Introduction

Clinical bioethics typically focuses on complex, dramatic healthcare topics such as organ transplantation, genetic testing, reproductive technology, rationing of healthcare resources, and end-of-life decision making. In contrast, everyday clinical ethics, sometimes called microethics, focuses on “ordinary” ethical issues that unfold within routine clinical encounters between patients, families, and staff members (Caplan, 1990; Smith, 2005; Nikku & Eriksson, 2006; Moon et al., 2009; Quarini, 2010; Ulrich et al., 2010; Carrese et al., 2011; Papanikatas et al., 2011; Frank, 2013; Mandal et al., 2015; Truog et al., 2015; Zizzo et al., 2016; Milliken, 2017).

Komesaroff (1995) was among the first to articulate that ethical issues animate every clinical interaction and, further, that the patient-clinician relationship is the source of clinical knowledge and site of therapeutic clinical action, possessing an irreducible moral dimension. The moral and ethical space of healthcare institutions provides a valuable foundation upon which everyday clinical ethics can rest (Walker, 1993). In 2007, Austin described that cultivating everyday ethics requires conceiving of healthcare environments as moral communities where clinicians recognize and incorporate ethics as part of routine practice. Indeed, the fundamental goals of the healthcare professions, as delineated in codes of ethics, serve as anchoring ideals towards which all clinical actions- and the clinicians performing them- should aspire (American Nurses Association, 2015; American Medical Association, 2017; International Council of Nurses, 2021).

Everyday clinical ethics can be considered a bridge between bioethics and clinical practice, and as a common constellation of ethical issues that occur regularly, arise often, and whose ethical dimensions are not typically recognized as such (Zizzo et al., 2016). Examples of meaningful everyday clinical ethics issues include respecting the time dedicated for appointments; honoring patient values and preferences during healthcare decision making; accurately explaining treatments and eliciting questions; and upholding patient confidentiality. Despite the seemingly routine and ordinary nature of these sorts of everyday clinical ethics encounters, these activities reflect the core components of clinical care and manifest in daily practice. Accordingly, such activities and their ethical aspects impact every patient interaction within the healthcare arena. Thus, these everyday ethical issues affect large numbers of people and hold potentially far-reaching implications (Smith, 2005). Like the population prevention paradox popularized by Rose (1981), emphasizing the significant value of small interventions for large numbers of people, everyday clinical ethics should be recognized for its inherent far-reaching importance and preventive potential (Smith, 2005; Zizzo et al., 2016).

Although clinicians ideally bring an attuned sensitivity to the ethical dimensions of their work as issues arise, the lack of ethical awareness and everyday ethics skills of clinicians have been identified as educational priorities in the healthcare professions (Caresse et al., 2011; Truog et al., 2015; Zizzo et al., 2016; Milliken, 2017). In contemporary healthcare environments, the large number of clinical interactions and associated time pressures can be barriers to clinicians practicing everyday clinical ethics. Furthermore, the skills needed in this domain are typically neither taught during training, nor reinforced once clinicians are in practice. As such, there is a need to delineate the skills required for clinicians to engage more fully in the everyday ethical dimension of their work. Indeed, some have advocated for an emphasis on cultivating ethical awareness and moral sensitivity, interprofessional learning and opportunities, communication skills, creating safe moral spaces, and receiving support from leadership (Milliken & Grace, 2017). Still others make the case for augmenting traditional case-based ethics education by including the nuances of everyday clinical ethics (Truog et al., 2015). It is important to note that the skills of everyday ethics can and should be mastered by every clinician; these skills are related to, but distinct from, the expertise of trained clinical ethicists.

The purpose of the present study was to identify the skills necessary for clinicians to incorporate everyday ethics into practice. Specifically, bioethicists were interviewed to identify the skills thought to be essential for everyday clinical ethics practice. Based on these interviews, examples of case scenarios were provided that could be used as an educational solution to increase everyday ethical awareness and to advance clinical ethics skills.

