We all know that nurse administrators should be helping to promote core ethical principles in nursing practice. After all, the American Nurses Association (ANA) Code of Ethics for Nurses places ethical concerns right at the center of nursing practice throughout its nine provisions.1 In addition, for Magnet®-designated hospitals, nurses must also demonstrate application of ethical principles, including how to use available resources, such as the ANA Code of Ethics, to address ethical issues.2 According to a study exploring moral distress in RNs, qualitative data suggested that RNs requested changes to and more information regarding biomedical ethics, ethics rounds, and ethics consultations.3 Not surprisingly, a vast amount of literature has emerged on nursing ethics and related areas. Despite this, relatively little literature exists on how nurse administrators can practically promote core ethical principles in day-to-day nursing practice.
We describe the contributions of the nurse administrator to our ethics committee's efforts of consultation, education, and policy development and how that involvement helped to promote core ethical principles in daily nursing practice at our facility.
The nurse administrator and ethics consultation
Our hospital is a 750-bed Level I trauma center in Northeast Ohio. We have burn, surgical, medical, and pediatric ICUs. Additionally, we're a Level III perinatal center, with a 49-bed neonatal ICU. As a county facility, we're the de facto safety net for all county residents and have as part of our mission the commitment to serve all regardless of ability pay.4 Our clinical ethics committee is, like most, an interdisciplinary committee that includes physicians from major clinical departments and representatives from pastoral care, social work, legal, and nursing. Our committee has a typical threefold mission of consultation, education, and policy development/review. Our experience suggests that the nurse administrator can play a valuable role in each of these areas.
Our ethics committee provides consultation on individual clinical cases, and the patient, family, surrogate, or anyone involved in the care of a patient can request a consult. We average 40 to 50 consults annually and nurses are the driving force behind many consult requests.5 Our consult service uses a “mixed model” for consultation, meaning that we employ an individual, small team or the full ethics committee when responding to a request for consultation on an as needed basis. A mixed model allows for a multidisciplinary approach with all of its inherent advantages—shared responsibility for topical knowledge, competencies, and the recommendations made to the care team and diverse expertise that can be tailored to the situation—while retaining flexibility in scheduling consults for timely response and avoiding the potentially intimidating nature of a full committee response.6
While utilizing a mixed model, we most commonly employ what we've termed elsewhere as an adaptive, small team approach, and it's here that the nurse administrator plays an especially important role.5 Our team consists of an ethicist (a member of our Center for Biomedical Ethics staff) and a nurse administrator, plus at least one other ethics committee member. Committee members who round out the consult team may include one or more people from a number of areas, including, but not limited to, legal, social work, pastoral care, adolescent medicine, child-life, and emergency medicine. Selection of the appropriate members for the small consult team is determined based on the circumstances of the case and who might offer the needed expertise, experience, and benefit, as well as on the availability of ethics committee members.
A typical step in our small team approach is to first meet with the healthcare team involved with the patient's care to discuss ethical concerns, consider appropriate options, and increase knowledge of and sensitivity to the ethical dimensions of treatment and care. The healthcare team normally includes the attending physician, medical resident, nursing staff, and a social worker or care manager familiar with the patient. Here the ethics committee nurse administrator is instrumental in getting the staff nurses to attend and coaching the nurse on his or her role in presenting the patient's issues. The mere presence of a nurse administrator can help nursing staff members to feel more comfortable offering their perspectives on the case. With encouragement and role modeling from the nurse administrator, nursing staff members are better able to participate and learn about the consult process. Additionally, the ethics committee nurse administrator's office phone number is listed as a resource for nurses to call if an ethical dilemma emerges. Nursing staff, having more connection and familiarity with the nurse administrator, often call her office first to discuss a developing situation. The nurse administrator uses the opportunity to discuss the consult process and prepare the nurse(s) for the team discussion.
The participation of the nurse administrator in ethics consultations also provides insight into the patient-care issues clinical nurses struggle with on a regular basis. One example of this from our experience involves the ethical challenges of caring for the chronically nonadherent patient. It became evident after a series of consults that some of our patient-care areas were struggling to address chronic nonadherence to plans of care by certain patients. In some cases, patient behaviors were so severe that they were having a serious adverse effect on the ability of the team to provide care according to established standards. Chronic nonadherence in many cases was compounded by inappropriate behavior toward nursing staff and other patients on the unit. To address this issue, the ethics committee, at the urging of the nurse administrator, convened a subcommittee with the goal of assembling tools and creating guidelines for dealing with chronically nonadherent patients in ways that both respected their autonomy and encouraged better adherence by patients who genuinely wanted to benefit from medical care.
