Addressing and Preventing Ethics Issues in Rural Settings

Ethics questions and conflicts will always be commonplace in rural health care practices. Despite the ethics knowledge and skills that clinicians and administrators may possess, ethics conflicts are stressful and time-consuming because of the inherent uncertainty surrounding such conflicts. To manage the potential negative effect of ethics conflicts, health care professionals and institutions should employ various strategies for anticipating and potentially decreasing the occurrence of such ethics conflicts in the delivery of today’s health care. Effective strategies for clinicians and institutions to employ include identifying ethics resources; creating networks with professional colleagues, ethicists, and hospital ethics committees; developing and propagating ethical standards of practice in rural facilities and clinical practices; facilitating community-wide ethics training and discussions, and collaborating with professional organizations. These proactive strategies for anticipating and potentially decreasing ethics conflicts can both enhance the quality of health care, and decrease the negative impact that such conflicts generate, including the stress and time consumed in addressing them. An additional approach for addressing rural ethics issues is for faculty in health care professional schools to implement strategies which focus on rural health care ethics and prepare professionals choosing to practice in rural settings. Ethics faculty should expand their understanding of the rural context’s influence on ethics challenges, and use cases focused on rural studies in the ethics curriculum. Practical Strategies for Addressing & Preventing Ethics Issues in Rural Settings 307 iNTroDucTioN Ethics conflicts, such as professional-personal boundary conflicts, end-of-life decision-making, and maintaining patient privacy and confidentiality, are a few of a broad spectrum of ethics challenges occurring in today’s rural health care settings. Rural health care professionals respond to the ethics challenges that occur in their clinics or in critical access hospitals based on their personal beliefs and experiences, community values, organizational policy, and/or understanding of ethical guidelines. The presence of ethics conflicts can create uncertainty and stress for both the involved health care professionals and the patient. For example, a nurse recognizes that a physician in a small, economically struggling rural clinic has written a prescription for an incorrect medication, only to have the physician tell her to “forget it, we are a having a hard enough time paying our overhead, so we do not want to acknowledge that I made a mistake.” Even though the patient was not harmed by the error, the nurse feels that she has a moral obligation to inform the patient, who is actually a neighbor. In another situation, a Medicare patient requests that a family physician write a prescription for a hypertension medication, which is actually to be used by his wife, who is not Medicare-eligible. The physician knows the couple well from their contact at a place of worship and other community activities, and is aware that such an action would be fraudulent, with dire consequences if it were ever discovered. But the physician also realizes that without writing the prescription to the man, his wife will go without the necessary medication. In both cases, the ethics conflict creates uncertainty, stress, and questions regarding how the provider should best respond to the situation. The cases can be further contextually complicated due to the frequent overlapping of personal and professional relationships and the “openness” of rural communities. As these briefly presented cases suggest, ethics conflicts are not a benign event for the involved persons, or for the clinic or hospital. There is a growing understanding that organizational and clinical ethics conflicts have a potential for a detrimental impact on today’s health care organizations in many ways.1-7 Box 15.1 lists potential problems arising from ethics conflicts. 308 Rural Ethics Resources In considering this list of the potential implications of ethics conflicts, it is easy to see that such conflicts are anything but trivial. The reality is that ethics conflicts can have a significant impact on the health care professional’s stress, workload, time management, and respect from the community. Similarly, ethics conflicts can impact the overall culture and financial success of critical access hospitals as well as clinics, and can ultimately impact quality of care. The vulnerability of rural health care settings and communities to ethical challenges and the frequency of ethics issues encountered increases the need for clinicians and institutions to develop their knowledge and skills in recognizing and managing ethics conflicts.9, 10 An important approach in response to ethics issues is the development of proactive, preventive approaches to ethical uncertainty and conflicts. Impact of EthIcs conflIcts In hEalth carE practIcEs staff Caregiver stress, deflated morale, weakened professionalism Patients Poor patient satisfaction, loss of self-referrals organization’s culture Diminished quality of care relationship with community Diminished organizational image, decreased trust, poor public relations and lower levels of philanthropic