Moral Distress, Giving Voice to Values

Transcription

1 Moral Distress, Giving Voice to Values Physician Burnout: Integrated Strategies for Diverse Stakeholders Heather Fitzgerald, MS, RN Clinical Nurse Ethicist Children s Hospital Colorado Faculty CU Center for Bioethics and Humanities

2 No relevant financial or commercial interests to disclose. Disclosure

3 Objectives 1. Describe a walk with Deb 2. Moral distress (antidotes to moral distress, speaking up, GVV) 3. CHCO work to mitigate moral distress, promote moral resilience and create & sustain an ethical environment.

4 Deb Saint-Phard, MD Cynda Rushton, PhD, RN Ann Hamric, PhD, RN Norine Hemphill, MS, RN Pat Givens, DHA, EdM, RN Jackie Glover, PhD Brian Jackson, MD, MA Dan Reirden, MD Deep Bow

5 A (brisk) walk

6 Moral distress Vast MD literature Controversy regarding the robustness of MD studies Experienced by all HCPs Distinguish between moral stress (anticipated) and moral distress (compromised personal and/or professional integrity). Authors (Bell, Breslin, Grace, Robinson, Jurchak and others) are finding correlation with nursing burnout, distancing from patients, numbing to moral sensitivity and likelihood of leaving the profession Also correlated with a sense of powerlessness to effect change or meet the needs of patients; ethical environments correlate to lower levels of MD

7 Moral Distress When a person believes they know the right thing to do but are impeded due to organizational or other constraints Jameton, 1993 The experience of being seriously compromised as a moral agent in practicing in accordance with accepted professional values and standards. Varcoe, Pauly, Webster and Storch, 2012

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9 Constraints Internal Lack of assertiveness Self-doubt Socialization to follow orders Perceived powerlessness Lack of understanding of the full situation External Inadequate staffing Hierarchies within the healthcare system Lack of collegial relationships Lack of administrative support Policies and priorities that conflict with care needs Compromised care due to pressure to reduce costs Fear of litigation Epstein & Hamric, 2009

10 Strategies to mitigate moral distress Speak up Build support networks Epstein & Hamric, 2009 Focus on desired changes that preserve moral integrity Mentoring Participate: educational activities, discussions Forums for interdisciplinary problem solving Address root causes in institutional or unit culture

11 Strategies to mitigate moral distress Supportive colleague-to-colleague dialogue Regular interdisciplinary team debriefings Rodney et al., Transparent communication between administration and practice Role models Keep the patient at the center Capacity and skill-building with moral reasoning skills, conflict resolution techniques Expand the identity-conferring commitment of moral agency

12 Strategies to mitigate moral distress Epstein & Hamric, 2009 Speak up Build support networks Focus on desired changes that preserve moral integrity Use mentoring and institutional resources Participate in educational activities and discussions Use forums for interdisciplinary problem solving Address root causes in institutional or unit culture Develop policies to encourage ethical discussion

13 Why don t we speak up? RNs don t want to be labeled as malcontents or pot-stirrers and would not challenge MDs if they perceived it would result in conflict, stress, reprisal. Interprofessional collaboration in the ICU suffers: Power dynamics Churchman & Doherty, 2010 Poor communication patterns jr team members are hesitant to speak up to sr colleagues due to fear of reprisal, embarrassment, appearing incompetent Organization and systemic factors - hierarchy Rose, 2011

14 GVV with permission, M. Gentile, 2018 Values-driven leadership development Assumes positive intent: we want to act on our values, how do we enact our values in professional practice? How do we increase the odds of enacting our values effectively?

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16 Crescendo Effect Epstein & Hamric, 2009

17 Ethical Commitments Provision 6.3 Nurses are responsible for contributing to a moral environment that demands respectful interactions among colleagues, mutual peer support, and open identification of difficult issues, which includes ongoing professional development of staff in ethical problem solving. p. 24 ANA Code

18 Ethics CHCO To serve as a professional, approachable presence in the unit/dept as a representative of the ethics committee, To facilitate ethics discussions among interdisciplinary colleagues, To communicate ethical questions or issues that arise to unit leadership and, as needed, to the ethics committee for education or consultation, To identify frequent/recurring ethical issues that may necessitate the need for education, a practice change, communication or an ethical framework.