Method

A convenience sample of bioethicists was recruited from the Center for Bioethics at Harvard Medical School (HMS) utilizing a snowball sampling technique. Participants included individuals from across several Harvard-affiliated hospitals. Inclusion criteria included participation in the monthly HMS Clinical Ethics Consortia and/or other clinically oriented educational outreach activities sponsored by the Center for Bioethics. Bioethicists were selected because they can be considered content experts whose work includes modeling and teaching ethics to clinicians at the point of care. Participants were invited via email to participate in a 45-60-minute semi-structured interview organized around two central questions: (1) What are the essential skills required for everyday clinical ethics? and (2) What are potential educational case scenarios to illustrate and teach everyday clinical ethics? Interviews were conducted either face-to-face or via telephone, based on the participant’s preference. Participants’ sociodemographic data, including sex, race, disciplinary affiliation, and years of general and bioethics-specific experience were collected at the beginning of the interview. Interviews were conducted between September 2019 and May 2021 by one female interviewer (ECM), PhD, RN, MBE whose background is in nursing, clinical psychology, and bioethics. Her occupation at the time of the study was as a master of bioethics student who attended the Clinical Ethics Consortia and, as such, she had been introduced to participants and for some she had established relationships at the time of the interview. Participants were informed about the aim of the study before the interviews. Interview notes were documented during the interviews and notes were read back to participants to confirm accuracy and meaning. During the interviews, no one else was present except the participant and interviewer. The study conforms with the COREQ checklist (Consolidated criteria for reporting qualitative research) (Tong et al., 2007).

Data Analysis

Sociodemographic characteristics of participants were summarized using descriptive statistics. The interview notes were subsequently analyzed using a qualitative content analysis approach, as outlined by Hsieh and Shannon (2005). To ensure rigor and reliability, the content analysis was conducted by two researchers (ECM and GL were unknown to participants and their background is medical education and clinical psychology) who grouped the skills suggested by participants into categories (Pope et al., 2000; Krippendorff, 2004; Pope et al., 2006; Tong et al., 2007; Vaismoraldi et al., 2013). The analysis followed several steps and was supported by Excel. First, both researchers immersed themselves in the data by independently reading through the interview notes. During a second independent reading of the interview notes, both researchers grouped the skills identified by the participants into broad categories. They then met several times to review, organize, and develop the categories identified as well as to resolve any discrepancies through discussion. Labels were jointly discussed for the categories of skills. The two researchers then applied the same qualitative coding approach to the educational case scenarios provided in the interviews to organize them by topic. Illustrative quotes of the essential skills and educational scenarios were selected and here identified throughout the text using the participant study identification number.

Finally, to assure the trustworthiness of the analysis and results, member checking was instituted whereby all study participants were invited to check the resulting categories for accuracy and resonance with their experiences (Rolfe, 2006; Birt et al., 2016). Member checking resulted in the identification of additional case scenarios (see Results). These participants did not, however, participate in the coding and analysis process. Eight participants contributed to manuscript preparation once the qualitative analysis was complete (MU, CM, RDT, JMM, KOK, MR, SLT, and ABM).

Ethical Considerations

The study design and protocol were reviewed by the Harvard Medical School Institutional Review Board and deemed exempt. Consent from participants was obtained before the start of the interview and willingness to be interviewed was taken as evidence of voluntary consent to participate. All participants agreed to the interviewer documenting written interview notes, and for the data to be used for educational and research purposes.

Results

Participant Demographic Characteristics

Twenty-eight (28) interprofessional bioethicists were invited to participate of whom 25 (89.3%) completed interviews. Of those who did not complete interviews, one did not reply to email, one had retired, and another was unable to be interviewed because of scheduling difficulties. All 25 participants were affiliated with the Center for Bioethics at Harvard Medical School and 15 (60%) had additional affiliations representing eight Harvard healthcare institutions. Participants included 16 women (64%) and 9 men (36%). Participants were predominantly white (80%). Participants’ professional backgrounds included nurses (37%), physicians (22%), humanities (philosophy, literature, education) (18%), lawyers (11%), social workers (4%), chaplains (4%), and psychologists (4%). There was a total of 602 years of professional experience across the participants, with a range from 3 to 50 years, and a mean of 24.08 (SD = 13.79) years. Experience in bioethics ranged from 1 to 38 years, with a mean of 14.76 (SD = 12.01) years. Table 1 summarizes participant demographic characteristics. Following data analysis, 19/25 participants (76%) participated in the member checking process.

Table 1 Participant demographic characteristics (n = 25)
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Everyday Clinical Ethics Skills

Categories of skills were identified for conducting everyday clinical ethics, divided into general skills and those that are ethics specific. In contrast to ethics-specific skills, general skills are skills that are not ethics-specific and apply across healthcare disciplines but have an impact on everyday ethics. Five general everyday clinical ethics skills included: (1) Awareness of Core Values and Self-Reflective Capacity; (2) Perspective-Taking and Empathic Presence; (3) Communication and Relational Skills; (4) Cultural Humility and Respect; and (5) Organizational Understanding and Know-How. Additionally, three ethics-specific skills, or skills specific to identifying and addressing ethical questions/conflicts, were described: (1) Ethical Awareness; (2) Ethical Knowledge and Literacy; and (3) Ethical Analysis and Interaction. Collectively, the general and specific skills were conceptualized by the authors as comprising a Toolbox of Everyday Clinical Ethics Skills.