giving legal Increased litigation and settlements regulations Negatively influences adherence to Joint Commission standards and other regulatory organizations organization’s Bottom line Operational, legal, and public relations costs8 Box 15.1 Practical Strategies for Addressing & Preventing Ethics Issues in Rural Settings 309 Because of the significant impact of ethics issues on today’s health care organizations and the recurring nature of many ethics challenges, providers should pursue a strategy of moving upstream to prevent or diminish ethics conflicts from occurring. By moving upstream we mean a systematic exploration and analysis of the factors leading to ethics conflicts. After determining the causes fostering the ethics conflict, health care professionals are in a better position to apply quality improvement strategies for addressing the root cause of the conflict. Such an approach is a shift in managing ethics conflicts from the traditional reactive style. Throughout this Handbook’s chapters, authors not only offered their reasoning in response to ethics cases, but also suggested various approaches for anticipating and decreasing the ethics challenges from arising. Several constructive basic strategies that rural health hospitals and clinics can implement to assist providers in proactively addressing ethics conflicts and potentially decreasing the frequency of the challenges are listed in Box 15.2. uNDersTaNDiNG PersoNal aND commuNiTY Values Rural health care professionals should examine their own values and how those values might influence their clinical or administrative thinking, behaviors and decisions. Personal values or beliefs are frequently based constructIvE stratEgIEs for prEvEntIng and copIng wIth EthIcs conflIcts ƒ Understand personal and community values and how they may impact the delivery of health care Identify and use ethics resources ƒ Develop and propagate ethical standards of rural practices in ƒ both clinic and hospital settings Enhance ethics awareness in rural communities through public ƒ forums and discussions Collaborate with professional organizations to increase ƒ understanding of ethics conflicts Expand rural ethics training in professional schools ƒ Box 15.2 310 Rural Ethics Resources on one’s own religious, ethnic, and cultural background. Health care professionals need to acknowledge their own values and balance them in relationship to professional standards of care, including the policies and practice of the health care facility and the values of the community. Related to recognizing one’s own values, health care professionals need to recognize and incorporate the values of the community within patient-care relationships. Each rural community is unique; however, rural communities frequently share values of their common dominant culture, such as a Native American culture in the American Southwest. If a provider did not understand a community’s values, this could create ethics issues. “Cultural ethics mistakes may arise when clinicians manifest unawareness of or disregard for indigenous values and behaviors by, for example, interfering with a healing ceremony, failing to work with the natural supports within families and communities... A second kind of ethical mistake may occur when clinicians overemphasize indigenous values to the point of diminishing the clinician’s own professional values and ethics...that are the basic guideposts for decision-making in most clinical situations.”11 Avoiding such ethics issues requires a provider to be familiar with community values, and to know the appropriate levels of balancing such values with ethical standards of professionalism. iDeNTiFYiNG aND usiNG eTHics resources Rural clinicians often feel isolated from other health care professionals in rural settings. This isolation can increase the stress level of rural practices. Addressing ethics issues can be complex, time-consuming, and challenging for the provider. Therefore, identifying and using expert resources can be beneficial in addressing ethics issues. For the rural health professional, it is not only important to develop one’s own ethics knowledge and skills, but also critically important to cultivate and use a network of various resources to provide consultation for patients’ medical, mental health issues, and ethics issues. For example, a rural family physician caring for a patient with an acute psychiatric disorder may discuss the patient’s care with a distant mental health expert. Similarly, when ethics issues arise regarding a patient-care issue, having a trusted colleague or ethicist with whom to discuss the situation can be beneficial. Potential ethics resources and networks are listed and described in Box 15.3. Practical Strategies for Addressing & Preventing Ethics Issues in Rural Settings 311 ethics literature and resources To successfully manage a broad spectrum of ethics challenges in rural practices, clinicians should acquire a basic understanding of health care ethics, including an awareness of basic ethical standards of practice. Ethical standards are generally-accepted guidelines for providers to use when responding to common ethics conflicts12, 13 as noted in basic ethics textbooks. Even though these textbook-based guidelines may lack a specific rural focus, they are an important foundation. Ethical standards can also be found in a wide variety of