision-making capacity?
    • ○ Is there an advance directive? Who is the designated health care agent?
    • ○ Do the other members of the inter-professional team have ethical concerns?
    • ○ Is there a tone of conflict or confusion about the patient's or team's goals of care?
• 5
  Expand your knowledge and skills in ethics—start a journal club, ethics education series, pursue formal training in bioethics and/or clinical ethics consultation. Use the newly revised ANA Code of Ethics for Nurses as a foundation(http://www.nursingworld.org/codeofethics)

  1. Include ethics content in orientation and continuing education
  2. Assess the ethical climate in the organization where you practice
  3. Perform a knowledge needs assessment regarding common ethical issues
• 6
  Become a member of your hospital's ethics committee or consultation service. Offer your clinical expertise as a valuable resource for supporting the organization to develop robust structures to address ethical concerns and conflicts.

  1. Begin inter-professional ethics rounds
  2. Partner with the Ethics Committee and/or ethics consultants to develop triggers for ethics consultation
  3. Adopt systematic tools to examine cases and explore concerns
  4. Commit to monthly or bi-monthly inter-professional dialogue
  5. Monitor cases that cause ethical concerns or moral distress
• 7Review of organizational policies / practices surrounding ethical practice. Inquire into the rationale for policies that create barriers to ethical practice or that silence the voice of nurses and others in the dialogue about ethical concerns. Offer constructive, evidence based alternatives.

In the Next Three Months

• 8Conduct research and quality improvement projects on ethical issues that commonly arise in critical care, individual or systems interventions to address specific concerns, or develop new conceptual or theoretical models for addressing them.
• 9Create a learning community on your unit, in your organization and nationally. Share your ideas and successes with others: http://www.bioethicsinstitute.org/nursing-ethics-summit-report/stories-of-change

Every Day

• 10Live your ethical values in every decision, action and conversation you engage in. The most powerful change agent is YOU!

Summary

Creating a culture of ethical practice is vital for all nurses and more importantly for the people we serve. Commit to the vision and stand together to strengthen our resolve to live our values in each moment and to develop and sustain a culture where every critical care nurse can make his or her optimal contribution by practicing ethically.