ETHICS MEETINGS IN SUPPORT OF

GOOD NURSING CARE: SOME

PRACTICE-BASED THOUGHTS

Bernadette Dierckx de Casterlé, Tom Meulenbergs, Lut van de Vijver,

Anne Tanghe and Chris Gastmans

Key words: ethical reflection; ethics committees; interprofessional dialogue; nurses;

nursing ethics

The purpose of this article is to clarify both the role of nurses in ethics meetings and the
way in which ethics meetings can function as a catalyst for good nursing care. The
thoughts presented are practice based; they arose from our practical experiences as nurses
and ethicists with ethics meetings in health care organizations in Belgium. Our reflec-
tions are written from the perspective of the nurse in the field who is participating in
(inter)professional ethical dialogue. First, the difficulties that nurses experience while par-
ticipating in ethics meetings are described. Then the possibilities for support of nurses in
their ethical responsibility are explored.

Introduction
The public are paying much attention to ethics. More than ever, the importance
of considering what types of decisions are made and carried out in health care,
as well as the meaning of these decisions and actions for the patient, is becoming
acknowledged.
It is an essential element of nursing to engage in a critical and permanent
enquiry into the best answers to a patient’s requests for care.1 The prerequisite of
ethics discussion arises out of the task of nursing itself and begins with the care-
giver in his or her relationship with the patient. Furthermore, the awareness is
growing that other perspectives, nursing as well as non-nursing approaches, are
equally important and necessary to find the right answers to patients’ demands
for care. This implies a combined effort rather than a solitary endeavour.
The recent evolution towards an interdisciplinary approach of caregiving con-
firms the importance of ethics discussion in health care.2

Address for correspondence: Bernadette Dierckx de Casterlé, Associate Professor, Centre

for Health Services and Nursing Research, Faculty of Medicine, Catholic University of
Leuven, Kapucijnenvoer 35, 3000 Leuven, Belgium. E-mail: bernadette.dierckxdecasterle@
med.kuleuven.ac.be

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 Ethics meetings in support of good nursing care 613
The growing awareness that a good practice of care requires reflection by dif-
ferent participants and disciplines has given rise to more formal interdisciplinary
ethics consultation and discussion on different levels. One can refer to this evo-
lution as the ‘institutionalization’ of ethics and ethics meetings. The establishment
of local hospital ethics committees is a case in point.3–6 However, the question is
whether the institutionalization of ethics and ethics discussion contributes to good
practice of care, because the risk exists that formal ethics meetings become an aim
in themselves. The precise contribution of nurses to ethics meetings also remains
an open question.7–9
By means of some practice-based thoughts, we want to clarify both the role of
nurses in ethics meetings and the way in which ethics meetings can function as
a catalyst for good practice of care. Our own practical experience with ethics
meetings in health care institutions in Belgium was the main source of in-
spiration for these reflections. First, we will examine the difficulties that nurses
experience while participating in ethics meetings; then the possibilities for
supporting nurses in this ethical responsibility will be explored.

Difficulties with ethics meetings

Nurses are becoming more and more aware of the importance of ethical reflec-
tion and meetings for nursing practice. There is no doubt about the fact that,
during nursing practice, important ethical work is done, whether consciously or
unconsciously. This entails that the ethical reflection will be either explicit, implicit
and unconscious, or totally missing. All this suggests that the difficulties in ethical
deliberation should not be neglected.
The identification of difficulties within ethics meetings is, on the one hand, an
exercise from which surprising elements will arise, while, on the other, it will
clarify daily practice and a series of possible approaches to facilitate ethics
meetings will become more visible.
In the description of difficulties, we differentiate three levels: micro, meso and
macro. This classification enables us to gain insight into ethics meetings con-
cerning nursing care, despite the fact that these levels are necessarily intertwined
because they are different parts of a complex reality.

