By Stacey Kusterbeck
Some nurses and physicians are taking on a role of ethics liaison to serve as a point of contact between clinicians, patients, and ethicists. At Memorial University Medical Center in Savannah, GA, about 25 ethics liaisons currently assist the ethics service. “These are nurses and physicians who get a reasonable amount of training in-house,” says Brian H. Childs, MDiv, PhD, HEC-C, professor of bioethics and professionalism and chair of the Department of Bioethics and Medical Humanities at Mercer University School of Medicine. The ethics liaisons take on these roles:
• facilitating early conversations with patients and families about the goals of care;
• assessing the treatment team’s understanding of ethical dilemmas;
• getting ethicists involved early if needed;
• seeking to improve conversations between different kinds of practitioners and therapists.
“We want to ,first of all, identify what may be a developing ethical issue,” says Childs. Ethicists ideally have goals of care conversations with patients and families within the first 72 hours of admission. Improving the communication between practitioners makes it more likely. “Then, at the back end, you see an increase in patient satisfaction,” says Childs.
To find ethics liaisons, ethicists identify nurses or physicians who are interested in ethics. Some clinicians are nominated by nurse managers or medical department heads. Most already have some ethics training in their background, usually from nursing or medical school or a certificate program. To bolster their ethics expertise, the ethics service provides the liaisons with half-day retreats every year. The liaisons review current ethical issues, with education provided by medical school faculty and the vice president for corporate and clinical ethics.
The majority of ethics liaisons are nurses. Initially, the nurse manager gave those nurses a certain number of hours each week as “protected” time for ethics work. “They are pushing back on that now, because of the reduction in the workforce. The key is, there has to be administrative buy-in where hours are protected. We are going to need to be creative in how we address that,” acknowledges Childs.
Ethicists, or an ethics liaison, goes to each hospital unit at least once a day to talk about what is happening with current cases. If there is any kind of ethical question for a case, the team decides whether a formal ethics consult is needed or not. It is helpful for everyone on the unit to know that the ethics liaison is the go-to person for ethics. “If ethicists show up daily, it keeps it on the front burner. Most of our work, really, is curbside,” reports Childs. “Ethicists are continually present so there is familiarity, instead of ethicists being like the Wizard of Oz hiding behind a curtain.”
Goals of care conversations are now happening earlier because of the ethics liaison’s involvement. “If ethics consults are delayed, the conflict may be so intractable that nobody can solve it,” explains Childs. With a proactive approach, some conflicts are avoided altogether. “You may get a decrease in formal consultations, because preemptively, you made sure they didn’t have an ethical conflict,” says Childs. “The earlier the conversation, the less ethics conflicts will arise down the line.”
At University of Rochester (NY) Medical Center, a 36-hour Ethics Liaison Program for nursing, run over a nine-month period, improved nurses’ confidence and knowledge about ethics, according to a recent study.1 Nurses were more confident in handling multiple ethical issues, including conscientious objection, patients leaving against medical advice, and assessing decision-making capacity.
However, ethicists faced some significant challenges in getting the program implemented. The cost for nine nurses to complete the program was about $17,000. “The biggest challenge was getting buy-in from nurse administrators that this project was important and could be helpful in improving nurse morale; and, perhaps secondarily, retention,” reports Marianne C. Chiafery, DNP, PNP-BC, a former clinical ethicist and associate professor of nursing at University of Rochester Medical Center. Over years participating in ethics consults, Chiafery had gained the trust of nursing administrators. At the time the ethics liaison program was being introduced, nursing units were struggling with major ethical issues during the pandemic and high nursing vacancy rates. “So administrators were open to ideas that could help stem the tide,” says Chiafery.
Still, ethicists needed to prove that the program was worth the money and time spent. Nurses attended sessions with didactic presentations, case analysis and discussion, and role-playing exercises. Nurses also interacted with other disciplines, such as chaplaincy, the legal team, and diversity officers.
The survey findings demonstrated that nurses gained much from the program, both personally and professionally. “It will be more difficult to measure if this makes any difference on staff retention. There are so many factors that go into a nurse’s decision to stay or leave a position,” acknowledges Chiafery. Still, the amount of enthusiasm on the part of participants is an encouraging sign. “The nurses were truly hungry for this kind of program and learning opportunity. I can’t put into words the energy the participants brought to the group,” reports Chiafery.
Many of the nurses offered anecdotal evidence of cases in which their ethics expertise made a difference in patient care. Unfortunately, it was difficult to translate this into concrete data to show administrators a financial return on investment. Chiafery shares these insights that could be helpful to ethicists implementing a similar program:
• Consistency of membership is important.
“The group members quickly came to trust each other, and part of that trust is based on familiarity,” explains Chiafery. When three nurses dropped out for personal reasons and one joined late, the dynamics of the group were mildly affected in the short term. “Certainly, unforeseen things can happen and that can’t be helped. But enforcing the idea of a full commitment to the program is important,” concludes Chiafery.
• Nurse managers already know some good prospects in their units.
“They know the qualities of their staff and can identify those who can be a good fit,” says Chiafery. The director for critical care nursing required interested nurses to submit an essay about why they wanted to participate. Those essays provided insight into what the nurses were hoping to gain from participation, which signaled whether they would be a good fit for the program.
• While an interest in ethics is clearly important, other qualities are also important.
Nurses who succeeded in the program tended to be informal leaders, respected by other team members, good communicators, good listeners, non-judgmental, and able to consider other perspectives, according to Chiafery.
• Nurses no longer felt alone when faced with an ethical dilemma.
Before nurses completed the program, many were unsure how to connect with available resources to help out with ethical dilemmas. Many did not know that ICUs had chaplains assigned to their unit, for instance. Nurses also did not realize that nurses can request an ethics consult and that no one can prevent them from doing so. During the program, the nurses met with another important resource — one of the hospital lawyers. Some nurses admitted having been intimidated by the idea of consulting with one of the attorneys. “Previously, nurses viewed The Office of Counsel as a fearsome office somewhere in the bowels of the hospital,” says Chiafery. After the program, nurses felt comfortable consulting with attorneys for help navigating situations when law and ethics collide. “The importance of these kind of contacts cannot be underestimated,” says Chiafery. “It’s easier to ask for help when you know who you’re calling.”
• Finding time and finances to support nurses being away from the bedside was difficult.
Critical nursing shortages and financial pressures remain significant obstacles. “In the short term, these stressors may be great. But in the long term, nursing ethics liaison programs can improve staff morale and patient care,” offers Chiafery.
- Chiafery M, Keady K. Nursing ethics liaison program: A pilot study. J Clin Ethics 2023;34:342-351.