General Skills

Five general skills were identified as foundational and relevant to scaffolding everyday clinical ethics practice. These skills are described below with illustrative examples from participants, identified by study identification number.

Awareness of Core Values and Self-Reflective Capacity

Among the general skills essential for clinicians practicing everyday ethics is understanding one’s own personal values and internalizing the core values of one’s profession that guide actions within patient-clinician relationships and healthcare organizations. Similarly, clinicians must possess sufficient self-reflective capacity to recognize one’s biases and to govern oneself according to these core values:

“Individual practitioners need to be given the space to learn, understand their own moral compass, to understand their own values and how these are created by family, culture, religious influence, and educational experiences. To understand and appreciate their values and how they were shaped.” (#18)

“Ability to articulate your core values and how they evolve over time. Most people do this unconsciously and [are] prone to errors. Making this conscious so one can identify and articulate the values…and the capacity to learn from your experiences.” (#19)

There was recognition that everyday clinical ethics includes a “virtue ethics piece…and the ability to understand medicine as a moral enterprise for the good of the patient” (#20). The process of recognizing “the biases we bring in and the assumptions we make” (#6) and engaging in ongoing self-reflection were important when affective emotions arose in clinical encounters:

“[Clinicians] need to be self-reflective. Why did I respond that way? Why did I get aggravated in that situation? Being open, aware of [our] biases and being able to self-reflect if you feel uneasy, uncomfortable and try to figure out the reasons why. This is part of thinking ethically.” (#11)

Perspective-Taking and Empathic Presence

Another everyday ethics skill included the ability to recognize, appreciate and respect the perspectives of patients, families, and other clinical team members. Simply put, “Taking the perspective of another” (#9) was considered essential to everyday clinical ethics. Part of that skill means embracing epistemic humility and understanding that we can be mistaken:

“[Be] open to differences of opinion, consider other points of view- not too dogmatic, not jumping to conclusions…Be sure that you recognize you may not always be right; another person will have legitimate perspectives.” (#11)

Participants noted that part of recognizing one’s fallibility means “Always being willing to be persuaded to go to another point of view. Many views are required- you can’t always go with the first one, there are many” (#5).

The related capacity to lend one’s empathic presence was also emphasized, “Compassion…is good for patients, business, and outcomes…and we have a big shortage of it…every day we are asking for the extraordinary [from clinicians]” (#14).

Everyday clinical ethics demands open-mindedness and effort on the part of clinicians to notice and respect others’ perspectives and to join in relationship through empathic presence so that careful, measured, informed conclusions can be drawn:

“Be able to debate with someone else who has a different way or balance of the same values so that you can both learn and come up with creative solutions. We all [need to] hold a multiplicity of values dear.” (#19)

Communication and Relational Skills

Given that issues may not be identified as being ethical, successfully employing everyday ethics means, “We need to have an ear for moral conversations- for how people express their values, even when not labeled as such” (#4). Well-developed, versatile, and effective communication and relational skills were viewed as the sine qua non for practicing everyday clinical ethics.

“Communication skills are high up on the list- on the everyday level. [These skills] bring people together to recognize different viewpoints to help people talk with each other rather than talk at each other.” (#7)

One participant explained, “Skills in communication are necessary components in enacting everyday ethics” (#2). Others emphasized the skills of “elegant listening” (#1) and “Listen- do not just stop talking but listen to understand and not just to think about what to say next” (#3). The importance of communication and relational skills was highlighted as essential for everyday ethical proficiency:

“Everyday ethics [requires] good communication skills, to convey empathy, neutrality, objectivity, and compassion.” (#10)

Another participant emphasized the spontaneous nature and range of communication and relational skills inherent in everyday ethics as a well-developed repertoire that unfolds during “ethical mini-moments” which were described as “the space in-between and how that space in-between impacts on the next move. Whether we touch, what we say, our next move…calm presence is important. People are usually ‘amped,’ so a steady presence helps” (#5).

Cultural Humility and Respect

The importance of “demonstrating respect and upholding dignity for all persons” (#9) was identified as an essential skill for everyday clinical ethics. Similarly, there was emphasis on practitioners adopting an everyday clinical ethics lens by showing evidence of curiosity, thoroughness in their interactions, and “not being too quick to judge” (#23). One participant quipped that to uphold everyday clinical ethics, clinicians need to be constantly asking questions, learning, and to “sip some humility tea” (#24).

