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Tweet your conscience

Twitter discussions and an upcoming summit are providing platforms for nurses to voice their concerns about ethics, organiser Cynda Rushton tells Amie Larter.

“The time is now for nurses to stand together to address some of the most vexing questions in healthcare with a clear moral compass and effective advocacy.”

These are the words of Cynda Hylton Rushton, the Anne and George L. Bunting professor of clinical ethics at Johns Hopkins University Berman Institute of Bioethics.

The Berman Institute, and the university’s school of nursing, have partnered with nursing organisations to launch a dialogue aimed at understanding “the contours of the ethical challenges that face the nursing profession”.

“Nurses have an ethical mandate to advocate on behalf of the patients and families they serve,” Rushton says. “This requires skillful discernment, ethical reasoning and bold, clear communications. Urgent change is needed and we are now poised to move from talking about our values to living them.”

The Nursing Ethics Summit will be in mid-August, where an expert working group will “articulate a comprehensive and strategic agenda for nursing ethics in the 21st century”.

During the group’s latest Twitter conversation, Nursing Review’s Twitter feed was flooded with the hashtag “NursingEthics”. We spoke to Rushton to find out why nurses are so keen to join the conversation.

NR: We have been following your #nursingethics series on Twitter.What first prompted you to start this campaign? 

CR: In advance of the Nursing Ethics Summit, we are using social media-based outreach and engaging with a broad and diverse group of stakeholders to raise awareness about the project and, more importantly, to begin the essential work of identifying the most pressing ethical challenges confronting nurses.

We want to learn about what keeps nurses up at night. What ethical challenges do they confront in their practice and on the horizon? And [we want] to understand [how] to create an environment where nurses can practise ethically and with integrity.

The primary platforms for this #NursingEthics engagement are our biweekly Twitter chats (we have additional chats scheduled for July 15, 29 and Aug 12) and our nursing ethics blog (http://bit.ly/Tm5OVn).

We are confident that our social media-based efforts to collect experiences, insights and the collective wisdom of nurses will enrich the process as we move towards a nursing ethics blueprint for action.

Are there any particular areas that nurses are struggling with more? Why?

Nurses around the globe are struggling to reconcile their obligations to their patients and families, their colleagues, the institutions where they practise and themselves. Many grapple with ethical challenges related to: the meaning of respect and dignity in an increasingly diverse population; new challenges regarding privacy in the face of unbridled access to information; informed consent in the context of profound gaps in knowledge generation and translation; confusion about how to reconcile differences in goals and preferences for people with chronic conditions and at the end of life; and an ever-growing concern about the impact of moral distress and threats to integrity on the recruitment and sustainability of the nursing workforce.

Nurses see firsthand the impact of policy decisions on the people they serve. The changing focus and structure of healthcare – specifically the financing of healthcare, the role of insurance and pharmaceutical companies and other enterprises – has created new and intensified ethical challenges about access to quality, safe healthcare services and ethical allocation of scarce resources, including time, relationships, technology and drugs. These ongoing debates challenge nurses’ ability to practise in alignment with their Code of Ethics and to fulfill their public promise to protect the health and wellbeing of those in need.

Inevitably, moral distress has emerged as a key issue amongst all nurses and is an area that will require innovative and courageous clinical, educational, and policy solutions – as well as research into effective ways to address it.

Is there enough training for nurses in how to deal with ethical concerns? What improvements, if any, are needed? 

Although [ethics is] recognised as foundational to the practice of nursing, many nurses do not receive sufficient ethics content in their entry level, advanced practice or doctoral studies. This is explained, in part, because the standards for nursing education do not include definitive objectives specifically focusing on the diverse knowledge, skills and attitudes that are needed to cultivate ethical character and abilities for ethical practice. In some instances, ethics is referred to alongside a litany of other content areas or subsumed in broad objectives that risk diluting its importance.

Many nursing programs have integrated ethics content into their curricula to the point of invisibility rather than prominence. A contributing factor is a dearth of nursing faculty with specific training in ethical theory, discernment, analysis and action. Career pathways for nurses to specialise in nursing ethics within advance degree programs have been limited and this contributes to the generalised lack of nursing expertise in bioethics. Without faculty with a foundational level of expertise in ethics, it is difficult to meaningfully integrate ethics content into theory and application courses. Concerted efforts will be required to create a new vision for nursing ethics education in the future.

What is being done to foster environments where nurses are fully supported in this area? 

Several of our strategic partner nursing organisations have been leaders in developing initiatives to support nurses in gaining the skills needed to navigate the current healthcare environment with more integrity. The American Nurses Association, for example, is engaged in a revision of the Code of Ethics for Nurses, to align it with the contemporary challenges in nursing practice in the US. Similarly, the American Association of Critical-Care Nurses has been a leader is developing education and practice resources for nurses struggling with moral distress.

There are islands of excellence in creating environments where nurses can practise ethically but more is needed. Many healthcare organisations now have more robust representation of nurses on ethics committees and clinical ethics consultation services. Some organisations are creating systematic mechanisms for identifying ethical conflicts before they become moral distress, and developing ethics infrastructure to make speaking up about ethical concerns safe.

What is your key piece of advice to nurses who are struggling with ethical concerns? 

Nurses have an ethical obligation to participate in recognising, addressing, and when possible resolving the inevitable ethical conflicts that arise in practice, education, policy and research.

When conscience calls – listen! Instead of dismissing or discounting concerns, pause to inquire into the nature of the conflict, discern the facts and context, humbly explore your own assumptions and distress, ascertain the ethical landscape and boundaries and commit to courageous action. Don’t go it alone. Engage colleagues, leaders, ethics consultants and others to participate in the process and to offer advice so actions are grounded in integrity. Begin to notice your own patterns of engagement and resistance in addressing the ethical issues in your practice; locate the gaps in your knowledge and skills and take specific steps to address them.

How many more #nursingethics conversations will you be hosting? When and how can nurses be involved? 

We have Twitter chats scheduled for July 15, 29 and August 12. Each will focus on particular themes within the broader question of, ‘What keeps nurses up at night?’ We will also continue to add blog posts on a regular basis during this same period and also encourage stakeholders to join in a somewhat less-constrained (at least in terms of total characters) conversation by reading, commenting and sharing these posts. We will also be sending out a weekly email that includes links to our Twitter chat archives and new blog posts. (http://bit.ly/T29ZF6)

As we continue through our ‘What keeps nurses up at night?’ conversations, we will try to carefully assess what sort of ongoing presence would be most valuable to the community. If we feel there is a continuing call for our #nursingethics chats and blogging, we will keep them coming. At the very least, we will develop some sessions to encourage robust conversations around the products of the summit itself.

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