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
No relevant financial or commercial interests to disclose. Disclosure
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.
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
A (brisk) walk
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
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
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
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
Strategies to mitigate moral distress Supportive colleague-to-colleague dialogue Regular interdisciplinary team debriefings Rodney et al., 2013. 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
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
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
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?
Crescendo Effect Epstein & Hamric, 2009
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
Ethics Liaisons @ 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.
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
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
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
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
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
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
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
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.
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
Quick fix?
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)
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
Ethical fitness?
Overwhelming?
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
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
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
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