“Humility and remaining open throughout the process. It’s easy to decide what the answer is or [express] judgment about what should be done. Really [the situation] isn’t static or as simple as it appears.” (#16)

Demonstrating cultural humility and showing respect for differences is an everyday activity in our diverse world, and it comes with myriad challenges. “Try to build rapport with all families even if [across] different languages…try to use the interpreters and the phone translators…Withhold judgment, respect humanity, and remember that everyone is equally deserving of respect of their humanity” (#25).

In addition to humility and respect for all persons, a broad appreciation for social justice and its relevance to healthcare was emphasized:

“[For] everyday ethics one needs to understand social justice. What are equitable and oppressive relationships, injustice- and know the difference…Need to know and recognize when you see it and name injustice… People [practicing ethics] need to be diverse- gender, race, religion, immigration [status], gender orientation, ability. If we did that, ethics would look a whole lot different.” (#12)

Participants also noted a need to “Be aware of what’s going on so that you do not say something that is triggering or insensitive about homelessness, alcohol, mental health.…be aware of the sociopolitical climate and the historical context like that of Black people and police brutality.” (#24)

Organizational Understanding and Know-How

Finally, with respect to general skills, everyday ethics requires a broad understanding of the organizational culture and values within which practice occurs, as well as know-how to navigate the system. As one participant emphasized, everyday ethics “is more than just seated within an individual clinician- it has to do with the team and the broader institution” (#12). Healthcare team members may be considered the human building blocks of an organization, those who uphold and model the ethical values of the community to enhance the moral space and ethical climate of the entire institution:

“How we treat each other. How we avoid harm in the activities we encounter on a regular basis. It’s not just what I do by myself, but how I contribute to an environment that promotes good. …Attention to the community. Gets back to the environment of care. Everyday ethics is more than simply an individual skill set, but the community values” (#13).

“Everyday clinical ethics requires knowledge of the medical [situation], the culture, the nuances of the interactions, the patient population, and the medical hierarchy…at least be aware, even if not comfortable” (#7).

At times, there can be differences between an individual clinician’s values and the expected organizational values that can cause tensions requiring discernment and attention:

“Everyday ethics [involves] how a clinician responds to institutional pressures to behave in a certain way- that may or may not be comfortable. The everyday quandaries one finds oneself in and the everyday questions that don’t have ready answers.…” (#11).

Ethics-Specific Skills

In addition to general skills, participants emphasized that everyday clinical ethics requires practically oriented ethical skills including Ethical Awareness, Ethical Knowledge and Literacy, and Ethical Analysis and Interaction. The ethics-specific skills were described as essential for successful practice of everyday clinical ethics.

Ethical Awareness

Adept ethical awareness is a fundamental skill that enables those engaged in everyday ethics to accurately recognize ethical issues in ordinary situations such that “at the bedside, a nurse might say “this doesn’t feel right” (#5). Without the capacity for astute ethical awareness, clinicians can miss the “moral moments” (#20) that unfold within clinical practice amidst everyday activities:

“It is essential to recognize that everything we do as clinicians is fundamentally ethical in nature and ought to be aimed at fulfilling our professional goals such as promotion of health, prevention of disease, and alleviation of suffering…this understanding constitutes ethical awareness.” (#2)

One participant captured the crux of ethical awareness as the “moral sensitivity to know something ethical is going on…and the moral courage to bring attention to it” (#22). Moreover, robust ethical awareness is essential to practicing “preventive” everyday ethics:

“The ability to recognize the moral moments in usual care… where we see value tensions and gaps between what we are doing and the values of patients, clinicians, departments, and institutions.” (#20).

If clinicians miss the cues that an ethically complex situation is emerging or occurring, then opportunities to intervene may be lost or delayed, if and until the ethical issue is more obvious and urgent:

“Illness, death, and declining patients- these are moral events. And those practicing everyday clinical ethics require an understanding of the things that happen in life or a hospital- and to prepare for them.” (#21)

Ethical Knowledge and Literacy

Ethical knowledge and literacy encompass a working knowledge and familiarity with general bioethical principles, such as respect for autonomy, beneficence, nonmaleficence, and justice. Beyond the four principles, learning and integrating a broader range of ethical theories, such as virtue ethics and narrative ethics, can enhance the capacity of those practicing everyday ethics. Participants emphasized that clinicians need “some foundation in core ethics knowledge,” (#7) “a basic knowledge of the language of ethics (#2),” and another summed it up as, “the chief skill is knowing how ethics works” (#4). Participants provided examples of ethical knowledge and literacy that are needed to fulfill everyday ethical responsibilities within specific settings:

