New Program Empowers Nurses to Manage Ethical Dilemmas in Clinical Settings

Ethical considerations are foundational to excellence in nursing, but the COVID-19 era has forced ethics to the forefront like few other times in history. Cleveland Clinic’s new Nursing Ethics Program offers specialized support to help nurses manage the ethical dimensions of their practice in the context of the pandemic and beyond.

Georgina Morley, PhD, is a staff ethicist in the Center for Bioethics and Director of the newly established Nursing Ethics Program. The program solidifies the growing partnership between the Center for Bioethics and the Nursing Institute. In addition to new tools and scholarship, it builds upon nurse-focused initiatives developed by Associate Director Cristie Cole Horsburgh, JD.

Ultimately, Morley says, guiding nurses in the framing of ethical challenges improves wellbeing for both patients and caregivers.

“My hope is to create and sustain a network of nurses who have expertise in exploring the ethical dilemmas of patient care through the lens of nursing practice,” Morley says. “The program is still in its beginning phase, and I am looking at ways to build and develop it, but that’s my goal.”

Morley suggests that some of the challenges of COVID-19 have stoked a rise in moral distress among healthcare workers. Because nurses perform so many patient-facing functions, they are especially likely to experience moral distress during the pandemic.

Types of moral distress

Moral distress is the psychological discomfort that occurs because of a moral event, Morley explains. The distress arises from a variety of sources.

• Moral constraint distress is experienced when a caregiver believes they know the right thing to do but isn’t able to carry it out. This often occurs when caregivers believe they are exacerbating a patient’s suffering rather than providing benefit. They feel constrained from doing what they believe is right.
• Moral uncertainty distress occurs when a nurse doesn’t know the right course of action and often occurs when they face an ethical dilemma because two or more options feel equally bad.
• Moral conflict distress arises when the nurse disagrees with someone else on the care team, the patient or a family members decisions.

“I also hypothesize there’s moral tension distress,” Morley adds. This occurs when a nurse feels uncomfortable about an ethical situation but can’t name the source of discomfort. Newly graduated nurses, for example, might not have the experience necessary to articulate what feels wrong.

Ethical issues have always been part of nursing, Morley says, but the pandemic has highlighted and exacerbated them. The allocation of limited resources raises ethical questions. Nurses facilitate final goodbyes via iPad. They watch some patients die without loved ones nearby. Ethically sound policies aimed at protecting the community from the virus mean fewer or no visitors.

Nurses bear the brunt of enforcing such restrictions.

“At Cleveland Clinic, we obviously have amazing ombudsmen, and we have people at the doors to make sure that our caregivers are kept safe, but having to educate and reiterate that we have rules is extremely difficult,” Morley says. “And it’s obviously difficult for families to accept when they know their loved ones are very sick and they can’t be with them 24/7 like maybe they would have been months ago.”

How the Nursing Ethics Program assists

It’s important to Morley that nurses see the program as a resource that includes new supportive activities, such as nursing ethics huddles.

“I was rounding on one of the units and somebody mentioned a patient that we might be seeing. They grabbed a nurse and said, ‘Hey, Ethics is here,’” and the nurse said, ‘Oh no!’ I said, “You’re not in trouble!’” “I want nursing and other caregivers to know that the staff ethicists in the Center for Bioethics provide a consultative service to help them navigate ethically complex cases. We are not the ‘ethics police.’”

Morley and program faculty member Dianna Copley, DNP APRN-CNS conduct nursing ethics huddles. “We’re trying to make time and space to speak with nurses to ask, ‘Are there any ethical issues going on with your patient at the moment? Let’s have a chat about those.’”

There’s no need to wait, however. Caregivers experiencing moral distress can meet with a clinical ethicist who can then create a safe space to talk about the ethical issues arising for them. “We also provide moral distress reflective debriefs in partnership with Caring for Caregivers,” Morley says. These sessions usually take place on clinical units so that nurses and other caregivers can drop in and talk about the challenges they are facing. It is not a root cause analysis, Morley says, but “we often have some action points for them that will come out of the debrief.”

Guidance takes different forms. In some situations, Morley says, there is a clear right thing to do, and the ethicist’s role is to hear from stakeholders and provide ethically supportable recommendations. In other situations, the recommendation includes more than one supportable option.

Either way, ethicists can bring new perspective to a case. “We’re not embedded in the same way that the team is with the situation,” she says. “We can take that step back and, using our ethics expertise, say ‘here are some suggestions.’ Then we’re placing the power back in the team’s hands.”

More than wellness

While moral distress hinders nursing caregivers’ sense of wellbeing, Morley notes that it’s important to distinguish the role of the Nursing Ethics Program.

“The tagline we have for the program is ‘Helping Nurses Thrive,’” she says. “There’s a link between morality and wellbeing, but there is a danger about seeing this as just about wellness and mental health. It’s about moral wellbeing and how we support caregivers and nurses to be the best practitioners in the everyday. Every interaction that a nurse has with a patient has the potential to have ethical repercussions.”

For more information, contact Georgina Morley at morleyg@ccf.org.