In nine years serving as the nurse ethicist at a children’s hospital, Patricia S. Robinson, PhD, APRN, NE-BC, has led dozens of consults.
“Almost every time, it was the result of one profession not trusting the intentions of another profession,” says Robinson, scientific director at AdventHealth Research Institute Orlando (FL).
Conflicts continually happened between nurses and physicians, families and physicians, and social workers and families. “It seemed to me that it reflected a lack of mutual trust, and led to a lot of unnecessary moral injury,” Robinson observes.
Weekly PEACE (Patient Experience and Communication Excellence) rounds, implemented in 2016 in the pediatric intensive care unit (ICU) at Riley Hospital for Children at Indiana University Health, had been shown to ameliorate healthcare providers’ moral distress and shorten length of stay for some patients.1 “It resonated as a potentially helpful tool,” Robinson says.
A similar approach was implemented at AdventHealth for Children’s neonatal ICU in 2018. Sessions are held biweekly or monthly, depending on the unit’s needs. “The idea was to have conferences about staff self-care and care of one another in cases that were sure to lead to moral distress without this intervention,” Robinson explains.
Rounds are scheduled 30 minutes after shift change. Doctors and nurses are so eager to voice concerns that some call in on their days off to participate. If a difficult case is under discussion, the family’s caregivers can attend when colleagues agree to cover their shifts. “We have equal participation between shifts because the night shift craved the ability to be heard,” Robinson adds.
To learn more about the benefits of PEACE rounds in the NICU, researchers interviewed 24 NICU healthcare providers and observed 12 interventions.2 The findings suggest PEACE rounds:
- improve interdisciplinary communications and collaboration;
- relieve employee distress;
- reduce the number of ethics consultations;
- do not need to be facilitated by a trained ethicist.
“Anyone with conflict management skills, whose focus is the team, would be appropriate,” Robinson notes.
Most cases center on misunderstandings due to poor communication, not ethical conflicts. “What we are really providing is a communication consult. We found a nurse educator, who was familiar to all clinical staff, to be an excellent facilitator,” Robinson reports.
Since PEACE rounds started, there has not been a single ethics consult in the NICU. Instead, “difficult questions have been answered by the medical team,” says Laura Baran, MS, BSN, RNC-NIC.
As a nurse educator for AdventHealth, Baran is viewed as a neutral member of the team, neither leadership nor a bedside nurse. “Even when it is not what bedside staff want to hear, there is more respect and understanding for decisions,” Baran says.
Team members tend to be more comfortable talking about patients and procedures than about their own distress and emotions. “Dedicated time for interdisciplinary self-care is the novel aspect of this intervention,” Robinson says.
That is particularly resonant during the COVID-19 pandemic. “This is a scalable approach in a time when moral injury is high, and there are not enough ethicists to go around,” Robinson offers.
A recent PEACE round revealed nurses wrongly assumed physicians ordered what the nurses viewed as nonbeneficial treatments to avoid litigation. In reality, the physicians were carrying out family directives, Robinson reports.
Additionally, another PEACE round revealed night shift nurses believed decisions made by the day shift seemed inappropriate. In one case, a night shift nurse was caring for a fragile neonate with no hope of long-term survival. During a procedure, the nurse noted grimacing and vital sign changes that indicated pain. “Parents and ordering physicians were not there to witness the suffering,” Robinson notes.
The problem was that family conferences and attending rounds happened only during the day. “This left the night shift voiceless,” Robinson says.
The team created a handoff tool that allows outgoing shifts to convey the reasons behind their treatment decisions. “With an ability to share information back to day shift providers, night shift staff felt more included and less isolated,” Robinson says.
The incorrect assumption in this particular case was that day shift nurses did not care about the baby’s suffering. “In fact, they were unaware of it,” Robinson adds.
The night shift nurses acknowledged they were obligated to communicate effectively to the day shift. Team members were asked to assume their colleagues had good intent. “There is increased trust that the treatment team, and families, intend to act in the best interest of patients,” Robinson reports.
In the NICU, families often are making critical medical decisions for a baby they have just “met.”
“Sometimes, they have months of preparation to consider their goals and values in light of abnormal ultrasound findings. Sometimes, they find themselves in the NICU completely by surprise,” says Kim Sawyer, MD, MA, a pediatric palliative care physician and bioethicist at St. Jude Children’s Research Hospital in New York City.
If infants’ gestational age and birth weight are major concerns, evidence-based data on survival and developmental outcomes help inform decisions. “However, how to apply that data to an individual baby’s care decisions, in light of a family’s values and preferences, can be difficult,” Sawyer says.
The emotional weight of making decisions for a new baby, which significantly affects the child and family, raises some unique ethical issues in the NICU. “This is not to say those issues don’t arise outside of the NICU. But a family typically has had more opportunities to get a sense of who their child is that may help guide them,” Sawyer says.
Ethics rounds can be a more casual forum in which to discuss complex ethics questions. Hopefully, this happens before conflicts arise. “This may help prevent moral distress, by giving staff a well-rounded, informed way to think through tough situations,” Sawyer adds.
- McManus K, Robinson P. Evaluation of NICU healthcare providers’ experience of patient ethics and communication excellence (PEACE) rounds. Adv Neonatal Care 2020; Jul 7. doi: 10.1097/ANC.0000000000000774. [Online ahead of print].
- Wocial L, Ackerman V, Leland B, et al. Pediatric ethics and communication excellence (PEACE) rounds: Decreasing moral distress and patient length of stay in the PICU. HEC Forum 2017;29:75-91.