“[It is] important for individuals to have training in ethical theory, it might depend on…the [level of] training, the setting. Everyone can learn about ethics- hit the highlights, give a table with highpoints. Theory gives different lenses and ways to view ethical issues so that you can come up with a range of different solutions to look at uncertainty and conflict.” (#18)

“Ethical literacy depends on [the setting] where you are. Need to understand ethical principles and frameworks for resolving and being comfortable with conflict and uncertainty. [Know the] main ethical principles- autonomy, beneficence, nonmaleficence, and justice. In pediatrics, for example, need [to understand] the basics such as parental authority and the role of the child in decision making.” (#16)

Participants emphasized the need to have basic ethical knowledge around common ethical issues such as upholding confidentiality, informed consent, identifying the standard of care for determining a patient’s best interests and approaches to equitable resource allocation. For example, “Understand the principles of informed consent…including the difference between fully informed consent versus tacit consent” (#15).

Ethical Analysis and Interaction

Ethical analysis and interaction equip clinicians with the ability to practically address relevant everyday ethical issues, the capacity to consider and analyze a range of potential everyday ethical solutions, and then to interact accordingly. Participants described myriad examples of everyday clinical ethics in action, noting that eliciting a patient’s values and preferences in the context of healthcare decision making is often not as straightforward as simply asking a question:

“Patients and families don’t have [their] values and preferences settled- and it comes close to paternalism, such as ‘Let me explain why you don’t want CPR.’ People’s values are not that well-articulated… being able to use these values and preferences to then help people to authentically create their own values and preferences, and to recognize them.” (#6)

Participants noted that “being able to draw out a narrative from different stakeholders” (#16) can involve considerations beyond the question itself, beginning with whether and how the patient is able to understand and engage in the decision-making process:

“How to [recognize when] capacity assessments are called for. This would be a HUGE step forward.” (#15)

Ethical analysis also requires keen observation and interpretation:

“For analytic skills- figuring out and taking things apart. What is happening? [Notice] power and bias…what is the power structure in our language? (#8)

Understanding patient and family narratives, power imbalances, and how language is used to guide decision-making can lead to greater understanding of the situation:

“One thing people need to realize is there’s no absolute black or white answer to ethical dilemmas… people need to discuss it, as a team approach, need to discuss these issues from multiple perspectives to determine the best interest of the patient and to balance [patient] autonomy and assuring safety.” (#17)

“Learning how to be curious [with] moral inquiry and how to draw out the different dimensions of an issue or ethical concern…spend time unpacking what feels wrong.” (#5)

Participants noted that knowing when and how to seek further ethics education and to initiate an ethics consultation when needed are an important part of everyday ethics.

Everyday Ethics Educational Case Scenarios

Participants identified a wide range of case scenarios that could be utilized to illustrate and teach everyday clinical ethics (Table 2). Topics for potential case scenarios that highlight everyday ethics issues included: not heeding patient concerns; time-sensitive situations and pressures; resource allocation; institutional rule adherence and prohibition; values, preferences, and decision-making; overhearing disparagement of patients/families in public or private settings; and social media dilemmas, among others.

Table 2 Potential educational case scenarios to teach everyday ethics
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For example, regarding not heeding patient concerns, a participant described a situation that could be utilized as an educational case scenario whereby the “patient reported pain [with] a perforated intestine, but clinicians missed the pain and the real issue because of focus on the patient’s history of drug use.” (#20) Regarding resource allocation case scenarios, a participant described the everyday ethical challenge of how to allocate time amongst patients during rounds on a busy unit, noting that, “Some [patients] get a half hour, some get zero. Time is our most precious commodity, and we are rationing it” (#15). Another everyday ethics case scenario in a community health setting revolved around having no arrangements to offer for breastfeeding mothers, “[Breastfeeding mothers] need to pump in a bathroom, clean the bathroom [before pumping], and worry [their] milk will come down. Where’s the dignity? Would anyone else want their meal prepared in a bathroom” (#22)?

During the member checking process, additional educational case scenario ideas were suggested, including knowing when and how to make an ethics referral, assuring the informed consent process and understanding informed refusal, and recognizing when capacity assessments might be in order and knowing who on the team would be qualified to conduct such assessments.