19 Ethics Champion Programs Supportive unit-based, hospital wide forums to: address moral distress at the unit and organizational levels deepen moral sensitivity clarify personal and professional values increase confidence in identifying, analyzing and responding to ethical issues, engaging in ethics conversations and education provide ongoing support draw on ethics resources

20 Ethical Competence Ethical sensitivity: Self-awareness Self-regulation Mindfulness Strong moral compass Recognition of ethical issues Empathy to consider others experience Ethical knowledge: Ability to define the problem Experience Training Education Ethical principles, precepts, theory Codes of ethics, law, precedent cases Lechasseur, et al., 2016

21 Ethical Competence Ethical reflection: Considering more than 1 or 2 viewpoints Awareness of personal and professional values Process of inquiry vs disagreement Ethical action: Strong problem-solving skills Ability to speak up effectively Ownership, ability to work w/others to resolve issues Implementation skills Lechasseur, et al., 2016

22 Ethical Competence Ethical behavior: Moral courage Risk-taking Self care Respect Modeling these qualities Moral motivation to do what is right for the pt Ethical decision making: Judgement about which action is ethical sound Openness to perspectives Assure all voices are included Ability to prioritize moral values over personal values Ability to recognize the core issue: pt well being Lechasseur, et al., 2016

23 Participant Survey, 2016 Survey to Ethics Champions of 3 Pediatric Hospitals via SurveyMonkey Survey included: Demographics Evaluation of ethical climate Open-ended discussion of impact of role of ethics champions

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25 Impact of Ethics Champion Program Please share ways that participating as an Ethics Champion has impacted your nursing/clinical practice. Responses: 70 out of 78 responded 8 major themes identified Each major theme included 2 to 3 sub-themes Most responses included from 2 to 5 themes

26 Impact of Ethics Champion Program 1. Increased awareness/recognition of ethical issue 2. Importance of support in addressing ethical issues 3. Increased individual moral agency 4. Increased knowledge/understanding of ethics 5. Increased perspective, ability to include others views 6. Increased utilization of ethics resources 7. Made a difference by impacting clinical practice 8. Importance of ethics discussions

27 I believe 100% that it has made me a better nurse. Overall, I have found that I am able to look at a situation more objectively and I can appreciate the opinions of others when addressing an issue. I have also changed the way I have interacted with my patients and families and I have found it easier to maintain a therapeutic relationship with my patients.

28 Ethical fitness? Requires being mentally engaged thinking, reasoning, grappling with difficult situations or their potential, on a regular basis, as well as a commitment to finding better ways to reach good outcomes. Kidder, 2009

29 Quick fix?

30 Ethical fitness About doing, not just thinking, reasoning or grappling About moral agency -- moving to action to benefit patients About promoting ethical environments where it is expected that we bring forward difficult issues related to patient care and/or institutional constraints upon ethical practice for discussion and review. (ANA 4.3)

31 Ethical fitness test Do we consider ourselves to be moral agents? Do we have conversations about the ethical implications of our work? Do we raise morally distressing issues for discussion and resolution? Do we work to enhance the ethical climate of our work settings? Storch, Rodney, & Starzomski, 2013

32 Ethical fitness?

33 Overwhelming?

34 Strategies to build ethical fitness Know who you are and what you stand for your core values cultivate your inner game Cultivate moral resilience capacity to sustain or restore your integrity in response to moral complexity, confusion, distress, uncertainty or setbacks Prioritize time and methods for reflection Rushton, 2016

35 Training regimen for ethical fitness Be in the moment notice the micro-ethical moments every day - to change the moment is to change the culture Don Berwick, Ask less what do I do? and more what am I a part of? pt at the center Train confidence and competence in speaking up

36 Guide to the Code of Ethics for Nurses with Interpretive Statements nurses, in all roles, must create a culture of excellence and maintain practice environments that support nurses and others in the fulfillment of their ethical obligations.the Code goes beyond a foundation of support for nurses; it seeks to construct a culture of excellence wherein meeting ethical obligations is an everyday expectation. ANA Code, p. 105

