1 Original Article
Using ethics education and a decision tree to increase ethics knowledge and ethics consults
in the hospice environment
Michael D Czechowskyj
(College of Health Professions,) Ferris State University, USA
Abstract
Background: Ethics education occurs in nursing schools around the country. Nursing students
are focused on absorbing the information needed to pass the licensure exam and they often forget
the ethics education they have learned in school. There was a need identified by nursing leaders
for continued ethics education in the hospice environment. Along with education, a decision tree
framework was given to the frontline staff. This helped them recognize ethical situations and
obtain the ethics consults they needed to take care of their patients.
Objective: This article aims to present the results of ethics education and the increased use of
ethics consults in the hospice environment.
Method: Create and present basic ethics education with supporting documents for a decision tree
the staff can use to help them make ethical consults.
Results: Pre-surveys were given to the hospice staff to assess their baseline knowledge of ethics
and what ethical situations they have encountered in their practice. After the ethics education
was delivered there was a post survey sent to the staff and the results showed an increase in
knowledge in how to use a decision tree and consult the clinical ethicist. Another metric that
was being monitored was how many ethical consults were being ordered. The current baseline
number was zero, and the expectation was an increase of two in the first month.
Conclusion: The pre-survey showed a lack in knowledge around ethical situations. This was
consistent with what nursing leadership had suspected. The pre-survey also showed that only a
small percentage of employees knew how to contact the clinical ethicist and would routinely
contact their manager or supervisor instead of the ethicist. After the education there was an
increase in ethics knowledge and more employees reported they would call the clinical ethicist
after identifying an ethical situation. There was no increase in ethics consults during the first
month after the education, but this continues to be monitored.
Keywords
Nursing, ethics, hospice, education, decision tree, consults
Introduction
Ethical situations and dilemmas are present in all types of nursing. After meeting with the chief
nursing officer (CNO) of Spectrum Health Continuing Care (SHCC), it was identified that the
nursing employees were lacking the knowledge needed to accurately identify ethical situations.
When ethical situations were identified there was not an established avenue for the employees to
follow to have these ethical situations rectified. This was a large concern for the CNO and it was
in her strategic plan to start working on this in the next year. There were two stages to her plan.
The first step was education for the nursing employees related to what ethical situations are and
how to identify them. The second step was to create a decision tree for employees to follow
when they encounter these ethical situations. By following this plan the expected results will
include better identification of ethical situations and more ethics consults.
Corresponding author: Michael D Czechowskyj, College of Health Professions, Ferris State
University, Big Rapids, MI, USA. Email: czechom1@ferris.edu
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Using Ethics Education
Background
The chief nursing officer (CNO) for Spectrum Health Continuing Care (SHCC) had identified
certain ethical situations that have affected her employees. Even though she has identified them
as ethical concerns the employees did not. The problem was direct care employees were not able
to identify ethical concerns until after the situation was out of control. After the ethical concerns
were identified there was no clear path to solve the ethical situation. This was alarming to the
CNO and this needed to change in the organization to better serve the patients, families, and
employees. The way to address this problem was to educate and support the employees after
making sure there was sufficient research to support this type of intervention.
Looking at the current research, nurses report a high frequency of ethically sensitive
situations in their professional activities.1 In nursing school students are focused on learning
what they need to know to pass the licensure exam, and this does not routinely include ethics.2
According to a study by Vynckier, et al. it revealed that current ethics courses failed to meet
basic objectives of ethics education.3 The poor consistency in nurse’s ability to follow ethical
reasoning and ethical practice, even between countries, indicates that nurse educators, and
leaders should develop nursing ethical competencies.4 Ethics education provides nurses with the
tools required to think critically on their care practice.5 A comprehensive ethical education plan
has been identified as a way to improve the nurses ability to manage ethical situations with
patient care.1 Research supports not just having an education plan but continued education on
medical ethics. Students failed to achieve learning outcomes related to ethics, so it is
recommended that they are place in the clinical setting for ongoing continuing education.6
One way to educate employees is using a problem-based learning (PBL) plan. When
teaching ethical content using a PBL plan verses a conventional lecture format the students
expressed greater satisfaction with PBL.7 There was no significant difference between the end
educational retention between the two programs.7 There was also no statistical significance
between PBL and small group discussion learning.8 If there are not significant difference in how
the education is retained then choosing the one the students expressed greater satisfaction with is
the logical choice.