In addition to the nurse administrator, the subcommittee included an ethicist (the chair of the ethics committee) and the committee's social worker representative. The subcommittee convened regularly, met with nurses in areas where the greatest challenges existed, consulted with experts in pain management and behavioral modification, and reviewed the literature. Ultimately, the subcommittee developed guidelines for addressing chronic nonadherence with support tools that included strategies for determining behavioral expectations, consequences of sustained nonadherent behaviors, and expectations of the healthcare team. The nurse administrator's participation on the ethics committee and as part of the consult service was central to helping our institution develop guidelines for addressing one of the very challenging ethical issues facing nurses in day-to-day practice.
The nurse administrator and ethics education/policy
One of the identified goals of our ethics committee is to provide an annual systemwide educational program on an ethical issue. Our experience suggests that the nurse administrator can play a valuable role here. For example, the guidelines for addressing ethical challenges raised by caring for chronically nonadherent patients became the focal point for systemwide ethics committee educational efforts the year after they were developed. Two other educational efforts are also worth highlighting.
The first of these was on professional boundaries and self-disclosure, which emphasized the fiduciary responsibility of nursing staff to maintain professional boundaries with patients and focused specifically on the appropriate and inappropriate use of self-disclosure with patients. This topic was adopted, in part, because of nursing administration's awareness of the challenges in daily nursing practice of maintaining professional boundaries given the amount of time nurses typically spend with patients and their families.
The nurse administrator took the lead in developing our nursing-specific presentation, which was then tailored by several members of the ethics committee to address their particular professions' concerns (social work and medicine, among others). The ANA Standards of Professional Performance for Nurses were used as the foundation for this presentation. The program was first presented by the chair of the ethics committee and the nurse administrator from the ethics committee at an annual national nursing conference hosted by our facility titled, Nursing: Understanding Today and Preparing for Tomorrow. The topic was later presented at an annual education day, attended by all nurses, and for each new orientation class throughout the year.
The second educational topic focused on health professionals, in general, and nurses, in particular, caring for family members or significant others in their professional role in the hospital setting. Importantly, this topic was selected after requests by nurse managers to the nurse administrator for the ethics committee to give them guidance regarding how to handle situations in which a family member of a staff nurse was admitted to the nurse's unit. Concerns regarding patient confidentiality, autonomy, and nursing judgment were identified as possible issues.
In preparing to respond to the nurse managers, we discovered that the Nurse Practice Act of our state doesn't prohibit caring for family members, in contrast to the American Medical Association's statement that recommends physicians shouldn't care for family members.7,8 However, the Act does recognize that individual hospital policy may offer direction. We determined that there was wide variation in practice regarding staff members caring for their own families throughout the system based primarily on the judgment of individual nurse managers.
The presentation involved a series of actual and hypothetical cases selected to raise the issue, asked participants to identify the pros and cons of nurses caring for family members in the hospital setting, and then highlighted some of the ethical considerations in addressing this issue. The latter were drawn from the ANA Code of Ethics for Nurses and the core ethical principles of autonomy, beneficence, nonmaleficence, and justice.
The Health Professionals Caring for Family Members educational initiative illustrates yet another potentially valuable contribution of the nurse administrator to ethics committee activities—helping to inform ethics-related policies. This educational initiative ultimately led to the creation of a systemwide policy addressing this issue for all levels of direct care providers. Based on feedback from the educational sessions and application of both the ANA standards for practice and guiding ethical principles, the policy states that staff shouldn't care for family members. Solutions include not admitting the family member to the nurse's floor if the standard of care can be maintained on another unit. If the standard of care can't be maintained on another unit, such as the neonatal ICU, then the nurse isn't assigned to the family member.
Although this particular policy, like the guidelines for dealing with chronically nonadherent patients, was especially driven by nursing concerns, it's clear from our experience that the nurse administrator can play a valuable role in serving as a conduit for nursing concerns that are relevant to a host of other ethics-related policies. For example, revision and clarification of do-not-resuscitate, informed consent, and end-of-life decision-making policies, just to name a few, all require focused and sustained nursing input.
A step in the right direction
Although the possibilities for nursing administration to interface with the ethics committee at any particular institution will vary, we hope that our experience shows that such an interface is well worth developing. This is critical if the ANA Code of Ethics or the rigorous criteria required for Magnet designation are to be taken seriously. It's our hope that this small first step will serve to stimulate further discussion of how nursing administration and the ethics team can work together to improve nursing practice and, ultimately, benefit the patients, institutions, and communities we serve.