37 Resources American College of Healthcare Executives. Creating an ethical environment for employees. Available at: Accessed 3/9/15. American Nurses Association. Code of ethics for nurses with interpretive statements. Silver Spring, MD Austin, W. Carnevale, F., Frank, A., & Garros, D. The experience and resolution of moral distress in pediatric intensive care teams: A Canadian perspective. The University of Alberta. Accessed Sept. 15, Bell, J., Breslin, J.m., (2008). Healthcare provider moral distress as a leadership challenge. JONAS Healthcare, Law, Ethics & Regulation, 10(4): Burston, A.S. & Tuckett, A.G. (2013). Moral distress in nursing: Contributing factors, outcomes and interventions. Nursing Ethics, 20(3): Chen, P. When nurses and doctors can t do the right thing. New York Times. February 5, Accessed April 1, Churchman, J.J. & Doherty, C. (2010). Nurses views on challenging doctors practice in an acute hospital. Nursing Standard, 24(40): Corley, M.C., Minick, P., Elswick, R.K. and Jacobs, M. (2005). Nurse moral distress and ethical work environment. Nursing Ethics, 12(4): De Veer, A. J. E. et al (2012). Determinants of moral distress in daily nursing practice: A cross sectional correlational questionnaire survey. International Journal of Nursing Studies, 50(2013): Epstein, E.G. & Hamric, A.B. (2009). Moral distress, moral residue and the crescendo effect. Journal of Clinical Ethics, 20(4): Gallagher, A. (2010). Moral distress and moral courage in everyday nursing practice. The Online Journal of Nursing, 16(2). Grace, P.J., Robinson, E.M., Jurchak, M., Zollfrank, A.A., & Lee, S.M. (2014). Clinical ethics residency for nurses. The Journal of Nursing Administration, 44(12): Grady, C. et al. (2008). Does ethics education influence the moral action of practicing nurses and social workers? American Journal of Bioethics, 8(4):4-11. Hamric, A.B. (2010). Moral distress and nurse-physician relationships. American Medical Association Vitrual Mentor, 12(1): Hamric, A.B. & Blackhall, L.J. (2007). Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. Critical Care Medicine, 35(2): Hart, S.E. (2005). Hospital ethical climates and registered nurses turnover intentions. Journal of Nursing Scholarship, 37: Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, N.J.: Prentice Hall. Kidder, R.M How good people make tough choices: Resolving the dilemmas of ethical living. New York: Harper. Lachman, V.D. (2007). Moral courage: A virtue in need of development? MedSurg Nurs. 16(2): LaSala, C.A. & Bjarnason, D. (2010). Creating workplace environments that support moral courage. OJIN, 15(3): Manuscript 4. Leape, L.L., Shore, M.F., Dienstag, J.L., Mayer, R.J., Edgman-Levitan, S., Meyer, G.S. and Healy, G.B. (2012). A culture of respect, part 2: Creating a culture of respect. Acad Med, 87: 1-6. Leonard, M., Graham, S. & Bonacum, D. (2004). The human factor: The critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care, 13:

38 Resources Mason, V.M. et al (2014) Compassion fatigue, moral distress, and work environment in surgical intensive care unit trauma nurses: A pilot study. Dimensions in Critical Care Nursing, 33(4): Moss, M., et al (2016). A critical care societies collaborative statement: Burnout syndrome in critical care health-care professionals. American Journal of Respiratory and Critical Care Medicine, 194(1): Murray, J.S. (2007). Creating ethical environments in nursing. American Nurse Today, 2(10):48-9. Murray, J.S. (2010). Moral courage in healthcare: Acting ethically even in the presence of risk. OJIN, 15(3): Manuscript 2. Musto, L. C., Rodney, P.A. & Vanderheide, R. (2015). Toward interventions to address moral distress: Navigating structure and agency. Nursing Ethics, 22(1): Olson, L. (1998). Hospital nurses perceptions of the ethical climate of their work setting. Image: Journal of Nursing Scholarship, 30(4) Olsen, L. (2002). Ethical climate as the context for nurse retention. Chart, 99 (3). Pauly, B., Varcoe, C., Storch, J. & Newton, L. (2009). Registered nurses perceptions of moral distress and ethical climate. Nursing Ethics, 16(5): Robinson, E.M., Lee, S.M., Zollfrank, A., Jurchak, M., Frost, D. & Grace, P. (2014). Enhancing moral agency: Clinical ethics residency for nurses. Hastings Center Report, 44(5): Rodney, P.A. (2013). Seeing ourselves as moral agents in relation to our organizational and sociopolitical contexts. Bioethical Inquiry, 10: Rose, L. (2011). Interprofessional collaboration in the ICU: How to define? Nursing in Critical Care, 16(1): Rushton, C.H. (2016). Moral resilience: A capacity for navigating moral distress in critical care. AACN Adv Crit Care, 27(1): Rushton, C.H., Caldwell, M. &Kurtz, M. (2016). Moral distress: A catalyst in building moral resilience. American Journal of Nursing, 116(7): Rushton, CH, et al. (2013). A framework for understanding moral distress among palliative care clinicians. J Palliat Med, 16(9): Rushton, C. H. (2006). Defining and addressing moral distress: Tools for critical care nursing leaders. AACN Advanced Critical Care, 17(2): Sauerland, J., et al. (2014). Assessing and addressing moral distress and ethical climate, part 1. Dimensions in Critical Care Nursing, 33(4): Schluter, J., Winch, S., Holzhauser, K., & Henderson, A. (2008). Nurses moral sensitivity and hospital ethical climate: a literature review. Nursing Ethics, 15(3): Storch, J.L, Rodney, P, and Starzomski, R Toward a moral horizon: Nursing ethics for leadership and practice. Toronto: Pearson, Canada Varcoe, C., Pauly, B., Webster G. and Storch, J. (2012). Moral distress: Tensions as springboards for action. HEC Forum, 24: Whitehead, P.B., Herbertson, R.K., Hamric, A.B., Epstein, E.G. & Fisher, J.M. (2015). Moral distress among healthcare professionals: Report of an institution-wide survey. Journal of Nursing Scholarship, 47(2): Wlody, G.S. (2007). Nursing management and organizational ethics in the intensive care unit. Critical Care Medicine, 35(2):29-35.

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