It is increasingly recognised that ethical dilemmas in the veterinary profession can be a cause of psychological harm to veterinary professionals (Williamson et al, 2022). Potential harms such as moral injury, compassion fatigue, disenfranchised grief, and post-traumatic stress disorder are commonly reported in human nursing (Giannetta et al, 2021), and studies of veterinary professionals suggest such harms may also be common in this industry (Moses et al, 2018).
There is a growing body of research into veterinary mental health and approaches to support and resilience (Royal College of Veterinary Surgeons, 2022a). This tends to focus on veterinary surgeons because of their decision-making responsibilities, but veterinary nurses are also faced with ethical challenges and the psychological issues these may raise (Quain et al, 2021).
As yet, there is little research into possible methods for mitigation of moral injury and related issues. However, it is possible to draw on research conducted in human medicine. Studies involving human nurses have evaluated a range of different approaches, including education, group discussion and reflective practice (Morley et al, 2021). These studies show that having a sense of moral community helps nurses evaluate their own decision making and supports them in giving voice to their concerns (Traudt et al, 2016).
Moral agency, or the ability to be able to speak up for patients, was also identified as a mitigating factor in moral injury (Hatefimoadab et al, 2022).
Moral injury in the medical field is often associated with a sense of betrayal; of not being able to act according to one's values (French et al, 2022).
Veterinary nurses can sometimes feel left out of the decision-making process, or that their voices are not heard (Vivian et al, 2022). There can often be a focus on personal resilience to overcome ethical challenges, but personal resilience has limited effectiveness if the person is not in a supportive environment (Rushton, 2017).
Developing opportunities for inter-professional ethical discussion may help mitigate the risk of moral injury. This article examines the use of Schwartz rounds and veterinary clinical ethics committees as possible approaches to reduce the risk of moral injury.
Schwartz rounds
Schwartz rounds are named after their originator, Kenneth Schwartz, who was diagnosed with cancer in his 40s and died after 11 months of treatment. During his treatment, he found the compassion shown by some doctors and nurses made ‘the unbearable bearable’ (Schwartz Centre, 2022). After his death, a foundation was created in his name to promote methods for supporting compassionate care in medicine (Schwartz Centre, 2022). Since that time, hundreds of hospitals in the USA, UK and other countries have adopted Schwartz rounds as a method for improving the emotional health of staff (Taylor et al, 2018). As with so many practices in human medicine, Schwartz rounds are beginning to be considered as a way to support veterinary professionals (Mind Matters, 2022).
The original structure for Schwartz rounds is a meeting of multiple staff with different backgrounds (Pepper et al, 2012). In the veterinary world, this might include veterinary surgeons, veterinary nurses, patient care assistants, receptionists, management and support staff, and anyone else involved in patient and client care and support. The format is a 1-hour meeting, usually at lunchtime, with food provided. Staff are encouraged to talk about cases they have found emotionally challenging; there is a trained facilitator to help start the discussions and keep them on track (Pepper et al, 2012). The focus is not on clinical practice or treatment, but on the emotional response of staff (Pepper et al, 2012).
Given that this is a relatively new approach, there is limited research regarding the effectiveness of Schwartz rounds in the UK medical community. Taylor et al (2018) carried out a scoping review that noted that ‘all of the interventions had evidence of positive benefits to self (e.g. raised self-awareness, resilience, job satisfaction, empowerment or overall well-being’. Studies have shown that Schwartz rounds can build a culture of openness (Baker et al, 2016), normalise emotions (George, 2016) and promote connectedness within the team (Maben et al, 2018).
These results suggest that Schwartz rounds might be helpful in the veterinary environment as well. The challenge is that, in busy clinics, it might be difficult to ensure that all staff are able to attend. One possible solution would be to have staff attend on a rolling basis, so that each Schwartz round consisted of a slightly different group, which would ensure that all members of the team would be able to benefit while still meeting operational needs. The advantages of Schwartz rounds are that they are not hugely time consuming, and there is a structure to follow.
The Point of Care Foundation (https://www.pointofcarefoundation.org.uk/) is the Schwartz Foundation representative in the UK, and they provide training and support for clinical providers. Veterinary businesses that would like to consider this option would be able to work with an organisation that has experience in implementing Schwartz rounds.
Ethics committees in practice
Most academic institutions involved in research in the UK have their own ethics committees (Koepsell et al, 2014). Research involving animals is often covered by the Animals (Scientific Procedures) Act 1986, although some veterinary research is covered under the Veterinary Surgeons Act 1966.
Research ethics committees are generally tasked with ensuring that research respects the rights and welfare of the participants (NHS Health Research Authority, 2021). Universities and the Royal College of Veterinary Surgeons (2022b) have their own research ethics committees that evaluate any potential research projects and provide guidance in ethical research design.
In human healthcare, clinical ethics committees are part of health boards and major hospitals, both in the UK and overseas (Aulisio and Arnold, 2008). These committees are responsible for ensuring that staff, patients and family have representation in the discussion and evaluation of treatment options, when ethical dilemmas are involved (Magelssen et al, 2017). The focus is on clinical cases and what went well or badly, in order to inform future clinical practice and policy (Magelssen et al, 2017).
Other areas of healthcare have instituted ethics committees. In Norway, clinical ethics committees were established in several municipalities (Magelssen et al, 2020). These were intended to provide support for a range of services, such as public health centres, nursing homes, home-based care, school health services, substance abuse and mental health services, and for general practitioners (Magelssen et al, 2020).