Micro level difficulties with ethics meetings

The micro level consists mainly of a personal relationship between nurse and
patient. 10 This is the context in which the concretization of ethical nursing practice
takes place. Therefore the nurse–patient relationship is an important issue in
ethical reflection. Considerations of how the care relationship can enhance the
patient’s well-being are thus at the centre of ethical reflection. Difficulties that
occur during this reflection process can have several modes.
The lack of professional knowledge to handle care problems constitutes a first
difficulty. The negative impact of such a lack of professional knowledge on the
(ethical) quality of the care delivered is obvious. The following example clearly
illustrates this. A severely ill patient suffers immensely owing to long-term
bedrest in the supine position and a painful pressure ulcer. Preventive measures

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are, however, hardly taken into account. The patient reacts with aggressive behav-
iour, and treats his wife and the caregivers gruffly. The nursing team deals with
this patient and his aggressive behaviour mainly on a verbal level. The nurses,
however, do not consider prevention of the decubitus ulcer or adjustment of the
patient’s medication.
It is clear that, in this case, knowledge to handle the care adequately and in a
professional way is lacking and that the patient’s needs are then misunderstood.
One can conclude that there is no critical reflection on the way in which the
patient’s well-being can be enhanced.
The existence of various interpretations of requests for care, or the lack of critical
analysis of these competing interpretations, is a second problem. This is shown
in the following example of a patient with explicit symptoms of headache. A nurse
notices that the patient usually suffers from headaches when his wife visits him.
After the nurse mentions this, other nurses come to the same conclusion, that
there exists a strong link between the patient’s headaches and his wife’s visits. A
nurse takes this conclusion seriously and tactlessly challenges the patient on the
topic. Hereafter, the patient clamps up completely and does not complain further.
As a result of the nurse’s conduct, contact between the patient and the caregivers
was seriously compromised. A few days later, a doctor diagnoses severe neuro-
logical brain damage and the patient has to undergo surgery. The nursing team
is left with moral qualms and several caregivers admit to having failed the patient.
Although lack of time is often an argument used to cover up other problems,
it can also pose a genuine problem for ethical reflection. Some nursing activities
are so time consuming that other care tasks cannot be carried out. Shortage of
time can imply that there is no room for critical reflection on certain aspects of
care. An example of this can be found in the context of rehabilitation. A patient
is being rehabilitated after an acute cerebrovascular accident, and has reached the
stage where bladder training as well as re-education for simple daily activities
(e.g. changing clothes) should be started. With the best will in the world, the nurse
cannot engage in these necessary training activities because she is pressed for
time. Critical examination and answering of this request for care will lead to a
situation in which the nurse lacks time to engage in other necessary patient care.
The patient’s ethical questions concerning care are sometimes too complex for
the nurse to answer, which constitutes a fourth problem. Consider the following
example: after having established good contact with a patient, a nurse hears the
patient’s explicit request for euthanasia. The nurse does not know how to cope
with this situation, although the patient does not want to talk about his feelings
and his request for euthanasia with other caregivers. Because of this, the nurse
experiences a strong feeling of powerlessness and perceives that she has reached
an impasse.
The routine handling of certain aspects of care, the fifth problem, also stands
in the way of a critical approach to patients’ needs. Nurses tend to disregard
certain requests because otherwise their routine is disrupted. A patient’s request
to use his or her own medication is a typical example that is often dealt with in
a routine manner. The situation of a 72-year-old patient who was admitted to a
medical ward illustrates the strong influence of routine behaviour on daily
nursing practice. Before his admission to the hospital, this patient used different
types of medication. For this purpose, he had drawn up a careful scheme, which

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was all the more necessary because time-management of the medication was
extremely important for therapeutic reasons. On admission to hospital, the patient
asks to be in control of his medication so that when he leaves the hospital he will
have the feeling that he is still in charge of his own therapy. This request was
with the approval of the attending physician. The nursing team, however, respond
negatively to the patient’s request because it is not customary for inpatients to
have control of their own medication. As a result of this, the nursing team take
over the patient’s medication management. The patient follows the nurse’s
instructions but, after two days, finds his carefully drawn up scheme totally aban-
doned. The patient is afraid to ask more questions and hence gives up his self-
care, thereby losing control over the therapy. When he is about to leave hospital,
the nurses find that the patient is totally confused concerning his medication.
During the first week after his discharge, a home care nurse has to visit him in
order to familiarize him again with the medication scheme.
A nurse’s lack of communication skills can also lead to less than optimal
handling of patients’ requests for care. Many questions remain unanswered
because patients do not have the chance to ask them. One can easily imagine the
situation of a nurse entering the room of a frightened patient, asking him if he
has slept well, and immediately commenting that there was a lot of hustle and
bustle on the ward that night with three emergency admissions. After the nurse’s
story, the patient feels no further need to communicate that the thought of yes-
terday’s diagnosis of an aggressive intestinal carcinoma has kept him awake the
whole night.

