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Peer ethics network created in Vancouver
Program puts frontline ethicists in every unit
It is a common reaction when a judgment call has to be made in any setting: We turn to the person next to us and say, "What would you do?"
When Providence Health Care system, a network providing health care at several sites in Vancouver, BC, was formed in 1997, the ethicist for the system saw an opportunity to build on that peer-adviser idea as a way to handle day-to-day ethical dilemmas. They created ethics mentors in every unit of every hospital in the system.
The Ethics Network was launched in 1999, and now is directed by health care ethicist Bashir Jiwani.
"When Providence came together, my predecessor, Kevin Murphy, [determined] what the ethics services would look like," he recalls. "He decided that every unit, every area, [and] every program would have an ethics mentor."
These ethics mentors were volunteers from the staff in those units. They were trained in medical ethics and were available anytime they were at work to help sort out ethical dilemmas as they arose.
"That person [was] a first line of support when an ethics question arose in the clinical setting," explains Jiwani.
"So we had our mentors, and they were trained and sent back to their units at their institutions," he continues. "The mentors at each institution [formed] ethics teams for their institution, to do some proactive kinds of work."
Jiwani says response to the Ethics Network has been enthusiastic — at its inception, 90 staff volunteers went through two days of training. As of this year, 400 ethics mentors — including staff, physicians, and nurses — have been trained and sent back to their units to be used as resources when ethics questions arise.
After a year, the network received rave reviews for what hospital staff described as its "collegiality" — the process of working through ethics questions with colleagues gave employees more confidence in their abilities to deal with the situations.
Hospitals are places of life and death so, for hospital staff, ethical dilemmas aren’t just theoretical — they’re a challenging, practical part of everyday work, says Jiwani. And being able to rely on the mentors who are on the floors and in the units to help solve ethical questions that arise in their areas of specialty makes sense, he adds.
Ethics Network mentors can call on Jiwani for ethical questions that are beyond their level of expertise. But when it comes to minor situations, the peer ethicists are available on all shifts and in all units, and have, in many cases, been highly successful in carrying out the goals of the program.
He says the successes of the program stem from the individuals who act as mentors, rather than the situations or units where they work.
"You can see places where it’s working and others where it’s not, and it has much more to do with the people and their sensitivity for the work than it does with what department they are working in," Jiwani adds.
Building on success, tweaking the weaknesses
As successful as the program has been in some respects, it is time to move on to the second phase, Jiwani says. That will allow the Ethics Network to build on its strengths while correcting some weaknesses.
"I have heard stories of some mentors feeling uncertain of what to do," he says. "They say nobody ever asks them anything, and they don’t really have the power to jump in and say, There’s an ethics issue here.’"
Future training will include more material to help the mentors better understand what to do with the new knowledge they have.
"We have some other challenges, as well," Jiwani admits. "We have recognized that the folks who attend the seminars might not have been trained well enough to do the tasks we were asking them to do."
Training is, by far, the greatest expense associated with the peer mentor system. But as the Ethics Network grew, Jiwani and Providence administrators realized they needed to give infrastructure some attention to allow the mentors to be most effective.
"The mentors were asked to do the work, but were not given the space on their units to do the work," he says. "The key is not just sending them to the educational programs and then saying, Go do it.’ We have to find room for them to use their expertise."
The second phase of the Ethics Network includes working with managers on all the system’s units to build up the ethics resources throughout the system. "We have some wonderful energy, and quite a few people with the sensitivity for ethics work, so now we are focusing on every specific program area and working with the leaders in those areas," Jiwani explains. "For example, we have a bunch of mentors in the eating disorders clinic, so now we want to work with the leaders of the program and say, Can we take one or two of these people out, give them more intensive training, and then create an infrastructure so these people are given the space to raise the questions ethics trains them to raise?’"
The Ethics Network at Providence is a homegrown ethics solution created by and for the facilities that make up the Providence network, but Jiwani says it can be tailored to work in systems or institutions in other areas and of other sizes.
In fact, Jiwani copied it himself.
"Before I came to Providence, I was working as an ethicist in one of the regions in Alberta, [structuring] a regional ethics program," Jiwani reports. "I knew Kevin [Murphy], and knew what he was doing here, [so] I drew on that a great deal.
"That’s one of the nice things about this — it’s eminently translatable to other settings."