Health Care Ethics USA Archives

Requiring standard training for everyone providing ethics consultation in a health system helps create common practice expectations and improves the quality of ethics services. The Clinical Ethics Intensive (CEI) is one of three parts to CommonSpirit Health's approach to meeting these needs.¹ The CEI offers high-intensity training on practical aspects of clinical ethics for ethicists and Ethics Responders who are or will be involved with clinical ethics consultation at CommonSpirit Health ministries. The purpose of the CEI is three-fold: (1) provide a standard base of training for everyone in the system who provides clinical ethics consultation; (2) give participants a chance to practice the skills needed for clinical ethics consultation; and (3) allow the ethicists to evaluate participants to see who is able to provide consultation on their own and who needs more time to shadow and observe consults.

At CommonSpirit, the title "ethicist" is used for people who are employed full time for ethics consultation and other ethics activities like education and policy review. An Ethics Responder is someone who has another role in CommonSpirit (social worker, nurse, chaplain, physician, etc.) and spends some of their time doing clinical ethics consultation during their regular working hours.

CommonSpirit's CEI is an entirely virtual program. This enables us to engage experienced ethicists from across the organization to share teaching responsibilities. In a similar fashion, virtual training increases opportunities to develop Ethics Responders in small or rural markets. Facilitating interaction between ethicists and Ethics Responders from a variety of locations also contributes to building a collaborative team, normalizing accessibility of ethicists for consultation, and ongoing coaching. Participation is limited to a maximum of 40 participants at a time from across the health system to make the virtual experience easier to manage. With three to four sessions a year, we can accommodate 120 to 160 Ethics Responders annually. We first offered the CEI in 2020 and began requiring it for Ethics Responders in 2023. In total, over 530 people in our health system have gone through the program.

The CEI is a skills based training. Ethics content such as norms, principles, laws, and concepts like informed consent or decision making capacity are covered in EthicsLab podcast episodes which participants are required to complete prior to CEI. Resources and materials are available digitally on our website. Other courses are available to Ethics Responders to expand their foundational knowledge.

The CEI spans two six hour days. Both days are facilitated through Zoom with multiple breaks throughout each day to make virtual learning easier. Each day begins with one hour of didactic; the first day focuses on conceptual tools and analytical skills, while the second covers conflict negotiation and mediation skills. The didactic is followed by role play sessions that occur in small groups in virtual breakout rooms. The role plays, which are the majority of the CEI, are designed to help participants develop specific skills in a supportive environment by utilizing those skills and tools in realistic scenarios. Finally, we end each day with a review of how to use the standard documentation tools for ethics consults, including both the electronic medical record and an internal database.

Over the five immersive role play sessions in the CEI, participants have one or two chances to play the role of Ethics Responder. Other participants intentionally experience the skills being practiced as they play the role of family member, nurse, physician, or chaplain. The role plays are based on realistic clinical ethics cases and are described in a short one-page summary that every participant receives. Each role also has a half page description unique to that role that provides background information about that role known only to the participant; in acting terms it is their "motivation".

Participants are asked to stick to their character and use phrases or sentences they have heard in real life to make it realistic but not overly difficult. We hope to strike a balance between creating some learner's tension for participants to struggle through but not create frustration that overshadows the opportunity for learning.

Each role play session is facilitated by a coach, usually one of the CommonSpirit ethicists, whose role is to provide real-time feedback to the Ethics Responders on their ethics consultation skills. Coaches provide feedback during the debrief at the end of each role play, and may also send private direct messages with real-time suggestions, or pause the role play mid-scene to offer suggestions if participants get stuck. Coaches use an evaluation tool that identifies the participants' use of essential skills and tools in clinical ethics consultation that have been implemented in the role play, and pinpoints areas for additional coaching. This tool was developed based on a combination of sources including relevant articles in the literature and the experience of our ethicists.² After the CEI, the ethicist works with participants in their region to either join the ethics consultation service, or set up a period of continued observation and evaluation.

The CommonSpirit CEI adds a few unique features compared to similar training programs at other health systems (See Table 1):

Table 1

We have also found several disadvantages to the way we have structured the CEI. First, a virtual role-play will never perfectly imitate an in-person interaction. Reading body language and responding to emotional cues can be difficult. This can make it hard to fully assess participants' skills. Second, it can be hard to always have the number of professional ethicists needed to serve as coaches. Ethicists are a scarce resource and sometimes urgent priorities arise. Third, most virtual events have a high no-show rate of registered participants. Relying on participants to fill essential roles in the role-play makes it hard to create an effective learning environment if several do not show up or have to leave for a period of time during the day. Lastly, participants who are new to ethics consultation or who lack general experience in family meetings may struggle. For some, the CEI is their first exposure to ethics work, which sometimes causes role-plays to pivot to conceptual questions rather than practical ones. We are continuously working to overcome these gaps. For example, we have started a separate education program focused on foundational knowledge and concepts in ethics. We have also on occasion asked some more experienced Ethics Responders to fill in when not enough ethicists are available.

On the whole, we have found virtual learning to be effective for providing initial education on practical skills and tools for clinical ethics consultation. The way we have structured the CEI allows us to engage a larger number of participants in a short amount of time. This is only one part of an education program for Ethics Responders, but it is a key component that complements in-person evaluation and ongoing observation. At the very least, it shows that virtual education in the practical elements of clinical ethics can be successful.

BECKET GREMMELS, PHD
System Vice President, Theology and Ethics
CommonSpirit Health
Dallas-Fort Worth, Texas

KRISTINE EHLERT, D.BE(C), M.DIV, MSW
Systems Director - Mission & Ethics
Hospital Sisters Health System
Lexington, Kentucky

ENDNOTES

1. The CommonSpirit CEI is based on similar training programs originally started at Ascension Health in 2012 and later CHRISTUS Health in 2015.

2. Wasson, Katherine, Kayhan Parsi, Michael McCarthy, Viva Jo Siddall, and Mark Kuczewski. "Developing an evaluation tool for assessing clinical ethics consultation skills in simulation based education: The ACES project." HEC Forum 28, no. 2 (2016). Core Competencies for Healthcare Ethics Consultation (American Society for Bioethics and Humanities, 2010), 2nd edition.