Meso level difficulties with ethics meetings

The meso level goes beyond the individual nurse–patient relationship and focuses
on the team (disciplinary and interdisciplinary) and the health care institution.
That there will be a broad spectrum of difficulties with ethics meetings at this
level can be inferred from the micro level problems. In addition, meso level ethics
meetings are confronted with a range of typical problems.
A first set of problems is related to the difference in knowledge, communica-
tion skills and the attention to, or the interpretation of, ethical problems between
team members. Given this interpersonal variation, ethical deliberation can lead
to a confusing meeting in which every member merely stands up for his or her
own personal opinion. These differences in personal opinion come to the fore
explicitly in interdisciplinary ethics meetings where separate individuals and dis-
ciplines, each with their own personal and disciplinary perspective, search for a
common answer to the patient’s request. The differences in opinion involve a
variety of value hierarchies and can cause communication problems or conflicts
that obstruct rather than facilitate the interdisciplinary ethical dialogue.
A second set of problems at the meso level is related to unskilled coaching of
the team meeting. In daily practice, one can find clear differences in team leaders’
competence to bring a group discussion to a favourable conclusion. Often, the
team leader lacks an easily manageable method to structure an ethics meeting.
In teams where there is an unskilled team leader, the handling of emotions
arising during the meeting is a third difficult problem. Emotions are often
regarded as a threat to ethical dialogue, leading to failure of the meeting. Indeed,

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the risk exists that the mishandling of emotions makes further team meetings
impossible. Nevertheless, emotions in ethics meetings are very natural and they
can bring the conversation round to necessary subjects for debate. When dis-
cussing sensitive ethical problems, emotional reactions can indicate the strong
involvement of the participants.
Bad experiences in the past of group discussions leading nowhere or ending in
merely negative consequences for team members, can create an atmosphere in
which frequent ethical problems are not discussed. This explains why burn-out
is a recurrent phenomenon at the meso level, with negative consequences for the
handling of patients’ requests and for nurses’ intrinsic motivation. Some examples
will help to explain. For several years, a nursing team has been receiving com-
plaints about a physician’s incompetence, but management is deaf to these com-
plaints. Another situation where burn-out threatens ethics meetings is one in
which problems with a charge nurse’s priorities in nursing care and with the pro-
fessional incompetence of colleague nurses are not addressed. In the long run,
team members will become indifferent if teams receive no signal that such
problems will be settled. On these wards, ethical thinking and functioning will
gradually disappear.

Macro level difficulties with ethics meetings

Nurses’ ethical thinking can also be viewed as an interactive process that con-
siders the extent of societal values and compares them with the ethos of nursing
practice. However, little thought is usually given to the question of if, and to what
extent, actual societal developments and developments in health care policy con-
tribute to good practice of care. Until now, ethics meetings at the macro level have
been very limited. Furthermore, the degree of contribution of nurses to this type
of debate remains very low. Nurses, however, have substantial information and
unique experiences related to their specific position in the caring process that can
enrich macro level ethical dialogue.
In society in general and in health policy in particular, economic and rational
values are predominant. This poses the first problem for ethics meetings on the
macro level. Continuous discussion on the allocation of health care resources
entails a clear ethical factor, namely the identification of health care needs and
the subsequent just allocation of resources.11 Owing to the scarcity of resources,
governments will always have to set priorities in the allocation of health care
funding. This priority setting is implemented on the basis of both economic and
ethical arguments. From time to time these discussions are carried out in the
media, and with great public interest. In this public debate, the role of the
management of health care institutions is also undervalued. Health care managers
can play an important intermediate role by both communicating the concerns and
experiences of people from within the field and vice versa, informing the field
about the decisions and intentions of policy makers.
Disagreements or obscurity concerning the vision about nursing and the essence
of nursing practice within the professional group constitutes another impediment
for macro level ethics meetings. If nurses themselves cannot manage to engage
positively in reflection on the essence of their practice, they will find it hard to
contribute in a constructive way to a public debate on good care. Therefore, open

