Address your moral distress
EDITOR'S NOTE: Heather Stringer is a freelance writer.
When a pediatric intensive care nurse approached the ethics committee at Children’s Hospital Colorado several years ago, she expressed concern about the high level of moral distress among nurses in her unit — and she sensed the problem was not isolated to the PICU.

She was interested in starting a program that would help nurses better navigate the ethical issues leading to moral distress. The hospital’s CNO agreed to the idea, and the ethics nurse liaison program was born in 2004.
Since then the program has grown dramatically and transformed the experiences of patients and clinical staff facing ethical dilemmas in nursing. Nurse.com talked to the leader of the program, Heather Fitzgerald, MS, RN, a clinical nurse ethicist at the hospital.
It sometimes seemed that medical teams expected ethics consults to result in a decision that agreed with their view, rather than consider the varying values and ethical issues at stake for interprofessional team and family members.”
— Andrea Holecek, RN
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Q: How did the ethics nurse liaisons program begin and how has it improved the dynamics in these complex situations? A: My predecessor started the program by approaching nursing clinical managers and directors to get recommendations for people who might be interested in ethics education and in being a resource on their unit. She recruited 30 ethics nurse liaisons who represented 15 clinical areas, including the pediatric, neonatal and cardiac ICUs, the ED, oncology and the transplant team.

This group started meeting every other month to deepen their confidence and competence in identifying ethical issues and supporting their teams. We now meet monthly and have guest speakers, review literature and watch short films or podcasts related to ethical issues, and follow this content with discussions.

Q: Could you give an example of how the liaison program is changing care at the bedside? A: In the meetings, the liaisons get an opportunity to learn how to skillfully navigate complex situations, and other nurses on their units seek them out when these circumstances arise. One of our ethics liaisons had been very involved with a number of patients and families dealing with end-of-life decisions, and she is known for her ability to decrease the anxiety felt by clinical staff and promote excellent communication in patient care situations.
There was a situation when the clinical team was concerned that it wasn’t medically appropriate to prolong a child’s life given their sense of the quality of life the patient would experience. The ethics liaison helped the team see how the child was loved and valued in the family system, and that their judgment about the child’s quality of life differed from the family.

She was able to align the team and family about the goals of care, clarifying that everyone shared the aim to promote comfort and prevent suffering. When the child later died, it happened with far less distress as a result of these important discussions.
Who’s teaming up with ethics nurse liaisons?
Physicians
Chaplains
Respiratory therapists
Social workers
Q: What else do ethics liaisons do? A: They hold at least two ethics rounds per year in which they provide an hour of education on a topic that is meaningful to their team. They also connect people to resources, such as ethics conferences or luminaries who are coming to campus to speak.
I’ve mentored other hospitals nationally that are interested in launching similar programs. Our liaison group has doubled in size in the last decade, and now we have 60 members. The program started with nurses, but now we’re including other disciplines like physicians, chaplains, respiratory therapists and social workers —though the vast majority are nurses. We also started providing continuing education hours for meetings, and their ethics liaison role also can count toward advancement on the clinical ladder.
A few years ago the liaisons group started studying literature indicating that moral distress is higher in settings where caregivers do not feel safe enough to raise ethical issues or speak up for patient safety. The literature suggested that taking action is a good way to mitigate moral distress and deepen ethical foundations of clinical practice.

To help caregivers take action, we developed a moral courage policy stating that caregivers are expected to speak up for patient safety and raise ethical issues, and those to whom concerns are raised are expected to receive these concerns with respect and collaboration. The policy was reviewed by stakeholders at all levels, and it went into effect in 2014.

To our knowledge, we are the first hospital in the country to develop this type of policy. We have come a long way from the dynamics of that contentious consult several years ago.

Q: What was the hospital culture regarding ethics before the program? A: It didn’t always feel safe or normative to give family and medical team members an opportunity to share their different perspectives on a situation. It sometimes seemed that medical teams expected ethics consults to result in a decision that agreed with their view, rather than consider the varying values and ethical issues at stake for interprofessional team and family members.

During one of my first ethics consultations seven years ago, I was dismayed by the intensity of the conflict between people in the room. The discord could affect patients and families and threatened to fracture relationships among team members.
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By Heather Stringer
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Liaisons work to help nurses feel safe enough to discuss ethical dilemmas
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