Nurses' Perceptions of Ethical Issues in an Academic Hospital Setting

Purpose:

Today’s healthcare organizations are becoming increasingly accountable for the many ethical issues and challenges that have arisen as a result of corporate management, technological advances, reproduction issues, genetic healthcare, and the demands of cost containment affecting the delivery of safe and effective cares (Cooper, 2002). With such changes and challenges in the healthcare system, studies have found that the once traditional ethical principles of autonomy, beneficence, and justice provided by today’s healthcare professionals are being severely tested (Cooper, 2002, p. 331). In addition, despite the Joint Commission on Accreditation of Healthcare Organization accreditation standard requiring healthcare organizations to develop and operate under a code of organization ethics, and the imperative need for healthcare professionals’ to perform in an ethical manner, research has found that there are still barriers between the clinical and organization ethics within the hospital systems.

Despite the prevalence and the identification by recent studies regarding the ethics consultative services vital role in resolving ethical disputes, little research has been conducted to evaluate the effectiveness and or barriers to the ethics consultation services within university or community hospitals as perceived by the nurses working in that institution. Studies have further recognized that there is significant lack of data on “the effectiveness of ethics committees and the committee members’ lack of education and skills for effective participation in case consultation.

Research Question: What are the perceptions of the registered nurses about common ethical dilemmas and the services of the Ethics Consultation Services (ECS) within an academic hospital setting?

 Methods:

Any person who is concerned about a potential clinical ethics issue at that academic hospital could request an ECS consult: patient, family member or friend, student, health care provider, administrator, or other hospital employee.  Typically the consultant would ask the caller to describe the ethical issue(s) and elicit background information.  If the query is a straightforward request for information, the telephone call may suffice.  If a formal consult appears to be indicated, the ECS consultant would address the patients’ primary medical physician to ask whether he/she is aware of the consult.  If the primary medical physician is not aware, the inquiring individual and the consultant may negotiate who will alert the primary physician. The ECS consultant would then discuss the case with the appropriate individuals (primary physician, relevant consulting services, nursing, social work, significant others and patient), conduct a chart review, and pursue any other information needed to frame the issues.  The ECS consultant may hold a formal case conference if needed.  At the conclusion of the consult, the ECS member will document a brief description in the patients’ medical chart including actions taken, and recommendations made or agreements reached.  The ECS consultant will further allude to the appropriate personnel that they are an advisory service; its recommendations are not enforceable.

Ethics consultant’s services were available 24 hours a day and seven days a week. A dedicated ECS pager was available for members of the ethics consultation services who do not carry their own pagers.  The ECS members were assigned to ethics services based from a rotation schedule that is set on a quarterly basis with assistance from the Medical Executive Office.  The administrative assistant entered the rotation in the hospitals e-call system and communicates any schedule changes to the ECS members.  The ECS chair served as back-up call. The ECS consultants were able to ask for assistance on a case from one another, from hospital administration (e.g., chaplaincy, social work, patient relations, risk management, administrator on call, legal counsel), and from other medical services (e.g., ECS might recommend a consultation by psychiatry, palliative care, etc.). In addition, the ECS consultants were able to converse with medical personnel, family members, primary care physicians and other sources of information on the patient's goals, values, preferences, medical status, and treatment options.

 A 10-item survey was designed to determine the extent to which nurses witnessed specific ethical issues, take actions to increase the involvement of ethics consultation services, and also to evaluate the RNs’ perceptions of the ethics consultation services. In addition, the survey included questions that measured the nurses perception regarding requesting an ethics consultation. A four-point Likert scale extending from ‘always’, which was scored as 1, to ‘rarely’, which was scored as 4, yes and no questions, and a five-point Likert scale extending from ‘very important’, which was scored as a 1, to ‘not at all’, which was scored as a 5, were utilized within the study. An open ended question was also provided at the end of the survey to elicit detailed comments and or recommendations about ethical issues or the ethics consultation services. Validity of the survey was developed as the team sat with a member from the ethics committee. The questions were changed several times to measure what the nurse “perceives” the ethics consultation to be. In addition, several nurse administrators at the hospital, the college Institutional Review Board (IRB), and the hospital IRB, also approved the questionnaires and the research methodology. Data collection was conducted with an online survey software tool which sent a survey to all registered nurses at the academic health center.

Results:

 Analysis of the data from 282 registered nurses showed most nurses perceived adequate support from the administration and the physicians in ethical dilemmas, however 69% of the participants responded as having no prior experience with the ethics consultation services at the hospital, and 32% were not aware of the ethics consultation services. Over thirty percent found the concerns for retaliation from a coworker, the time required for an ethics consult, the perception by some providers that an ethics consult suggests wrongdoing or failure, and the difficulty of asking for a consult were important barriers to asking for an ECS consult. In addition, several qualitative responses were provided by the nurse participants elaborating on the experiences they have had with concerns for retaliation from a coworker.  Additional results will be discussed.

Conclusion:

A recommendation was made to include ethics consultation education in the general orientation process as well as within yearly in-services held by the Ethics Consultations Committee. Furthermore, it was recommended that nurses within the inpatient hospital setting should become more aware of the ethical resources available to them within their hospital work environments and the appointed ethics consultation services available to them so that they utilize the ECS more in resolving ethical dilemmas or disputes, improving patient care by responding to healthcare professional’s requests, and assisting in the debate and resolution of ethical cases and ethical policies.  In addition, to allow for a more thorough evaluation, further studies to evaluate the perceptions of ethics consultation services by various disciplines within the academic hospital setting (patients, family, other health care team members) should be conducted.