BY: MONSIGNOR STEVE WORSLEY, MD, STL, and PAM DUCHENE, PhD, ARNP, CNAA
Msgr. Worsley is vice president, mission and ethics; and Dr. Duchene is vice president, patient care services, both at St. Joseph Hospital, Nashua, N.H.
Case No. 1: Judy, a seasoned emergency department nurse and a devout Catholic, is concerned about the care provided to women who visit her department seeking contraceptive services. In many states, including New Hampshire, "Plan B", or the prescription of two levonorgestrel tablets (0.75 mg/tablet), is available to women aged 17 and older who request emergency contraception.1 Recognizing Judy's distress, a colleague suggests that she request an ethics consultation. In 20 years of practice, Judy has never participated in an ethics consult and is unsure of the implications of doing so.
Case No. 2: Margaret is distressed when her patient pleads, "Leave me alone — I want to die." The patient had been brought to the hospital by her family for refusing to eat. Although the patient has plenty of complaints, none of them is a terminal illness. A consulting psychiatrist believes the patient has an easily reversible case of clinical depression. Margaret is torn between her desire to help the patient get better and her feeling that the hospital should respect the patient's wishes.
These examples are not unique — they occur in hospitals across the country. In both cases, an understanding of the Ethical and Religious Directives for Catholic Health Care Services and relevant hospital policies might have helped reduce staff conflict and stress.2 Yet many staff members in Catholic health care remain unfamiliar with the ERDs and the wisdom they offer, even though they were first published more than 35 years ago.
Here at St. Joseph Hospital and Trauma Center, Nashua, N.H., we were surprised to discover, during a mission assessment conducted earlier this year, that many of our employees were unfamiliar with the ERDs. In fact, we found that, although St. Joseph possessed a well-established ethics program and had invested considerable energy in ethics education, many of our employees didn't know how to request an ethics consult.
Since every St. Joseph employee participates in and shares responsibility for the organization's ethical behavior, we felt compelled to reexamine how we share information concerning key ethics resources. The approach we were taking to ethics education was clearly not adequate.
Fortunately the tools needed to ensure hospital-wide familiarity with the ERDs and other ethics resources already existed within our facility.
Using Exiting Tools
Computer based learning (CBL) is increasingly used throughout our organization for both mandatory and optional professional development. Our employees are accustomed to monthly systemwide updates on topics such as safety and compliance. Participation is verified and test results are routinely tracked for all employees. Departments in which employees lack routine access to computers (e.g., housekeeping, food service) have developed effective practices for reviewing materials in a group setting and in multiple languages. Moreover, staff members are able to access CBL from any work site or during any shift. CBL has dramatically improved compliance in completion of mandatory educational programs.
Building on the success of CBL, and drawing on materials published by CHA, we prepared an online introduction to the ERDs. We also prepared a second module explaining how to request an ethics consult and what to expect from it. In just six weeks, almost half of our 1,750 associates had successfully completed both modules. Such a response would not have been possible without CBL, especially since our employees are based at multiple sites and work varying shifts. We are now developing additional modules in collaboration with specific departments (e.g., labor and delivery, finance) that will be customized to their specific needs and contain relevant case examples.
Technology helps us ensure that every employee is invited to participate in the ethical conversation and life of our organization. Of course, we recognize that CBL is an adjunct to other means of learning, not a substitute for it.3 Shared reflection on real cases lies at the heart of our educational process. Scholars such as Fr. Kevin Fitzgerald, SJ, PhD, of Georgetown University; Philip Boyle, PhD, of Catholic Health East; Jan Heller, PhD, of Providence Health & Services; and Sr. Carol Descoteaux, CSC, PhD, have come to St. Joseph to lead discussions of ethical issues. These discussions are enormously popular with our staff.
Like many other health care organizations, ours has benefited greatly from the National Ethics Champions Collaborative developed by Boyle and his colleagues. Technology has made real-time participation in these conferences possible anywhere in the country. With Boyle's approval, our hospital's information systems staff makes recordings of past conferences available to employees on demand, 24/7, from any computer within our organization. The recorded conferences also provide us with a wealth of material that we use for facilitated ethics discussions in local physician practices.
In addition, ethics programs offered by our sponsor, Covenant Health Systems, Lexington, Mass., and by CHA offer good value at modest cost.
A Database for Ethics Consults
Ethics consults offer excellent learning opportunities for both individual caregivers and our organization as a whole. Accordingly, we have begun tracking our ethics consults using a database constructed for us by our colleagues in St. Joseph's Quality and Resource Management Department. The database offers an effective and flexible means for determining, for example, where requests originate and which questions are asked most frequently.
The database also provides a convenient tool for retrieving old consult reports and patient charts while, at the same time, strengthening patient confidentiality. In doing so, it enhances our ability to support process improvement throughout our organization — a goal established when we adopted a "Next Generation Model" approach to clinical ethics last year.4 Thus we are better able to keep our commitment to improving the experience of patients and staff, both now and in the future.
Low Cost of Implementation
The success of these ventures is due in large part to the strong support and the keen insights of our colleagues in St. Joseph's Information Systems, Medical Affairs, Quality and Resource Management, and Patient Care Services departments. They knew what would work and how to make it happen.
By using tools that were already in place within our organization and familiar to our employees, the work and expense associated with implementation were limited. With existing technology, we have been able to:
- Ensure that all employees have 24/7 access to the ERDs
- Provide all employees with an introduction to basic ethical principles, as well as guidance in how to apply them and how to obtain help
- Document employee comprehension individually, by department, and across the system, thereby identifying needs for additional ethics education and support and opportunities to provide it
- Offer a variety of additional resources for ethics education, customized according to individual or departmental needs
- Analyze ethics consults for opportunities to improve the way we deliver patient care
What began as a mission assessment undertaken at the behest of our sponsor became the catalyst for greatly strengthening the ethical resources provided to associates throughout our organization. All clinicians experience situations like those presented at the beginning of this article, and many work in organizations with strong ethics committees and programs. However, resources are of value only if people know of their existence. At St. Joseph, we have developed a new awareness of the depth and dimensions of the resources we have available to resolve ethical dilemmas.
NOTES
- R. K. Zurawin and L. Ayensu-Coker, "Innovations in Contraception: A Review," Clinical Obstetrics and Gynecology, vol. 50. no. 2, June 2007, pp. 425-439.
- U.S. Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, 4th ed., 2001, Washington, DC.
- L. Helle, et al., "Ain't Nothing Like the Real Thing: Motivation and Study Processes on a Work-Based Project Course in Information Systems Design," British Journal of Educational Psychology, vol. 77, no. 2, June 2007, pp. 397-411.
- For more on the "Next Generation Model," see N. P. Bancroft, "The 'Next Generation' Model," Health Progress, vol. 85, no. 3, May-June 2004, pp. 27-30, 55; and K. Murphy, "A 'Next Generation' Ethics Committee," Health Progress, Vol. 87, no. 2, March-April 2006, pp. 26-30.