Other reasons to have continued ethics education is related to how nurses are trained and
the intent to retain the current nursing staff. Nurses come from different educational
backgrounds, including ADN, BSN, MSN or even DNP. With these varied education
backgrounds they are all taught differently when it relates to ethics. Having a comprehensive
standard bedside ethical education plan could have positive effects on relationships with the
interdisciplinary team, better communication with patients and families, and less stress and burn
out caused by ethical dilemmas.9 If this is done at the bedside then it will not matter what their
educational background was as they will all be learning ethics together in their current
environment.
Just having an educational plan is not enough. Once the ethical dilemmas are identified
the nursing employees need to have an outlet and support to deal with these situations. This
comes in the form of a decision tree leading to an ethics consult. Nurses are willing to use an
ethical consultative service, but the ease of access to this service is vital. In one study 90.3% of
nurses responded that they would use a consultative service to help them with ethical dilemmas.1
This indicates there are enough ethical situations which make nurses feel this service would be
beneficial.1 Creating an environment where direct care employees have access to ethics consults
Czechowskyj
3
is an important step in providing great care for their patients. One way to provide the nursing
employees this access is by using a decision tree. Decision trees can be a useful tool use on a
daily basis to help provide guidance on an agreed upon standard of care.10
Method
The methods used consisted of identifying an appropriate venue, surveying the employees to
gain baseline knowledge, providing them with ethics education and a supporting decision tree,
then conducting a post-survey to determine if the education made a difference.
Venue
The venue used was at Spectrum Health Continuing Care (SHCC). SHCC is a large facility with
many different service line units and home care areas. This project focused on one department
that had expressed the most interest in dealing with ethics. This department was the hospice
division. In the hospice division there have been many ethical situations identified and they were
in need of some support. The hospice space consists of in-home hospice, inpatient hospital
hospice, and a dedicated hospice unit. Physicians, nurses, social workers, chaplains, and support
staff all provide care for the hospice patients.
The hospice department conducts “town hall meeting” for all staff every other month.
These meetings include specific updates and also provide a venue for continuing education. The
hospice director identified this as the best time and space for the ethics project to be conducted.
There were two different offerings for this meeting to catch most of the staff. The project was
presented at both of these meetings.
Survey
With the venue and hospice space identified as the area of need, a comprehensive plan was
developed with the help of the system ethicist. A pre-education survey testing the baseline
knowledge of ethics was the first step. The survey consisted of matching basic ethical principles
with their definitions. The ethical principles used were autonomy, beneficence, nonmaleficence,
justice, fidelity, and paternalism. The employees were then asked to apply these principles to six
different story problems. The survey was collected before any education was provided. The
survey was approved by both the ethicist and the chief nursing officer (CNO). The next step was
to present the education.
Education
There were two different sections to the education plan. The first section was education about
ethics and the principles. The education was done using power point slides. The slides contained
basic information about the six main ethical principles of autonomy, beneficence,
nonmaleficence, justice, fidelity, paternalism. Each principle was discussed in depth to give the
employees the knowledge they would need to help understand and solve the real world examples
that were presented in the rest of the education. Each principle contained real stories taken from
the hospice space so the staff could relate and connect. The intent was for the employees to
apply their new knowledge to each story and apply an ethical principle that was taught at the
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Using Ethics Education
beginning. Further discussion was encouraged related to each principle and how the hospice
employees could respond or when it was appropriate to obtain an ethics consult.