profession–specific sources including the American College of Physicians Ethics Manual,14 professional codes of ethics, and various position papers on a wide variety of ethics concerns. This Handbook provides an expanded bibliography with a useful list of resources. In addition, many ethics centers have created useful Web sites that offer a wide range of resources. Networking with Professional colleagues In addition to developing his or her own ethics-related knowledge and skills, the rural health care professional can develop a network of colleagues, who can be consulted to provide support or advice regarding ethics challenges. Seeking the perspective of clinicians outside the immediate situation can provide the rural provider with insight, clarity, and supportive advice. The network of colleagues should include professionals from various disciplines, such as dentists and mental health providers. Depending on the particular clinical situation, additional colleagues outside the health care field could also be useful resources, including clergy, school principals, local government leaders, and police officials. EthIcs rEsourcEs and profEssIonal nEtworks ƒ Ethics literature and Web-based resources Professional clinician or administrative colleagues ƒ Health care ethicists ƒ Hospital ethics committees ƒ Academic-based ethics programs ƒ Box 15.3 312 Rural Ethics Resources The importance of identifying and using professional colleagues is not limited to ethical challenges—such a network can be beneficial to clinician-care issues, as well as decreasing the stress often associated with working in rural communities. Networking with ethicists Rural health care professionals should also identify health care ethicists to provide them with consultation and training. Despite the general lack of trained ethicists living or working in rural settings, many are available through the telephone, e-mail, Internet, or telehealth programs. Ethicists can assist the rural clinician or administrator in reasoning through an ethically challenging situation. The rural provider’s development of contacts with ethicists and clinicians can alleviate the potential sense of isolation which can come when dealing with ethics situations in rural areas. The American Society of Bioethics and the Humanities (ASBH) is a large professional society that focuses on scholarship and teaching of health care ethics issues. The ASBH Web site offers a directory of members by state that can be accessed to help identify a nearby member. identifying Hospital ethics committees Clinicians should identify those health care facilities that have ethics committees with case-consultation services. Many critical access hospitals have ethics committees that can provide a forum in which to discuss ethics issues with a multi-disciplinary group of professionals who have knowledge and skills in applied ethics. The chair of the committee should be able to describe the scope of the committee’s activities, including when the committee meets, and how a clinician can access the committee. In those hospitals where there is no ethics committee or program, clinicians might consider working with others and the hospital’s administration to develop such a program.15 accessing academic-Based ethics centers Rural clinicians should identify and use academic-based ethics centers and Web sites that can provide ethics resources. Ethics centers’ Web Practical Strategies for Addressing & Preventing Ethics Issues in Rural Settings 313 sites can be valuable sources of information, resources, and material. Many of those Web sites are listed in the Handbook’s bibliography. In addition to ethics-focused sites, there are several outstanding general rural resources, including the Rural Assistance Center (RAC) and the National Rural Health Association (NRHA). DeVeloPiNG aND ProPaGaTiNG eTHical sTaNDarDs oF PracTice Rather than just reacting to ethics questions, rural clinicians can anticipate and proactively address recurring ethics conflicts. For instance, rural health care professionals can collaborate with clinical colleagues, ethicists, and ethics committee members to draft, disseminate and provide training around ethics practice guidelines that pertain to recurring rural ethics conflicts. One approach is to proactively identify recurring ethics conflicts in a particular clinic or rural health care facility. A recurring clinical ethics case involves different patients, at different times, in different settings, but raises the same basic ethics conflict, such as end-of-life decisionmaking, or conflicts of interest. Once the recurring ethics conflict is identified, the team could develop an ethical practice protocol that provides guidance for addressing the conflict in the future. The guidance can help reduce the situation’s impact, or even prevent it from becoming a conflict. This type of proactive approach has been suggested by several authors.16-20 The proactive approach to addressing ethics conflicts is based on five basic steps, as listed in Box 15.4. This proactive, preventive approach can be used in various settings and situations. For example, in a practice staff meeting the question could be asked, “What are the situations that create uncertainty or conflict, which come up over and over in this practice?” These ethics issues could then be prioritized, and systematically and thoughtfully