The North Carolina State University Veterinary Hospital started a clinical ethics committee for veterinary practice (Rosoff et al, 2018). This was based on common practice in human medicine, after examination of several clinical ethics committees. The impetus behind this move was from a veterinary social worker in the hospital who described problems associated with veterinary treatments advancing more quickly than approaches to implementation, resulting in ethical challenges for staff and clients (Rossoff et al, 2018).
After perusing the literature, the authors concluded that no clinical veterinary ethics committee was in existence elsewhere; this led them to develop their ethical committee based on a human medicine model.
Function of a veterinary ethics committee
Similar to a clinical ethics committee in human medicine, a veterinary ethics committee should evaluate ethical dilemmas seen in practice and provide useful recommendations for resolving similar issues in the future. Ethical theories and the stated or assumed values of different stakeholders can be used in the evaluation process. These are considered alongside normal clinical decision making, animal and human welfare concerns, and legal and professional standards. The committee should agree on suitable recommendations, which are summarised and submitted to management and the rest of the team. Policies can then be written or adjusted based on the needs of the organisation and the values of its members.
Meetings and actions
The frequency of committee meetings will depend on the needs of the organisation. Every 6–12 months is likely to be sufficient, depending on the frequency of ethical issues being raised. Every member of staff should have the opportunity to raise ethical issues. This can be done via a specific email account, in written form, or any other method suitable to the situation.
Having the option to submit concerns anonymously may ensure that people feel able to raise issues without the risk of retaliation, especially when the issue relates to personal or organisational behaviours within the organisation. However, when people have specific issues about behaviours within the team, they should be encouraged to follow normal procedures. Team members should be made aware that the ethics committee is for resolving differences in values, not personal clashes.
One member of the team – typically the chairperson – will be responsible for collating and summarising the issues raised. This summary will form the basis of the meeting agenda and should be circulated before meetings. This allows members to consider the issues beforehand and do any research they feel is appropriate.
During the meeting, each issue is discussed. The clinical, welfare, practical, professional, legal and ethical implications should be considered, as appropriate to the issue. Each member should have the opportunity to speak. The aim of this discussion is to agree on recommendations for future actions. Decisions need not be unanimous, but they should represent the considered reflection of the majority of the groups.
After each meeting, one member will have the task of summarising the issues and recommendations. This information should be fed back to the whole team, especially those responsible for policy and decision making. The recommendations are not necessarily binding but help to inform the decision-making process.
Composition of an ethics committee
An ethics committee may have any number of members. Ideally it should have enough that most or all of the stakeholders have some kind of representation. However, keeping the numbers low makes it easier to have efficient meetings and come to an agreement. Specific numbers are best decided based on the type and size of the organisation.
Membership should change from time to time, to ensure the full range of different opinions is heard. A suggested composition for a veterinary ethics committee, based on Slowther et al (2004) and the author's own experience is to have a chairperson, a team member and external or lay members.
Chairperson
This person should generally be relatively experienced and senior, with a good understanding of professional ethics. However, it is usually best for this person not to be part of the management team, as this can create the impression that the committee is a rubber stamp for management decisions, rather than an independent group representing everyone.
Team members
The committee members should represent a selection of different parts of the team. Examples might be veterinary surgeons, veterinary nurses, veterinary care assistants, students, or receptionists.
Ideally, there should be a mix of different genders, cultural backgrounds, and lengths of experience.
The makeup of the specific organisation will determine the number and characteristics of the members, however it should be varied enough to be reflective of different values within the team.
External or lay members
The external or lay members of the committee are people with knowledge of professional values and decision making, but who are not part of the veterinary industry. They are there to provide the voice of the general public. Examples of suitable members might be those from a professional background with its own code of ethics, such as lawyers, accountants or ministers. One external member is likely to be sufficient.
Committee output
As discussed above, the committee should provide a summary of the issues and the committee's recommendations to the team. When decision makers of the organisation have meetings, they should consider the recommendations. The goal is to ensure that there is the smallest possible gap between the values of the organisation, the values of the employees, and the policies and decisions that govern normal activity. Ideally, the process should be transparent; that is, each employee should see that issues have been raised, discussed and that the results were included in decision making. While it is unlikely that everyone would be happy with every decision, team members should feel that they have a voice, and that their values have been considered.
Conclusions
Intra-professional communication about ethical issues has been shown to have positive effects on mental health in medical teams. Veterinary professionals are likely to experience similar benefits. Clinical ethics committees offer a structured approach to ethical decision making and feedback and may be suitable for veterinary referral hospitals or multi-practice groups. They offer an opportunity for veterinary nurses to be involved in ethical discussion and decision making. Veterinary nurses could also play a role in advocating for a committee approach and the management of a committee. This approach has the potential to improve communication in teams and allow all team members an increased sense of moral community and moral agency.
KEY POINTS
- Ethical challenges are frequent in veterinary practice, and workplace support can improve staff resilience when faced with dilemmas.
- Given the frequency of ethical dilemmas arising in veterinary practice, and the possible prevalence of moral injury in the veterinary profession, Schwartz rounds or ethical committees may be helpful in ensuring the values of all stakeholders are considered.
- Schwartz rounds are relatively easy to implement and have been found to be valuable for medical staff worldwide.
- The findings of an ethics committee can help shape policy decisions that recognise the values of all stakeholders, which in turn may improve feelings of moral agency and community among veterinary staff.