The second part of the plan was to educate the employees on the new decision tree
(Figure 1). The decision tree was developed to help the employees in the moment when they feel
they have identified an ethical concern. The decision tree helped guide them to the next steps
and what tools they could use to provide the system ethicist with the information needed to assist
the team in making the best decision for the patient and their family. One important part on the
decision tree is the red box which gives the employees the permission to call the ethics hotline at
any time during this process. This shows support for the direct care staff to use the chain of
command and obtain what they needed to take care of their patients and families.
Figure 1. Ethics decision tree.
Post-survey
After the education was delivered a post-survey was sent. The post-survey consisted of the same
questions that were in the original pre-survey. This survey was electronic and was sent to the
same employees who received the initial education via email. The post-survey was sent out 30
days after the initial education to test the effectiveness of the education and retention. It also
served as a reminder to use the ethics hotline for any ethical concerns.
Results
The project was developed to increase ethical knowledge and present the employees with a
decision tree to help support them in their practice. There were metrics that helped to determine
if these goals were obtained. The first was an increase in basic ethics knowledge that will be
Czechowskyj
5
measured using the percent of correct answers on the surveys. The second metric looked for an
increase in ethics consults called to the system ethicist.
The pre-survey results were collected and trends were discussed with the leadership team.
There were a total of 53 pre-surveys returned. The average score was 8.5 out of 12 questions or
71% correct. This surprised the leadership team as being higher than expected. The other
interesting results revolved around the question “How do you request an ethics consult?”. The
most common answer, 83%, was “contact manager or supervisor”. The leadership team was
concerned that the employees felt like they had to go through their leader first. This is where the
decision tree helped the employees use the chain of command to call the ethicist at any time.
The post-survey results proved to be more challenging to obtain. There were only nine
surveys returned. The average score was 77% correct which was higher than the initial survey.
This would suggest that the education made a difference and the employees retained the
information over the life of the project. With the question “How do you request an ethics
consult?” there was a decrease in the number of employees who picked “contact manager or
supervisor” to 66%. This means there was in increase in responses from 17% to 33% of
employees who would contact the clinical ethicist when they encountered an ethical concern.
Even with the post-survey numbers being small they pointed to a positive change in ethical
thinking in the hospice environment.
The second metric that was monitored was the amount of ethics consults that were placed
by SHCC. At the beginning of the project there were no ethics consults reported. With the
clinical ethicist as the main contact for the consults, they were reporting the number of consults
they have received from SHCC starting after the education was delivered. At the conclusion of
this project there were no consults called to the clinical ethicist. This suggests that this metric
was a longer term metric that needs to be continuously tracked. It could also represent a need for
more education or more visibility of the decision tree.
The results sparked meaningful conversation about different ethical situations the hospice
team has been involved with. There was also discussion related to the decision tree and how this
can help support the bedside staff and the tough situations they encounter. The ethics hotline is
available all hours of the day every day. The clinical ethicist and the hospice administration
were supportive of staff using the hotline when they felt they needed help and were not getting it
from their up-line. This demonstrates the organizations commitment to supporting the direct
care staff.
Conclusion
When faced with difficult ethical situations, health care organizations need to help support the
direct care staff in making the right decisions for their patients. In the rapidly changing health
care climate nurses will be faced with more and more ethical dilemmas.11 Providing them with
continuing ethics education and the support they need to make the right decisions is crucial. This
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Using Ethics Education
will only strengthen the nursing workforce and help provide the best collaborative care possible
for the patients and their families.
Continued nursing education is one method that can be effective in increasing the direct
care nurses knowledge of ethics and how to identify them sooner. Education alone will not make
the difference, there needs to be commitment from the organization to provide the employees
with the tools to act when the ethical concern is identified. At SHCC they have completed both
of these steps and are committed to doing what is best for the patients, families, and direct care
staff in their organization.
Czechowskyj
7
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