We have all faced the challenges of moral distress and ethical dilemmas as nurses. As a young pediatric ICU nurse, I saw medicine and nursing help patients in their most vulnerable moments. I also occasionally saw health care extend suffering when palliation and relational care should have been prioritized. Those distressing moments are the ones that still haunt me.

Many nurses burn out and leave nursing after experiencing moral distress, especially in ICU settings. Others realize that nursing is a calling, and that gaining additional experience and knowledge can deepen our resiliency and our ability to give back to patients and health care colleagues.

I realized early on that I wanted to gain more decision-making authority and training in clinical ethics to provide my patients with the best care possible, to relieve the moral distress of colleagues, and to practice ethically. These aims led me on a journey to become a nurse practitioner (NP) and eventually to discover the role of the NP ethicist to provide a unique perspective to patient care.

The journey to a unique role.

After nearly 12 years of nursing, I continue to practice in the pediatric ICU as an NP. When I was a new NP, I channeled my nursing experience to provide unique “just-in-time” discussions with other health care staff and families to prevent moral distress. I tried to ensure that colleagues and families kept in mind that the goal was to heal and help patients whenever possible. When healing wasn’t possible, we could always help patients through compassionate care. By drawing attention to the purpose of health care, my goal was to reduce moral distress and empower families and other health care professionals.

A ‘shared mental model.’

These conversations included discussing the perspectives of families and staff along with the clinical status of patients, in this way sketching out what could be called a shared mental model to guide us in helping our patients. These interactions and heartfelt conversations spurred my desire to pursue a master of arts in bioethics and to become involved in clinical ethics and nursing ethics.

Through my experiential and educational journey, I realized that NPs have a unique role in which they must practice the fundamentals of nursing ethics while also being held accountable to the ethics of those who diagnose, treat, prescribe, and promote health. As described in the 2005 proposal by Peterson and Potter that NPs should have a code of ethics of their own, “NPs are and always will be nurses, but they possess unique skills and have a unique role that sets their profession apart.” Based on my own experience as a nurse and then an NP, I too came to believe that NPs would have a different perspective as ethicists than would nurses or physicians. What, specifically, made their ethical concerns and priorities different?

A nurse practitioner ethicist is distinct from a nurse ethicist.

To answer this question, I performed guided research into the history of nursing ethics and the role of the nurse ethicist. During my studies, I read Marsha Fowler and was encouraged to see that, historically, nursing ethics has preserved its central focus of serving patients. This theme reveals that the essentials of nursing practice are devotion to the good of patients, loyalty to other health care professionals, and assisting society to improve patient care. This is lived out when nurses give back and care for patients without seeking personal gain.

I also looked into the nurse ethicist role in relation to health care ethics consultation. Health care ethics consultants are consultants who seek to assist patients, health care teams, families, and others to resolve ethical questions regarding conflicts, uncertainty, or appropriate ethical decisions. In my recent article in the Journal of Nursing Ethics, I wrote that others have described the nurse ethicist as a nurse who has “extensive clinical experience practicing nursing, has expertise in nursing ethics and nursing science, has experience navigating health care systems, has experience in building rapid relationships with families and patients, and knows the ethical duties and virtues required of nurses.” These advanced skills place nurses in a position to most effectively help health care teams and families with ethics consultation services, especially given the relational nature of nursing care and nursing’s commitment to the good of the patient.

An NP philosophy of practice.

After these studies, I set out to describe how the new skills required of NPs might also make the NP ethicist distinct. As already noted, NPs are held accountable to the ethics of those who diagnose, treat, prescribe, and promote health. This guided me to study medical ethics and philosophies of medicine. From these studies, I determined that NPs must honor the aim of medicine to help and heal patients. Given that NPs are nurses who are devoted to the good of their patients and must also honor the good aims of medicine, I concluded that NPs must practice from a specific philosophy of NP practice. This philosophy of practice asserts that NPs must practice the essentials of nursing service and devotion to the patient’s good while using their advanced skills to help and heal patients when able.

To put it succinctly, the NP ethicist retains all of the benefits and concerns of a nurse ethicist, while also gaining the unique scientific training, experience, and skills that set NPs apart. The NP ethicist also compassionately relates to NPs who face moral distress and ethical challenges that are specific to the NP profession.

A few examples might include NPs consulting with colleagues and patients and their families about who should be the decision-maker for a pediatric patient, or about what would be in a patient’s best interest regarding withdrawal of life-sustaining therapies versus prolongation of life with technology, or about whether the health care team is making the best medical recommendations when patients are suffering as a result of medical interventions.

As an NP ethicist committed to the philosophy of NPs, this philosophy leads me to only provide ethical recommendations that honor the healing, helping, and caring NP–patient relationship while remaining devoted to the good of patients. NP ethicists uniquely connect the ethical world of philosophical analysis with lived experience as both nurses and NPs. My hope by sharing my experience as an NP ethicist is to encourage others to value their nursing history and to become NPs and NP ethicists, using this unique perspective to serve their patients, communities, and ethics teams.

By Jesse Michael Kay, assistant professor of pediatrics, Division of Critical Care Medicine, at Baylor College of Medicine and intensive care nurse practitioner and group ethics consultant at Texas Children’s Hospital