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Nurses learn to 'speak the language of ethics'
Program helps nurses contribute to ethics discussions
Some of the language of ethics doesn't come naturally to nurses, according to a nurse-ethicist. But an initiative by Indianapolis-based Clarian Health aims to make ethics training and discussion second nature to the 5,000 nurses working there.
"All nurses will encounter ethical issues, and as a new nurse, you develop experience on a continuum from novice to expert," says Lucia Wocial, RN, CCNS, PhD, nurse ethicist at Clarian's Charles Warren Fairbanks Center for Medical Ethics. "You become more aware of ethical issues as you gain more experience, and by centering our ethics training around the units where they work, their ethics training develops along with their experience."
The Fairbanks nursing ethics program focuses particular attention on the system's intensive care units, where severe illness and high-tech medical care often raise important ethical questions for hospital staff, patients, and families. Through staff education, consultation support, and research, Clarian's nurses will have support in managing ethical conflict and emotional distress that can result from carrying out a plan of care that sometimes contradicts their beliefs about what is in the best interest of the patient.
Nurses confront ethical dilemmas, too
Wocial says that while "nurses don't drive the bus" when it comes to treatment decisions, they often are the people patients and families have the most frequent contact with, and often get asked difficult questions while carrying out prescribed treatment.
"Doctors are in charge, and one of the challenges I've seen as nursing has come into its own is that nurses talk about nurse ethics in an adversarial way [to physician ethics], and that's counterintuitive," Wocial explains. "We need to introduce nurses as an interdisciplinary team member. The initial grant from the Methodist Health Foundation to begin the program in nursing ethics is consistent with Clarian's desire to bring nurses to the ethics table as equal partners. The most recent $5.4 million gift from the Richard M. Fairbanks Foundation will support this program and others at the Fairbanks Center."
Nurses don't establish plans of care, she continues, "but we have input and an ethical perspective, and as a nurse you have a completely different relationship with patients than physicians do, so you have a different perspective that can be extremely valuable."
For example, a DNR (do not resuscitate) order is a physician's order, so a nurse can't have "the DNR talk" with families to actually establish the order, Wocial says. However, nurses are in a good position to talk with the family about what to do when the patient can't speak for himself, and generally prepare the family to talk with the doctor about the DNR order.
"And when you help teach nurses to speak the language of ethics, they can make more of a contribution to the health care team," she adds.
The nursing ethics program at Clarian centers around unit-based discussions; the nurse ethicist and other faculty from the Fairbanks Center go to individual nursing units to conduct conversations in ethics. The topic of the conversation is driven by those who come to the conversation, typically a patient situation happening on the unit, or a type of situation often encountered. The goal of the conversation is to provide a morally safe space for participants to discuss their concerns and identify strategies for managing their distress or resolving ethical problems.
"The unit-based discussions can give them real-time opportunities to learn to speak about ethics in an effective way, to harness emotions they feel about ethical issues and channel it into a constructive approach to the issue," Wocial suggests. Each unit-based session is an hour long; as of early January, Wocial, who has been on the job since July 2007, already had 80 such sessions scheduled.
"What we know is that nurses who participate in the discussions go back and participate on a different level with their patients at the bedside," she says. "They take the skills and thinking that we role model during the discussions, and they take that back to the bedside."
Predictably, nurses on critical care units and oncology units are creating the most demand for the unit-based ethics discussions.
"When you're facing the issues of patients dying, the nurses who are exposed to dying patients for hours a day have a higher need for ethics conversations," she says.
The discussions aren't just changing how nurses interact with their patients, Wocial adds. "We're starting to see how it affects how nurses communicate with physicians," she says.
"They are thinking more about what's happening, rather than just reacting to the situation. It's very easy to just react to something you hear about, but when you step back and think about it and sort it through, you can see that there's an ethical decision being made there, when before you might have been so busy that you didn't recognize it. And that's what we're encouraging nurses to do," which is important, she points out, because as a profession, nurses make up the largest proportion of members on Clarian's hospital ethics committee.
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