Discussion

“Moral moments” and related everyday ethical challenges are ubiquitous within clinical encounters, yet the skills and capacity of clinicians to recognize and address these issues in real time remain unidentified and underdeveloped. In our study, we turned to experienced bioethicists, as the de facto ethical specialists, to provide insights and practical advice about cultivating everyday ethics skills amongst practicing clinicians. Experienced bioethicists reported a range of skills, which were coded into general and ethics-specific categories, thought to be essential to prepare and fortify practicing clinicians within their roles to ensure the capacity and confidence to integrate everyday clinical ethics into their practice. Participants also identified educational case scenarios that could be utilized to promote clinician learning of everyday ethics practices. Beyond individual level skills, there was recognition that a receptive, supportive organizational culture was also essential to creating and upholding an ethos compatible with everyday clinical ethics.

To be well-rounded, capable, and confident at everyday ethics, participants described that clinicians need a varied, responsive skillset encompassing both general skills and ethics-specific skills. Among categories of general skills, clinicians require understanding of their core values and self-reflective capacity; deftness at interpersonal perspective-taking, genuine empathic presence, strong communication and relational skills; cultural humility and respectfulness; and organizational understanding and know-how.

Beyond these general skills, everyday ethics also requires clinicians to hone ethics-specific skills, including ethical awareness, ethical knowledge and literacy, and ethical analysis and interaction. The interplay between the “general skills” and the “ethics-specific skills” is akin to training in Advanced Cardiac Life Support (ACLS) required for most intensive care clinicians. ACLS training prepares clinicians with a general skill set, allowing them to identify and intervene in the case of a cardiac arrest or other emergency. However, when the basic skill set is insufficient in addressing the needs of the patient, ACLS algorithms prompt clinicians to pursue expert consultation. We imagine the general ethical skills as a skill set that all clinicians should possess in order to identify and begin to address ethical issues; however, when these skills are insufficient, expert consultation with an individual fluent in the ethics-specific skill set (i.e., trained clinical ethicist) should be pursued.

There are similarities between the ethics-specific skills identified in our results and the American Society for Bioethics and Humanities (ASBH) Core Competencies for Healthcare Ethics Consultation, described as the “core competencies” required for clinical ethicists conducting ethics consultation (ASBH, 2011). However, the findings here are meant to represent skills that all clinicians (not formally trained ethicists) should possess in the context of their daily practice, whereas the ASBH Core Competencies represent a skillset specific to the trained clinical ethicist, an ethics expert. These everyday ethics-specific skills include knowing when to initiate ethics consultation, as noted above.

Although general skills are normally taught- at least in part- during medical, nursing, and healthcare training (Cannaerts et al., 2014; Wasson et al., 2017; Lechasseur et al., 2018), participant responses revealed that the most crucial of ethics-specific skills required for everyday ethics is arguably ethical awareness, or the ability to recognize that something ethical is unfolding and demands attention. This is a skill that is often underemphasized in clinical training (Milliken, 2018). Ethical awareness was described as an essential linchpin in the toolbox for clinicians between the threshold of general skills and moving on to incorporate a repertoire of more ethics-specific skills. Milliken (2017) argues that unrecognized everyday ethical issues are a symptom of underdeveloped ethical awareness on the part of clinicians. Ethical awareness may be experienced amongst clinicians as feeling that “something isn’t right,” moral distress, discomfort and tensions related to disparate values and goals, and disagreements or conflicts between patients and clinicians, within clinician teams or within families, or at odds with organizational expectations, guidelines, or standards. As ethical awareness develops and matures, clinicians can become more familiar and more adept at recognizing and identifying ethical issues.

Another ethics-specific skill reported to be important to practicing everyday ethics includes growing clinicians’ familiarity, fund of knowledge and literacy about ethical concepts, principles, and theories to better understand ethical issues and how to approach them through ethical analysis and interactions. Other models, like James Rest’s (1994) Four Component Model, includes identification of the ethical problem (moral sensitivity), the application of moral judgment, engagement of moral intention, and ultimately the pursuit of moral action. This model is conceptually useful, and compatible with our findings, when considering the development of clinicians’ everyday ethics sensibilities and skill set as involving elements of recognition, analysis, and agency.

Participants offered a range of ideas and educational case scenarios that could be utilized to enhance everyday ethics including clinicians’ familiarity with core ethical principles (e.g., respect for autonomy, beneficence, non-maleficence, and justice), focal virtues (e.g., compassion, discernment, trustworthiness, integrity, and conscientiousness), and narrative approaches (e.g., listening to patient stories and gathering healthcare histories). Participants also readily identified common case scenarios that engender ethics, such as assuring informed consent, allyship with minority and marginalized people, shared decision making, time and resource allocation, and healthcare access and disparities (see Table 2). Overall, participants’ suggestions for everyday ethics-specific skills and related case scenarios were compatible with the integrative model advanced by Zizzo and colleagues (2016) whereby everyday ethics serves to detect unseen areas and mobilize practicing clinicians as moral agents by combining elements of clinical ethical theories including narrative ethics, virtue ethics, and care ethics, among others.