discussed, to create an ethically-grounded, proactive guideline. Once established, the guidelines could be shared, and theoretically might decrease the uncertainty of how the conflict or question should be addressed. A preventive approach to ethics conflicts can also be employed with hospital ethics committees. A common activity for almost all ethics 314 Rural Ethics Resources committees is to have an ethics consultation service, which can assist staff in addressing ethics conflicts. This approach tends to be reactive, in response to a current conflict. This traditional reactive approach to complex and challenging ethics conflicts can be helpful to involved parties. However, this process has several potential concerns. First, responding to an ethics conflict can be demanding, occasionally necessitating a rapid response. Second, time limitations can affect the availability of ethics consultants and thus preclude a thoughtful review of the conflict. Third, as has been noted, the traditional process accepts the perspective that ethics conflicts are recurring. Additionally, the presence of ethics conflicts can potentially take a toll on the culture of the organization, because of staff’s ethical uncertainty or questions. Despite these concerns, having a competent and available ethics consultation program is essential, because ethics conflicts will arise that need immediate reflection. However, the addition of a preventive approach is also critically important. After an ethics committee or ethics consultation service responds to a conflict, the consultants should facilitate a process to identify the underlying causes for the conflict, and consider corrective actions to decrease its potential occurrence in the future. For example, in applying a Root Cause Analysis process to ethics conflicts, ethicists would seek to determine why the conflict occurred, and what can be done to prevent it from happening again. a proactIvE approach to EthIcs conflIcts ƒ Identify the recurring ethics issues that create conflict or uncertainty Study the ethics issues in a systematic, system-oriented manner ƒ Develop ethical practice protocols to guide clinicians and ƒ executives on handling the conflict when it arises again Propagate the protocols into the organization’s culture so that ƒ all staff are aware of the guidelines and the rationale driving the guidelines Review whether the protocols are adequately addressing the ƒ ethics conflict and decreasing its recurrence Box 15.4 Practical Strategies for Addressing & Preventing Ethics Issues in Rural Settings 315 The process is used to focus on improving systems and processes, and when needed, redesigning them, rather than focusing on the individuals involved in the conflict. Having a proactive approach to ethics conflicts may be just as important to the rural provider as employing an effective ethics consultation service. Emphasizing the prevention of ethics conflicts by fostering the development of ethical practice protocols or guidelines, which are integrated into the culture of the organization, can enhance the quality of patient care by reducing the frequency of ethics conflicts. The proactive approach to addressing ethics conflicts within the context of hospital ethics committees’ activities would use the same basic five steps as noted above. For example, a member of the ethics committee or consult team could meet with the patient safety officer, the head of Human Resources, or a Vice President of Operations, and ask the question, “What are some of the recurring ethics issues that you or your staff encounter that create uncertainty or conflict?” Those identified ethics issues could then be systematically and thoughtfully discussed by ethics consultants and staff from the particular program or section over a period of time, leading to ethically grounded, proactive guidelines. Once the guidelines were propagated, along with the ethical reasoning underpinning them, the ethics committee could then provide staff with guidance for addressing the conflict when it reoccurred. This proactive ethics approach is similar in reasoning and process to the patient safety movement, with its goal of improving quality of care by reducing medical errors.21 Even though a proactive process that leads to the development of ethical practice guidelines may seem arduous, it has the advantage of creating an environment of increased ethical certainty and staff morale—thus avoiding emotionally draining and time-consuming ethics conflicts. In the end, practical, anticipatory approaches can enhance the clinic’s or hospital’s overall ethics environment by helping the staff better understand what is the right thing to do; thus reducing the recurrence of ethics conflicts. 