Making the Ethics Call Benefits Nurses and Patients

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Indicators of Ethical Issues

Nurses can identify a number of early indicators of ethical issues, according to a study by Carol Pavlish, Ph.D., RN, FAAN, Katherine Brown-Saltzman, MA, RN, and their co-investigators.* These indicators include:
  • Vulnerability of a patient
  • Signs of conflict
  • Nursing distress
  • Signs of patient suffering
  • Ethics rules violations
  • Unrealistic expectations
  • Signs of poor communication
Early Indicators and Risk Factors for Ethical Issues in Clinical Practice. Pavlish C., Brown-Saltzman K., Hersh M., Shirk M., & Nudelman O., Journal of Nursing Scholarship. 2011 Mar;43(1):13-21.  

By Megan M. Krischke, contributor

Katherine Brown-Saltzman, MA, RN, co-director of UCLA Health System’s Ethics Center encourages nurses to find out what resources are available to them so they know what to do when an ethical situations arises.

July 5, 2011 - “Nurses are dealing with ethical issues every day, but they aren’t always aware of it,” said Katherine Brown-Saltzman, MA, RN, co-director of the UCLA Health System’s Ethics Center. “As a nurse, you are the scarce resource. As you plan your day and decide who, and what, will take priority, those are ethical decisions. Of course these are not the issues that get taken to the ethics committee, but I think it is important for nurses to understand that ethics touch everything they do.”

Nurses should also be aware of the ethics resources available to them in their own organizations. Depending on the size of the facility, resources could range from a single ethicist to an ethics committee, to having nurses on their unit who serve as liaisons between the unit and the ethics committee.

According to Brown-Saltzman, knowing what resources are available when an ethical issue arises is so important that she encourages nurses to ask about it during job interviews and to allow the answer to influence their decision about where to accept a position.

She considers the topic of great importance because when nurses are in a situation in which they have a sense of the right thing to do, but are unable to do it for any variety of reasons, it causes moral distress. And moral distress can build in a person until it results in everything from burnout to absenteeism to disconnecting with patients and patients’ families.

“For many years nurses felt this unnamed frustration and fatigue—what we have come to know as moral distress,” stated Heather Fitzgerald, BA, BSN, RNC, clinical nurse ethicist at Children’s Hospital Colorado in Aurora. Children’s uses nurse liaisons from each unit who work with the ethics committee. “Nurses may feel limited in their ability to address an ethical situation for any number of reasons including workplace dynamics, cultural issues, fear of repercussions or even self-imposed obstacles such as being afraid that they won’t be able to communicate clearly what is bothering them.”

“What we see clearly in the research is that taking action decreases the effects of moral distress. Even when the outcome wasn’t what the nurse hoped for, when the nurse took action by going up the chain of command or requesting a committee review or contacting the ethicist, moral distress was decreased,” explained Brown-Saltzman.

“We want nurses to know that when they have a gut feeling that something isn’t right they can approach one of the nurse liaisons. Because these liaisons have received additional training in ethics they can help evaluate whether the situation is something that can be handled on the unit or if the ethics team should be called on to help support the discussion,” stated Fitzgerald.

“The opportunity for a safe place and method to examine how we feel, explore the ethical questions, test our assumptions and continue to grow in our nursing practice serves to fill the tank, rather than drain it,” she added. “These cases are extremely complex and don’t often resolve with a lot of closure. The chance to find some kind of meaning, identify some way these patients and families might teach us about what we do well—and what we have yet to learn in our care of them—is very valuable.”

In addition to lessening nurses’ moral distress, calling on the services of the ethicist or the ethics committee can ease the burden for everyone involved.

“Bringing in a third party can slow down the conversation and create a moral space for communication between family members and/or clinicians that wasn’t there before,” Brown-Saltzman stated. “Sometimes just having the ethics person present to reframe the situation around ethical issues helps all the parties to see more clearly.”

“Also, because some situations have such grave consequences or are such a complex ethical dilemma— where no matter what you do there will be harm and significant consequences—having that greater committee representing many different values and disciplines, including lay members, creates a system of checks and balances and can help the clinicians, the family and the community carry the decision,” she continued.

Brown-Saltzman urges nurses not to use a call to the ethicist as a threat wielded over others, but to work collaboratively, presenting ethical concerns to the team by talking about why a consult will be helpful. Ideally, with the focus on excellent care, everyone should feel fortunate to have the assistance of the ethicist or ethics committee.

She also cautions against thinking that a call for ethics help will result in an immediate solution.

“Ethics is process oriented,” she emphasized. “There is rarely an absolute right answer. Often you are choosing between greater harms. Additionally, an ethics committee has no more power than that of a consultant. They will outline what they see as being the key ethical issues and make recommendations, but they can’t force the hand of clinicians.”

“Excellent clinical care of patients and families is both an art and a science,” reflected Fitzgerald. “Deepening our ethical skills helps us practice the art of patient care. It sometimes feels like we don’t have time in our fast-paced clinical settings to think about the art of care, but it is essential we do. When we do this well, communication is significantly improved. The result is that staff, patients and families are much more cohered as teams and much more satisfied with the experience.”

“And ultimately, this is all about the care of the patient and their family,” she continued. “There are safety aspects, there are team communication and dynamics and operational elements. It serves health care institutions to really support open, effective communication around the difficult aspects of any ethically challenging case because it benefits the patient and their families as they have to be engaged in this process, as well.”

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