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 Ethics meetings in support of good nursing care 617
and constructive ethics meetings within the nursing profession are necessary to
eliminate the defensive attitude towards other professional groups.
Closely connected with the previous problem is the lack of confidence in the
value of the nurses’ decision making and their contribution to the macro level
ethical dialogue. The increasing complexity of health care and health policy
strengthens the impression of nurses in the field that their responsibility stops
with individual caregiving. Rarely, if ever, do nurses realize how valuable their
contributions and experiences are to shaping and supporting ethical consultation
and meetings in the health care sector. They are privileged witnesses of patients’
experiences, so they can provide valuable and necessary information on the
primary needs of patients, on the gaps in health care and health policy, and on
the impact of policy on actual patient care.

Possibilities of enhancing ethics meetings

The list of difficulties that nurses experience while participating in ethics meetings
at the different levels is not comprehensive of all problems and does not pretend
to be so. Nevertheless, this overview points to the various possibilities that exist
to support nurses in their ethical responsibilities. The identification of possibili-
ties for contributing meaningfully to ethics meetings will clarify the ethical char-
acter of nursing practice in a positive way. As in the description of the difficulties,
we differentiate three levels of good practice: the micro, meso and macro.

Micro level possibilities of enhancing ethics meetings

Good knowledge about the meaning of and solutions to patients’ need for care
constitutes a first priority in supporting nurses in their ethical responsibilities. It
is vitally important that nurses should first consider carefully patients’ needs for
care. If this condition is fulfilled, they can seek the best human solutions possible
on the basis of their professional knowledge and experience. If nurses cannot give
a ready-made answer to a problem, they can call upon the expertise of colleagues
or others in the common pursuit of a well-considered solution; indeed, it would
be dangerous to pretend that one has all the answers to all the problems.
Obtaining proper knowledge about the actual content and the solution of nursing
problems is, therefore, a prerequisite for good nursing practice.
Communication skills are essential for handling ethical questions of care in a
sound way. This factor should not be underestimated. The skill of approaching
patients in an unprejudiced way takes some effort. Whether one can or cannot
discuss ethical issues with patients in a skilful way depends particularly on the
integrity with which the content of the discussion is broached. This demands of
nurses that they develop a caring attitude with great attention to recognition and
self-expression. A charge nurse must be able to embody all these characteristics
in order to manage the nursing team successfully.
Nurses have to be stimulated and supported in listening to patients’ needs for
care and in interpreting these needs. Finding out what a patient feels and lives
through, what a patient wishes to communicate, whether verbally or nonverbally,
is the most important guideline in the interpretation of the patient’s need and

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request for care. Effective clinical leadership offers major opportunities to engage
nurses in this kind of listening. When patients are not able to express themselves
well, immediate feedback is the best and most efficient method available to help
nurses in their task as caregivers. If a nurse is inadequate at eliciting patients’
needs for care, it is the charge nurse’s responsibility to indicate to that nurse that
a minimal degree of professional behaviour is expected.
A lack of available time to deal in a proper way with all patients’ needs is a
reality of nursing practice. This does not alter the fact that there are possibilities
to deal with the time problem and its implications in a constructive manner.
Avoiding secrecy and covering up, and the assurance that there is room to speak
one’s mind are two necessary conditions for handling the demands of nursing
practice adequately and preventing burn-out. Lack of time is often (at least partly)
an organizational question. A collective undertaking within the team to prioritize
care needs could be helpful in finding innovative ways to handle patients’
requests. Nurses have to learn to accept the apportionment of job responsibilities
and they have to bear in mind what they can offer patients as well as what they
can not offer. Acceptance of their limits constitutes a real challenge for most
nurses. The importance of good leadership is again underlined.
Communication skills are not only of the utmost importance in the relation-
ships between caregivers and care receivers, they are also necessary elements of
interdisciplinary relationships. Nurses need to be able to state their opinions and
their positions to other professional groups. Self-confidence and communication
skills are the basic requirements for adequate profiling of the nursing profession
and its input into interdisciplinary dialogue. Education, as well as good institu-
tional leadership, appear as valuable instruments to enhance nurses’ competence
from this perspective.

