Nurses Create Moral Spaces to Foster Ethical Decisions

Nursing practice is an inherently value-laden endeavor in which caregivers encounter and manage myriad ethical issues in their daily practice. How do we ensure that the care provided aligns with each patient’s longstanding values? What interventions are clinically appropriate, and who gets to make such decisions?

As any nurse will tell you, the answers are seldom black and white. It is within that gray area that moral dilemmas arise, create moral distress for the nursing team and negatively affect patient outcomes.

The creation of dedicated “moral spaces” — a safe space in which nurses can openly discuss and reflect on the ethical and moral dimensions of patient care — can be an effective way to ease moral distress, explains Georgina Morley, PhD, MSc, RN, HEC-C, Director of the Nursing Ethics Program at Cleveland Clinic.

“Ethics is seldom discussed in nursing school, which is problematic in light of the increasingly complex healthcare landscape,” says Morley. “Lack of focus on moral issues creates a gap in our ethics competency and confidence that can contribute to and exacerbate feelings of moral distress.”

“Nurses struggle with ethical issues all the time, so a moral space can be an important opportunity to consider issues of right and wrong,” agrees Cleveland Clinic Nurse Manager Susan Wilson, BSN, RN, CCRN, NE-BC.

“When managing certain critically ill patients, it can be difficult to remain objective when considering all aspects of the situation. Although caregivers may use their own personal beliefs as a guide, they must also learn to honor the wishes of patients and their families.”

Building a safe harbor

To address the need for safe moral spaces, Morley and a faculty team
that includes Cristie Horsburgh, JD, Associate Director of the Nursing Ethics Program, and Clinical Nurse Specialist Dianna Copley, DNP, APRN, ACCNS-AG, CCRN, launched the Moral Spaces education program and research study in late 2022. The research team also included Nancy Albert, CCNS, CCRN, FAHA, FCCM, FAAN; Julie Gorecki, MBA, BSN, RN, NEA-BC; and Rosemary Field, MS, APRN, AOCNS, who helped provide education and mentorship. The inaugural program included 20 registered clinical nurses and assistant nurse managers drawn from 11 of Cleveland Clinic’s Northeast Ohio locations.

A second cohort began a Moral Spaces program in April 2024, which includes 26 participants. The 42-hour program combines didactic, classroom-based education with immersive, experiential opportunities such as observing ethics consultations and transplant selection committee meetings.

“We created this program so we could increase nurses’ confidence through additional education in ethics and the skills of ethical analysis,” Morley explains. “Our aim is to empower nursing staff to manage everyday
ethical issues.”

To that end, the program’s objectives include building ethical competence; mitigating moral distress; gaining confidence in speaking with patients and families about their values; and becoming better prepared to face the ethical challenges encountered in clinical practice.

Such concepts have not always been a part of nursing practice, explains Wilson, whose own nursing career spans 44 years. “In my early years, these kinds of discussions weren’t even on the radar. Now, it’s not just acceptable to have these conversations, but Cleveland Clinic expects us to do so. Leaders preach to ‘Speak up!’ all the time.”

Assistant Nurse Manager Jodi Smith, BSN, RN, works with Wilson and was a member of the inaugural Moral Spaces class. As the unit’s ethics resource nurse, Smith now feels better prepared to support and educate her staff on questions surrounding ethics and patient care.

“As an assistant nurse manager, I’m someone our staff turns to when they have questions,” Smith says. “Maybe they’re having a hard time talking to a patient’s family, for instance, or to a physician. So when this program was launched, I thought it would be a great opportunity for me to sharpen my skills and learn how to manage these difficult situations in the best possible manner. It’s helped me be a better resource person for the unit’s nursing team.”

Enlisting support

Beyond the unit’s weekly ethics rounds and her own expertise, Smith also feels confident calling on Cleveland Clinic’s ethics consultation service when further help is needed. “Their involvement in these discussions is key,” she says. “And being able to talk about difficult situations is the essence of creating moral space.”

Among the issues frequently discussed are transplant decisions, disagreements between patients and their families, challenges collaborating with family members, and end-of-life concerns.

Smith recalls a young man who arrived on the unit with his mother. “The mom wanted to be involved in her son’s care, but they hadn’t had a close relationship in years,” she explains. “The young man was terminally ill and in excruciating pain, so we ultimately concluded that continuing to treat him was causing more harm than good.”

The mother, however, was insistent on further intervention. “Although the patient was alert and oriented enough to tell us to stop, she wanted us to keep going. The situation was not only distressing for our patient, but it was also morally distressing for our unit’s caregivers,” she recalls.

An ethics consultation helped resolve the dilemma. “The mother and the rest of the family eventually came to terms with the fact that the best thing we could do for the patient was keep him comfortable,” Smith says. “At that point, the family was able to let him go peacefully.”

Wilson recalls a similarly difficult case involving a young single mom with seven children. “Jodi recognized that, while we could no longer help the mother, we could certainly help the children,” she says. Smith not only enlisted professional support for the children, but also created several keepsakes for them, including a memento of their mom’s fingerprints and a “heartbeat in a bottle” — a strip from the patient’s ECG, nestled in a small jar.

“Jodi’s actions truly helped provide a sense of closure,” says Wilson. “Maybe we couldn’t stop this mother’s illness, but at least we could help her kids go on.”

Providing clarity and closure

The freedom that comes with the program has been liberating for Wilson. “I am so glad that nursing has evolved to the point where we can talk about our feelings instead of just bottling them up,” she says. “Not long ago, it wasn’t acceptable to talk about moral distress or seek supportive resources; there simply were no resources available. Nurses are now so thankful to have an avenue that we didn’t have before.”

Smith adds, “As my nursing career has progressed, I’ve seen such incredible change. Programs like Moral Spaces are essential in helping caregivers deal with the distress that arises from ethical issues on the unit.”

The opportunity to freely examine moral issues also bolsters Cleveland Clinic’s claim as a “high-reliability” organization, Wilson notes. “This is teamwork, this is collaboration, this is great communication between nurses, physicians and families. This is everyone working together to care for the patient.”

Feedback has helped establish the Moral Spaces program as a legitimate source of education and research, says Morley. “We just finished analyzing survey data from the first cohort of nurses, who provided great feedback.” Survey responses indicated that participants found the program timing, content and duration to be highly acceptable. Importantly, nurses reported increased knowledge and confidence in ethics and their ability to provide ethical patient care.

“We also received feedback from nurse leaders and program participants about ways in which ethics resource nurses have positively affected patient care,” says Morley. “By routinely reviewing advance directives, we can alert the team about a living will, for example, and ensure that we are always using the authorized surrogate decision-makers when engaging in end-of-life decisions.”

“I’ve been here for a long time, and I have seen the evolution,” says Wilson. “When I first started, Cleveland Clinic was just a big hospital. Now it’s a globally recognized healthcare system focused on its caregivers and their ability to provide the very best in patient care. And I’m proud to say I work here.”