How Children’s Health uses consult services to mitigate moral distress

The RISE team developed a consult service that can be activated in one of two ways when staff experience moral distress. Children's Health staff can request a moral distress consult by sending an email to the RISE team's inbox or by paging the on-call facilitator for the RISE program.

Most of the consults are scheduled as needed based on outreach to the RISE team. However, some clinical teams have regularly scheduled forums due to the baseline complexity of their patient population.

To familiarize the staff with Integrated Ethics, Children’s Health held education sessions on all units, facilitated ethics discussions, and leveraged "ethics champions.” The education sessions and ethics discussions raised awareness about the ethical dimensions of care and made people comfortable with requesting a moral distress consult. Ethics champions, who come from departments across the hospital, participate in a 12-month training curriculum focused on moral distress, pediatric bioethics, conflict transformation, caregiver grief, and group facilitation. They raise awareness about Integrated Ethics and, if they choose to complete additional training, may also serve as moral distress consult facilitators.

IMPLEMENTATION TIP

Identify high-risk units early
Perform a needs assessment to partner with the units at highest risk for moral distress.

Children’s Health trains their own team members to become facilitators. Facilitators should be trained in moral distress and bioethics, trusted by their colleagues, skilled in group facilitation, and capable of challenging group assumptions when necessary.

Since beginning moral distress consults in 2016, the RISE team has crafted a mandatory 12-month training curriculum for team members who would like to become facilitators and/or ethics champions. The curriculum consists of one 90-minute session every month. Each session contains a didactic presentation and facilitated discussion to promote critical thinking and engagement with the class material. Children’s Health uses this format to prepare facilitators to competently and confidently engage in difficult conversations with other team members. Sessions are taught either by seasoned members of the RISE team or a content expert.

Once finished with the courses, newly trained RISE team members with an interest in group facilitation must observe a minimum of 3 consults with an expert facilitator. Then they co-facilitate with an expert facilitator for several sessions before leading their own session.

IMPLEMENTATION TIP

Use your internal resources
Engage current team members with a background in bioethics, group facilitation, and conflict transformation to facilitate moral distress consults and train other team members.

When a moral distress consult is requested by a staff member, two RISE team facilitators arrange an hour-long meeting with relevant staff. The meetings follow the four-step process detailed below.

1. Facilitators establish confidentiality. They take note of the number of attendees, the disciplines represented, and the themes of the case, but they do not track names of attendees. The facilitators ask the group to remain open and respectful of different perspectives during the session.
   
   
2. Participants share details of the experience that led them to request a moral distress consult. Typically, the clinician most familiar with the details of the case shares their perspective first. Remaining participants add details to provide more context.
   
   
3. The group focuses on uncovering potential root causes for moral distress. At Children’s Health, facilitators encourage team members to challenge their own perceptions and explore parts of the narrative they may not have previously considered.
   
   
4. The facilitators work to elicit differing perspectives from the various individuals participating in the consult. If most in the group present as like-minded, the facilitators ask open-ended questions to prompt those in attendance to consider potential alternative viewpoints.

Moral distress consult facilitators often surface recurring themes requiring broader action. Facilitators are encouraged to elevate these themes to senior leaders, while protecting the confidentiality of everyone involved. If such a theme arises during the course of a consult that may be helpful to relay to the team or leadership for follow-up, the participants discuss together whether to provide permission to share this information outside of the session.

Additionally, RISE team facilitators are trained to refer individuals and teams to additional resources for follow up, such as the employee assistance program (EAP), as appropriate.

IMPLEMENTATION TIP

Know when to use virtual vs. in-person consults
Use virtual moral distress forums as needed, but not as the only offering. While virtual meetings offer increased flexibility and accessibility, they can limit the opportunity to read body language and foster connection.