316 Rural Ethics Resources eTHics aWareNess aND DiscussioNs iN rural commuNiTies Rural professionals can develop and implement community-wide education programs to foster patient awareness. Such programs often address topics to promote preventive care, such as weight loss/fitness, smoking cessation, and advance-care planning. However, community forums can also address ethics-related topics, including privacy and confidentiality, boundary issues, and end-of-life decision-making. For example, a critical access hospital can organize two to three community forums a year. Health care professionals can talk about a particular topic in an informal open atmosphere. The community forum session can create a dialog about the selected topic to enhance the understanding of the issue. Some educational events can be facilitated in collaboration with community leaders, such as clergy, to gain broad support and interest. The National Rural Bioethics program, based in Missoula, Montana, has facilitated community forums using the Readers Theater approach. A Readers Theater is designed to provide education and to stimulate informed conversation. The Readers Theater technique was developed and pioneered at East Carolina School of Medicine, where actors read a story line that describes problems that develop when providing health care. The scripts can be based on various common ethics issues encountered in rural settings, and participants may try on different roles. As described in the National Rural Bioethics Project’s Educational Resources Web site, “incidents are described in the voices of physicians, nurses, hospital administrators, patients, families, and clergy. An administrator or physician may read a nurse’s or a patient’s lines, a patient may assume the physician’s role. After the reading, the actors and audience engage in a discussion of the issues and themes.”22 It has been noted that the scripts have been well accepted by a wide variety of rural audiences and health care providers, providing a way to talk about the ethics issues. Potential scripts can be found on the National Rural Bioethics Project’s Web site.22 In addition to community-wide programs, rural clinicians working in various settings such as a small clinic should have clearly thought-out ethics practices. These ethics-grounded practices should be openly shared with patients and built into the overall culture of the clinic. Practical Strategies for Addressing & Preventing Ethics Issues in Rural Settings 317 Clinicians can also develop pamphlets delineating their ethical standards of practice to complement the discussions. Pamphlets on various topics can be available in the clinic waiting room, or given to patients during one-on-one visits. collaBoraTiNG WiTH ProFessioNal orGaNiZaTioNs In addition to collaborating with colleagues and ethicists, rural health care professionals can foster linkages with national and state professional organizations that focus on rural studies for educational opportunities, networking contacts, and as a vehicle for promoting and addressing rural health care concerns. Even though professional organizations rarely focus on rural issues, rural health care professionals can encourage planners of health care conferences, often held at state or national professional meetings, to include a spotlight or seminar on rural issues. These meetings can provide an opportunity to engage with others concerning rural health care, including the ethics challenges inherent in rural practice. Rural health care professionals can also actively participate in national professional organizations’ committees that establish standards of care to ensure that a rural perspective is recognized. They also can work with such organizations in advocating for adequate rural health care resources. Despite the lack of a rural focus in many professional organizations, there are stateand national-level organizations focused on rural health that provide information and support on rural specific issues. These organizations also serve as strong advocates for rural health care. exPaNDiNG ProFessioNal TraiNiNG iN rural HealTH care eTHics In addition to strategies employed by rural health care professionals in their practices, health care faculty at professional schools that train future rural health care professionals should implement strategies to address rural health care ethics issues in the curriculum. Such strategies can enhance the knowledge and skills of future rural health care professionals in addressing ethics challenges. In some schools, training could also be inter-disciplinary, that is, training that includes multiple professions, such as nurses and physicians. 318 Rural Ethics Resources The overall goals of rural ethics training, as noted in Box 15.5, should ensure students’ ability to perform the skills identified. Rural ethics training can be planned and implemented in both the preclinical and clinical years of training, involving mentors and preceptors as well as classroom faculty. To achieve the basic goals of rural ethics training, several strategies are suggested in Box 15.6. rural EthIcs traInIng goals ƒ Identify ethics issues present in clinical care Recognize how the rural context influences ethics issues and the ƒ professionals’ responses to them Perform an ethical analysis; applying ethical principles and ƒ professional standards Locate rural ethics resources ƒ Identify strategies to anticipate and decrease ethics issues in ƒ clinical practice Box 15.5 stratEgIEs to Expand rural EthIcs focus In profEssIonal EducatIon ƒ Increase the faculty’s understanding of the impact of the rural context on ethics issues Build opportunities into the curriculum for students to learn ƒ about rural ethics issues Have the faculty use rural-based cases in teaching and ƒ publications Have the faculty share their own ethics challenges or situations ƒ for discussion to enhance students’ awareness and comfort in identifying and discussing ethics situations Evaluate the student’s recognition and response to ethics ƒ