Meso level possibilities of enhancing ethics meetings

First of all, it is a basic essential for team leaders to have skills to lead discus-
sions of ethical problems.12 This entails that: (1) during the meeting everyone has
a chance to speak their mind; (2) the team leader should be able to focus on the
conversation’s thread; (3) the problem has been correctly defined at the start of
the discussion; (4) there is agreement on the objectives of the discussion; (5) the
team leader is able to lead the interchange of the different ideas; and (6) the team
leader is able to bring these different opinions to an agreement. These require-
ments emphasize how strongly ethics meetings differ from general group con-
versations. It is essential that group leaders possess these skills, which can be
attained through both theoretical and practical training.
Dealing with emotions that arise in team meetings is another important aspect
of the leader ’s task. Acknowledging these emotions by naming them and by con-
sidering them as natural elements of ethics meetings is not so dangerous or dif-
ficult as it is sometimes claimed. Within health care, emotions need an appropriate
place. Nursing cannot avoid taking into account the emotions of patients, family
members and caregivers.
There are several ways of leading when there are complex ethical problems
in ethics meetings. First of all, the team leader must be thoroughly competent
at leading a group through discussion of complex ethical issues. Expertise in

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 Ethics meetings in support of good nursing care 619
evaluating a problem for its content is a second important condition for success-
ful ethics meetings. It may be necessary to obtain expert advice on different
aspects of the matter in hand. The advice of an ethics committee can also be a
helpful option. Such an expert committee can be set up to analyse and structure
difficult ethical issues in order to give advice. This should result in easier handling
of these issues. An important part of an ethics committee’s job is to put the for-
mulated advice into practice. However, this phase of ethical deliberation is often
beyond the scope of ethics committees, and, as a result, the committee’s efforts
at clarifying the ethical issues do not bear fruit in daily practice. An ethics com-
mittee should, therefore, not be made up of only clinical experts and people from
within the immediate practice, but also of people who have the expertise to bridge
the gap between theory and practice. Public interdisciplinary meetings for all the
professionals involved are an example of a step towards the integration of ethical
advice and daily professional practice.
Ethical burn-out can be avoided by correct evaluation of ethics meetings.
Professionalism is a prerequisite for every ethics meeting. This can prevent the
meeting being viewed as unnecessary and useless. Burn-out can also be avoided
when team leaders take up their responsibilities with regard to the results of the
ethics meetings. Clear statements about confidentiality are of the utmost impor-
tance to success. Sometimes confidentiality is especially important in order to
secure the possibility of exploring different ethical viewpoints. It can nevertheless
be important to brief management on the results of a meeting in order to attune
them to the basic philosophy of the health care institution concerned.
Lastly, there is the responsibility of the institution’s management, which must
take the essence of nursing seriously by adopting a favourable stance towards
nurses’ ethical task of care. Management should undertake all possible actions in
order to communicate the health care institution’s ethical position to all its
sections/ranks. An explicit statement of values signals the fact that ethics is taken
seriously. Management should act in a consistent way vis-à-vis certain values.
Inconsistency between theory and practice constitutes a greater threat to ethical
thinking and good ethical practice than scant information on ethical issues.

Macro level possibilities of enhancing ethics meetings

On the macro level there are also several possibilities to shape and stimulate ethics
meetings in health care in general and in nursing in particular. The bodies and
institutions concerned with health care, such as public services, educational insti-
tutes and professional organizations, should stimulate or support ethics meetings.
Government policy on health care always has, implicitly or explicitly, an ethical
dimension and has, more than we are aware of, a strong impact on the ethical
dimensions of everyday nursing practice. In deciding and allocating the available
health care resources, it is implicitly made clear what kind of care is important
and what kind of care is not. For example, when health policy favours palliative
care, the patient groups and caregivers involved will be pleased. Other patient
groups (e.g. those who are chronically sick and/or elderly), however, will ask for
more financial support, but this will not be available. This example indicates how
important it is that, at policy level, appropriate attention is given to ethics
meetings. The public responsibility that nurses have, both as individuals and as