In our view, the common morality and virtue ethics may serve as useful foundations and guides for everyday clinical ethics. The common morality represents a set of universal norms shared by persons committed to morality including, for example, to avoid causing suffering to others, to prevent harm, to tell the truth, and to nurture the young and dependent (Beauchamp & Childress, 2019). Breaches of these universal norms, as when participants described feelings that “something isn’t right” and associated with ethical awareness, can reflect everyday ethical challenges in clinical practice. Similarly, virtue ethics was identified by participants as relevant to everyday ethics, with respect to clinicians’ core values such as integrity and trustworthiness within communicative interactions and relationships with patients (Childress, 2009). Professional organizations often incorporate aspects of virtue ethics into their codes of ethics (Donovan et al., 2009). Virtues and values that can be encouraged amongst clinicians to contribute to a flourishing everyday ethics culture include compassion, trustworthiness, integrity, respectfulness, and humility, among others (Beauchamp & Childress, 2019; Donovan et al., 2009).

Further, the moral and ethical space of healthcare institutions provides a valuable foundation upon which everyday clinical ethics can rest (Walker, 1993; Austin, 2007; Liaschenko, 2016). In keeping with the participants’ identification of good communicative abilities and organizational understanding as requisite everyday ethics skills, Walker (1993) prioritizes narrative storytelling and keeping the moral space open where ethicists are free to shift from the role of “engineers and experts” to that of “moral architects and mediators.” In 2007, Austin made explicit that cultivating everyday ethics means to conceive healthcare environments as moral communities where clinicians can be engaged in everyday ethics as part of their standard practice. This can not only combat serious institutional symptoms of dehumanization, fragmentation, and the focus on doing (rather than being present in relationship), but also support practicing healthcare staff who may feel increasingly alone, powerless, and voiceless (Lamiani et al., 2021). An everyday ethics approach holds some promise to promote healthcare organizational cultures that are attentive to moral sensibilities and ethical issues; embrace cultural humility; encourage self-reflective practice; and assure hospitality and equitable treatment to patients and clinicians alike (Meyer et al., 2020; Kalevor et al., 2022; Essex et al., 2023).

Practice and Educational Implications

Developing the skills identified for practicing everyday ethics may offer protection for clinicians from moral distress, or, at the very least, equip them with the skill set to recognize morally challenging situations. Moral distress has been described as the suffering that arises when clinicians cannot act according to what they perceive as morally right (Jameton, 1984). Being aware of one’s own values and of the values at stake in a situation, mastering communication skills to voice one’s own concerns, being able to take the perspective of the other persons involved, and understanding organizational values and practices may converge to help clinicians navigate morally distressing situations through the process of discerning and acting upon their moral agency.

Our findings have several implications for educational practice. Some authors (Sisk & Dubois, 2022; van Schaik et al., 2023) suggest that providing reflective opportunities and debriefing for clinicians after ethical events occur could promote everyday ethics by generating mindful awareness of power hierarchies in relationships, implicit biases and implications of clinicians’ verbal and non-verbal communication. Our results highlight the potential value of including everyday ethics education for healthcare practitioners across disciplines and levels of experience, in ongoing clinical coursework, practice experience, and as continuing education offerings (Grace et al., 2014; Robinson et al., 2014; Jurchak et al., 2017; Mokwunye et al., 2012; Dong, et al., 2018; Rachwal et al., 2018; Stolt et al., 2018; Lee et al., 2020). Ideally, such educational opportunities would occur before common first-hand encounters of everyday ethical events and as part of ongoing debriefing as events are identified and addressed (Meyer et al., 2012, 2020; Rachwal et al., 2018; Kalevor et al., 2022). Participants identified several educational case scenarios depicting common everyday challenges that could be incorporated into educational offerings to cultivate awareness of everyday ethics and ethical virtues. Such scenarios could be used to craft case studies to be discussed in unit-based rounds or embedded in simulation-based education to attune clinicians to their moral intuitions, clarify personal and professional values, and sharpen ethical awareness of issues embedded within scenarios. Through case scenarios such as those suggested by our participants, healthcare students and practicing clinicians could learn to appreciate and better recognize the ethical aspects of their practice, refine skills they may already have, and build upon their everyday ethics repertoire.

