Implementing Ethics Rounds: Facility Overview and Best Practices

In healthcare facilities, ethics rounds are structured, periodic conversations about the status and plan of care for patients, with a focus on ethical issues. For nurses, providing ethical care is an obligation that is built into the profession. However, the specific language of ethics can get lost in the shuffle of daily tasks — until incremental frustrations build up to an overwhelming sense of moral injury, or a patient experiences a drastic crisis that requires an ethical consult.

Both scenarios can be prevented with proactive, consistent rounding designed to bring ethical issues to the surface. In this article, we’ll discuss possible structures for ethics-based rounding, including staff mix and frequency. You’ll learn about the history and evolution of healthcare ethics programs (HCEPs) and the immediate and long-term effects you might see when you put your process in place. Use the best practices provided at the end of the article to get your facility’s improved rounding process off to a strong start.

Ethics in Healthcare: Early History

As healthcare becomes more complex, clinicians need more resources for making ethically sound decisions. Early hospital ethics committees formed in the 1960s and 70s to address questions with no simple right or wrong answer, such as:

• Which patients would have access to a limited number of early dialysis machines?
• Could a patient’s family order cessation of respirator therapy or tube feeds?

Committee structure varied widely, and implementation was the exception rather than the norm.

The Turning Point in the 90s

In 1990, a case involving patient Nancy Cruzan shed more light on how medicine and ethics are intertwined. Following a car accident, Cruzan was comatose and kept alive solely by a feeding tube. Her parents argued for termination of the feedings, and the resulting legal case led to public controversy, with some in the healthcare community arguing that she was a prisoner of medical technology.

Due to this case and others like it, Congress passed the Patient Self-Determination Act, giving patients in the U.S. the right to autonomy. In addition, The Joint Commission issued a requirement that accredited organizations must have a system in place for handling ethical issues.

Current Practices for Addressing Ethical Issues

Today, it’s estimated that as many as 97% of hospitals have a healthcare ethics program (HCEP) in place. Programs may include a formal ethics committee that serves as a resource, often when a particularly complicated or distressing case arises. Some healthcare organizations employ a full-time clinical ethicist who holds an advanced degree, such as a Master’s in Bioethics or Health Ethics. Ethicists provide consults to staff, patients, and family members.

Since the late 1990s and throughout the 2000s there has also been an increasing focus on proactively engaging with ethical principles, instead of always waiting until committee input or an ethicist consult is requested.

What Is the Purpose of Ethics Rounds?

Ethics rounding has emerged as a strategy for giving healthcare staff a chance to have routine discussions about ethical considerations. The process is designed to:

• Encourage the use of ethics-based language.
• Give the healthcare team a chance to voice ethical concerns and receive feedback.
• Proactively address patient needs and ethical dilemmas.
• Educate clinicians about ethical principles.

Examples of Ethics-Based Rounding

The exact process differs according to unit needs and available resources. Here are two examples to show you possible structures for rounds.

Benefits of Ethics-Based Rounding

Implementing rounds of this type can decrease moral distress for nurses, bring teams together, and reduce burnout. In addition, the built-in component of raising awareness of ethical principles can help nurses more consistently act on behalf of their patients — a commitment that is foundational to nursing.

Challenges of Ethics-Based Rounding

Here are some challenges to consider:

• Nursing staff who already feel short on time may resist participating in these discussions.
• Carving out time may mean pulling nurses away from direct care duties, temporarily leaving patients with fewer caretakers.
• Nurses may initially be intimidated by the terminology.
• Nurses may feel that experts are speaking down to them rather than engaging in productive dialogue.

3 Best Practices for Implementing Ethics-Focused Rounds

Your approach to setting up proactive ethics rounding will depend on the pace of your unit, your patient population, and your resources. With those details in mind, consider the following three best practices. The right approach will ensure that rounds are successful from the get-go.

1. Emphasize the Why Behind the New Process

To help your nursing staff see the value of these rounds, present evidence from a similar unit that implemented the process and saw benefits. For example, a nurse manager working on a dialysis unit could showcase research from a similar unit, and share that “nurses on this unit reported higher levels of job satisfaction and felt more confident about advocating for their patients within one year of implementing ethics-based rounding.”

You may also need to address foundational questions about the approach, such as:

• What does ethics have to do with my daily nursing practice?
• What is the difference between morals and ethics?
• What is the purpose of ethics rounds?
• How will this help our patients?

2. Combine With an Existing Rounding Practice

If you have an existing daily rounds routine, consider integrating ethics discussions intermittently. For example, at Michigan Medicine, an ethicist joins in on ICU staff’s morning rounds once a week to contribute insights and answer questions. In this way, ethical issues can be caught and addressed before they escalate, and staff gain increased awareness of recurring ethical issues on the unit — without deviating from their usual schedule and routines.

3. Encourage Open Dialogue

Most nurses received training about ethics in school, but learning about the principles from a textbook and facing them in real life are two very different things. Set a standard that all questions are valid. Encourage staff to speak up, even if they’re unsure of what terms to use. Initially, the language may feel clunky, but with time it will become more familiar.

Get More Nursing Leadership Insights

Implementing ethics rounds is one way to help nurses on your team gain confidence and find more satisfaction in their work. Looking for more guidance? Our healthcare leadership tips and strategies are designed to help you optimize your team’s performance.