The Efficacy of the Nurse Ethicist in reducing Moral Distress: What can the National Health Service learn from the United States?
Having first been introduced to nursing thirty years ago, moral distress (MD) is not a new concept. Despite this, research regarding moral distress has been largely absent from nursing literature within the United Kingdom (UK), yet it has received increasing research interest in the United States (US). Nurse researchers in the US have sought to understand moral distress and are developing ways in which to reduce moral distress and its effects. With the support of The Florence Nightingale Foundation and The Royal College of Nursing Foundation, the author of this paper travelled to various institutions on the East Coast of America to meet nurses leading the field of research into moral distress. The author learnt first-hand the ways in which these nurses are working to reduce moral distress at the individual, team/unit and organisation/institution level.
Drawing upon both the author’s experiences whilst in the US and the current literature, the ways in which moral distress is being addressed will be discussed. These findings suggest that the UK needs to identify in what form moral distress exists amongst UK nurses. Once the nature of moral distress in the UK is understood, we can begin to develop ways to address moral distress and its effects. It will be argued that the role of the nurse ethicist is worthy of replication within a UK context. Although the role of the ‘nurse ethicist’ remains uncommon in the US, the term ‘nurse ethicist’ is utilised more widely within this article to include nurses who are also working as Healthcare Ethics Consultants (HEC) and are active within Clinical Ethics Committees (CECs).
In addition to supporting the role of a nurse ethicist, it is suggested that the NHS ought to implement CECs more widely and adopt the use of ethics consultations, to bring ethics to the bedside, to formally discuss ethical issues, and ultimately reduce moral distress. The nurse ethicist therefore provides a unique opportunity to help bridge the gap between individual and organisational ethics, acting as a moral compass to guide nurses at all levels (Wocial et al., 2010a).
It was found that moral distress often operates across three levels (individual, team/unit, and organisation/ institution), and that the most effective way to reduce MD is to target its effects across the three levels.
In order to reduce moral distress at an individual level, a number of assessment strategies were first developed. I was able to meet with Professor Rushton and Dr Wocial who have developed and piloted assessment tools, enabling individuals to recognise and measure the level of MD at a certain snapshot of time. These tools could potentially assist in both identifying factors that contribute to MD, and testing the effectiveness of interventions designed to alleviated MD and could be important first steps in the UK to both introduce and legitimise the concept of MD. (Wocial and Weaver, 2013).
Both mindfulness and resilience are gaining traction within the nursing literature as ways in which nurses can care for themselves and thereby reduce stress and burnout (Cohen-Katz et al., 2004). Mindfulness teaches the skill of being present with awareness, acceptance and attention, aiming to reduce judgements and expectations so that one can foster a more compassionate approach (White, 2014). I was able to participate in The Compassionate Care Initiative (CCI) at The University of Virginia (UVA) directed by Professor Susan Bauer-Wu. The aim of the CCI is to nurture compassionate care amongst the UVA healthcare community, with the belief that nurses will practice compassionately when they are also able to take care of themselves. By teaching nurses to practice mindfully, they are given the tools to reduce their stress, enhance collaborative relationships and regulate their emotions. The CCI offers drop-in sessions of mindfulness, meditation, yoga and tai chi.
In order to reduce MD at a team/ unit level, nurses in the US are able to request ethics consultations. The goal of a traditional ethics consultation is to find a patient-focused ethical resolution to a moral dilemma or in the case of moral uncertainty. Although an ethics consultation does not in itself diminish MD, it is believed that the process of consultation can (Wocial, 2002). Since ethics consultation promotes open and honest communication amongst the team, moral distress can be reduced at the team level by opening channels of communication and building more collegial and trusting relationships. On an individual level, the ability to openly discuss concerns diminishes frustration and feelings of powerlessness
I had the opportunity to spend a week with Dr Lucia Wocial, nurse ethicist at Charles Warren Fairbanks Center for Medical Ethics (FCME). Dr Wocial facilitates unit-based ethics conversations (UBECs). Unlike ethics consultations, UBECs were developed as a direct response to the growing issue of MD, and the need for meaningful conversation amongst bedside nurses regarding the ethical issues they face in clinical practice (Helft et al., 2009). Building upon the hypothesis that nurses are more likely to utilise resources that are unit based, the focus of a UBEC is on the participant’s needs, not the patients (Wocial et al., 2010b). UBECs are informal group conversations and in most instances only nurses are present. Like ethics consultations, UBECs are thought to reduce the effects of MD at an individual and team level.
Other institutions have developed similarly targeted approaches to reducing MD. At Johns Hopkins Hospital, Professor Rushton facilitates moral distress conversations for requesting healthcare professionals. Often these occur at the time of, or following a particularly ethically challenging case and enable time to reflect upon the pertinent issues. Whilst at UVA, Dr Epstein and her colleagues provide both a moral distress consultation service in order to assist healthcare professionals during times of severe moral distress. All of these strategies provide the opportunity for healthcare professionals to respectfully discuss their concerns regarding the moral aspects of certain cases, issues can be clarified and further teaching provided (Wocial, 2002).
In order to address moral distress at the institutional/ organisational level there is increasing emphasis upon creating institutions that are conscientious of their ethical practices. Research highlighting the important links between MD and hospital ethical climate is growing. In the US study by Whitehead et al (2014), a shortened version of Olson’s Hospital Ethical Climate Scale (HEC-S) was used to measure healthcare professionals perception of their institutions ethical climate. HEC-S mean scores were negatively correlated with MDS-R scores (p<.0001), indicating that higher perceptions of the hospital’s ethical climate were associated with lower moral distress scores. Although these findings do not establish causation, they suggest that improving the ethical climate across the entire institution can reduce MD at an organisational level, not just at a team or individual level.
In the US, CECs and CEC members are increasingly integrated into the organisational infrastructure of institutions (Doyal, 2001). CECs oversee the provision of ethics consultations, review cases, develop and revise existing policies pertaining to clinical ethics, such as informed consent or withdrawing life-sustaining treatments, and facilitate ethics education (Caulfield, 2007).
McClimans et al. (2012) argued that utilising Clinical Ethics Committees could improve the quality of care in UK hospitals, as they would support hospital trusts to fullfill the quality improvements asked of them by the Care Quality Commission (CQC). Utilising the recommendations of The Francis Report as their example, McClimans et al. (2012) highlight the ethical implications of many hospital deficiencies, for example in the case of Mid-Staffordshire, a lack of provision of compassionate care. They discuss how the provision of quality care necessitates that ethical standards must be upheld. According to McClimans et al. (2012) there are currently 82 CECs in the UK providing ethics education, consultation and policy development, but this number needs to grow if we are to develop the ethical climate of UK hospitals and reduce the potential for MD amongst UK nurses.