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a professional group, cannot be emphasized strongly enough. By their strategic

position in health care and their specific function in the delivery of care, nurses
have valuable information at their disposal. In addition, the government should
facilitate ethics meetings at different local and national levels by giving sufficient
and effective incentives.
Lobbying and the activities of pressure groups of caregivers and health care
institutions can contribute to effective ethics meetings in health care. The contri-
bution that these institutions and specific professions can make requires critical
reflection and discussion of the ethical dimensions, as well as their implications
for patient care. Such ethics discussion enables them to act as expert partners in
societal, political and other macro ethical debates.
Finally, these groups can also support ethics meetings via specific stimuli. The
formulation and communication of ethical viewpoints are valuable initiatives
because health care institutions have the responsibility to communicate
these recommendations within the organization so that they can be applied.
The organization of ethics education is another tool for supporting ethics
meetings.
Educational institutions are another important player that can contribute to
effective ethics discussion in health care. The training of nurses who are compe-
tent to care by way of ethics meetings requires an educational climate in which
the ethical dimension of care is at the centre and where there is explicit attention
to and room for ethics discussion. Effective and qualitative ethics meetings require
specific ethical knowledge and skills, so educational training programmes should
pay explicit attention to sufficient and professional ethics education. In addition
to this, the increasing importance of interdisciplinary education should be empha-
sized. Undoubtedly, the awareness of other perspectives and disciplines, as well
as acquiring skills in interdisciplinary thinking, consultation, discussion and
decision making contribute greatly to the quality of ethics meetings.

Conclusion
Ethics meetings are not easy, especially when they function as an instrument in
support of good nursing practice. Ethical reflection is not only a right, it is also
a duty that originates in the essence of the nursing task. Nurses occupy key posi-
tions for realizing this ethical task. This responsibility begins on an informal level
in daily practice. Personal commitment to patients’ well-being is a nurse’s starting
point for ethical reflection. However, the nurse’s responsibility does not end there.
Nurses can also contribute in a variety of ways to formal ethics discussion and
meetings on the meso and macro levels. The willingness of large groups of nurses
to take up this ethical responsibility contrasts sharply with their usual diffidence.
This preparedness, however, risks being affected negatively by the growing com-
plexity of the care process.
Fruitful ethics meetings, in order to realize humane care, require an ethical con-
sciousness that is broader than merely an active participation in consultation. The
ethical responsibility of nurses is then understood as a core element of their
practice. This responsibility goes beyond the intimacy of the patient’s room, the
ward and the health care institution. It is of crucial importance that nurses, as

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individuals, as a team, and as a professional group, articulate and communicate

the professional values that guide their own practice.
Training is another priority in enforcing nurses’ contributions to ethics
meetings. Contrary to what is sometimes claimed, professionalism and expertise
make or break ethics. For nurses, this professional expertise implies that they have
to be capable of expressing and advocating the patient’s perspective in a skilful
manner. Therefore, special attention should be given to the moral and personal
development of students, and to the development of communication skills of both
students and lecturers during their educational and professional training. Above
all, the curriculum should be embedded in an explicit ethical perspective of care.
Training nursing students in how to apply their professional expertise effectively
towards humane care is of the utmost importance here.
Finally, nurses should have sufficient professional and mental strength so that
they are able critically to examine the practice of care in pursuit of the best
humane care possible on individual, intradisciplinary and interdisciplinary levels.
Hence, it is necessary that nurses should identify their power, both as individual
caregivers and as a professional group, in order to use it creatively in favour of
patients. Professional empowerment is thus another priority in enabling nurses’
contributions to ethics meetings. Nursing ethics committees, ethics rounds and
other formal mechanisms give nurses the opportunity to strengthen their profes-
sional growth insofar as they are not merely used for positioning and defence of
their own discipline against others. Given that interdisciplinarity is becoming so
important, marginalizing it should be avoided. More important than the formal
institutional mechanisms is the stimulating climate in which nurses and other
health care professionals truly have the opportunity to develop themselves as
persons and professional caregivers. This requires the development of strong
leadership in nursing.

Bernadette Dierckx de Casterlé, Chris Gastmans, and Tom Meulenbergs, Catholic

University of Leuven, Belgium.
Lut van de Vijver, Maria Middelares Hospital, Sint-Niklaas, Belgium.
Anne Tanghe, Université Tunis El Manar, Tunisia.

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