Simulation-based education (SBE) can offer a safe psychological space to practice emerging skills and lends itself well to learning everyday ethics skills such as perspective-taking, empathic presence, and communication and relational skills (Browning et al., 2007; Meyer et al., 2009). Standardized patient methodologies offer advantages of providing valuable individualized feedback and encouragement to learners regarding their empathic presence, communication, and interpersonal skills that are, arguably, the crux of manifesting everyday ethics (Browning et al., 2007; Meyer et al., 2009; Nestel & Bearman, 2014; Bell et al., 2014). Moreover, Ziv and colleagues (2003) consider simulation as the ethical educational choice since it does not put patients at risk for substandard care and protects patients from harm. Simulation-based education has been successfully integrated into ethics education (Buxton et al., 2015; Krautscheild & Brown, 2014; Lewis et al., 2016; Donnelly et al., 2017; Krautscheid, 2017; Ruyak et al., 2017; Diaz Agea et al., 2018). For example, to address gaps in learning and to educate students in accordance with the American College of Nurse-Midwives Professional Code of Ethics, Buxton et al. (2015) utilized SBE to explore ethically challenging midwifery scenarios. Similarly, Ruyak and colleagues (2017) demonstrated the value of simulation education to explore ethical issues of grief and loss, as well as the concept of conscientious objection as put forth by the American Nurses Association. Krautscheid and colleague’s work (2014, 2017) explored the relevance of simulation education specifically with respect to microethical challenges related to nursing medication administration.

Several limitations of this study must be acknowledged. The sample of bioethicists was recruited from a single, urban, northeastern, US, academic bioethics center housed within a medical school that offered ongoing education and professional community engagement. Although participants represented several healthcare institutions, they were affiliated with the same center for bioethics and, therefore, may express a vision of everyday ethics and of related skills which is implicitly embraced in that specific setting. Data were collected from experienced bioethicists who, in most cases, were clinicians themselves. As such, the question arises: are experienced bioethicists in the best position to determine the everyday ethical skill set of practicing clinicians who do not have formal ethics training? A more bottom-up, complementary approach to learning about everyday ethics, and the requisite skills to express it, would also engage patients and practicing clinicians directly about the most common value tensions that arise and constituent components. Lastly, the semi-structured interviews were not audio-recorded, but rather field notes were written in real time and reviewed with subjects for accuracy and meaning. It is also worth noting that most interviews took place prior to the advent of the COVID-19 pandemic and, as such, findings are not reflective of the additional stressors placed on healthcare systems during that challenging time.

To address these limitations, future directions to identify the requisite skill set for everyday ethics might include conducting interviews with a more diverse cohort of bioethicists, as well as practicing clinicians who do not have formal ethics training. Similarly, it would be valuable to ascertain the lived experiences of practicing clinicians regarding their perceived everyday ethical challenges and whether the suggested educational case scenarios include a resonant, representative, and thorough inventory. Beyond interviews, more diverse data collection methods could be employed to better understand and establish everyday ethics skills and educational needs, including ethnographic observation, clinician journaling, and review of formal and informal reasons that generate ethics consultations. Crafting realistic, replicable, experiential educational case scenarios based on the suggestions of our participants, for role play and other simulation-based educational modalities, could move the needle forward on building everyday ethics skills and capacity within our clinicians and across our healthcare organizational cultures.

Conclusion

Everyday clinical ethics unfolds within the moral relational space of encounters between patients, families, and clinicians. Yet, there are educational gaps in preparing interprofessional clinicians to recognize ethical issues and to practice everyday ethics. Essential skills for everyday ethics include an understanding and integration of core values and self-reflective capacity, the ability to take others’ perspectives and to be empathically present, versatile communication and relational skills, genuine cultural humility and respect, and organizational astuteness. Cultivating keen ethical awareness and the ability to recognize ethical issues, even if not labeled as such, are critical skills in helping clinicians to practice everyday ethics- and, we believe, need to be explicitly discussed, modelled, taught, and nurtured. Building a sound working knowledge and fluency of ethical principles and approaches and bringing them to bear to generate concrete ethical steps constitutes essential foundational skills for those practicing everyday ethics. The combination of general and ethics-specific skills identified by participants enables building greater awareness, capacity, and confidence amongst clinicians in ubiquitous everyday clinical encounters. Importantly, a receptive values-based organizational culture promotes an ethos of everyday ethics as essential and complements the individual skills and effort of clinicians to uphold the dignity of patients, and to address needs in a manner consonant with patients’ values and preferences. Bridging the everyday ethics educational gaps is overdue and stands to build capacity amongst clinicians to embed ethics into their standard practice. Embracing such an everyday ethics approach holds the promise of catalyzing a more responsive, preventive approach to ethical tensions and transforming our healthcare institutions into vibrant moral communities that can better sustain us all.