CÉLINE BAELE FROM MORAL DISTRESS AS A PSYCHOSOCIAL RISK TO MORAL RESILIENCE IN HEALTH CARE ORGANIZATIONS INCOSE CONFERENCE, BRUSSELS 15.09.2016 CÉLINE BAELE DORINE COOLEN HERLINDE DELY
WHO ARE WE Céline Baele (celine.baele@howest.be) Research group nursing studies Work and Organizational Psychologist Research group Nursing Studies ethics in care Howest University College West-Flanders Campus Bruges Ethics in care Exposure Knowledge point Informal care Informal carerfriendly HR Twitter: @CelineABa Moral distress Remiscence
CONTEXT Sector Workability Flemish organizations 54% Care homes 51,4% Hospitals 57,4% Welfare 68,9% Bron: Workability-Monitor /Werkbaarheidsmonitor (SERV, 2013)
PROJECTS Moral distress in residential elderly care (March 2014- December 2015) European Social Fund Woonzorggroep GVO : group of 8 residential elderly care institutions; 800 employees, 1000 residents
PROJECTS GOAL To investigate the concept moral distress To survey the causes of moral distress To develop a plan and strategies for action to detect, discuss and adress moral distress in residential care organizations
PROJECTS PRACTICAL RESEARCH Semi-structured interviews (n=16) and focus groups (=6) Survey (n=648) Development and testing of tools: instruments, workshops
WWW.MORELESTRESS.BE Morele stress in de ouderenzorg Woonzorggroep GVO
MORAL DISTRESS RECOGNIZAB LE EMOTIONAL DISTRESS & WORK LOAD
CAUSE personal values, vision and beliefs reality Moral conflicts Moral dilemmas Moral uncertainty Contrasting experiences
TESTIMONIES When I started working here, I was frustrated about the lack of professional material and sterile equipment. I wasn t able to provide decent wound care. I just knew it wasn t right. People developed cystitis due to sterility errors. I tried to stand up for my patients and brought it up in team meetings. Older nurses told me: You need to let it go. They [the management] won t listen. After a while, I started thinking: Why should I even try? It s pointless. I stopped caring about it. I feel sad for my patients and I m angry. Registered Nurse, 23 y.
TESTIMONIES
CRESCENDO EFFECT MORAL RESIDU That which each of us carries with us from those times when in the face of moral distress we have seriously compromised ourselves or allowed ourselves to be compromised. (Webster & Bayliss, 2000) Over time, higher levels of moral residue contribute to increased levels of MD. Left unadressed, crescendos can erode care providers moral integrity, resulting in desensitization to the moral aspects of care. (Hamric, 2012) TIME
EFFECTS: INDIVDUAL Rushton & Kurtz, 2015 Symptoms Physical Fatigue (physical) exhaustion Sleeping problems Physical complaints: headache, neck pain, back pain, stomachache Emotional Frustration Anger Guilt Anxiety Depressive feelings Burnout-symptoms (emotional exhaustion, cynicism, reduced professional efficacy) Behavioral Avoidance, distancing Apathy, indifference Turnover Verbal aggression Agitation Spiritual Loss of meaning Loss of personal and professional authenticity/ integrity
EFFECTS: TEAM Conflicts tensions! Moral distress caused by collegues! EFFECTS: QUALITY OF CARE Emotional distancing/desensitization/depersonalization ( compassion fatigue ): effect on patient care Conflicts in teams: effect on communication and coöperation (Rushton, 2006) (Piers et al., 2012; Özden et al., 2013; Wiegand & Funk, 2012; de Veer et al., 2013; Schluter et al., 2008; Hamric, 2012; Pauly et al., 2012; Varcoe et al., 2012; Davis et al., 2012)
EFFECTS: ORGANIZATION Turnover Absenteeism / burnout Diminished quality of care Austin, 2012; Pines & Aronson, 1998; Özden et al., 2013; Piers et al., 2011; Oh en Gastmans, 2013; Schluter et al., 2008, Rittenmeyer en Huffnan, 2009; Hamric, 2012; Wiegand & Funk, 2012 professionals resigning from their practice due to moral distress may be an indication that the healthcare environment has become toxic. (Austin, 2012,p.28)
EXIT-NEGLECT-LOYALTY-VOICE Hirschman (1970). EXIT VOICE (speaking up) NEGLECT (distancing, avoiding) LOYALTY (hoping)
THE OTHER SIDE OF THE COIN Moral sensitivity = engagement, commitment Barometer for quality of care Taking a break reflecting upon acts Action arises from discontentedness = reflection and ethical growth
MORAL RESILIENCE Learning from experiences of moral distress Constructively addressing moral distress (anger/frustration as strength) Standing up for good patient care As an organization/ as a team / as a carer / als a person Ethical growing-force
TESTIMONIES Sometimes it s 10.30 a.m. when the morning tour is done. That means the last resident still hasn t had his breakfast yet. I find myself thing: That poor person hasn t had something to eat for 16 hours. SIX-TEEN hours. How is that even possible? It makes me angry. I call my collegues and we look for solutions. What can we do, so that it doesn t happen again? Caring assistant,
TESTIMONIES It s important that professional carers are able to experience moral distress. If you can not in my opinion you don t even provide good care. You need to question yourself and the organization of care. When I m feeling morally distressed, I often have the feeling I m falling short. But I m convinced that afterwards, I m providing even better care, because I reflected upon it. Head nurse,
BASIC THOUGHTS I. Moral distress is inherent in the nursing profession/ health care II. III. IV. Moral distress is a psychosocial risk and should be given attention within the scope of well-being at work Moral distress is no individual problem. Adressing moral distress is a shared responsability. Moral distress can have adverse effects and should be addressed. Addressing moral distress is worth the effort. V. Moral distress carries an ethical growing-power. Moral resilience can enhance quality of care and employee fulfillment
RESOURCES Individual resources Self-knowledge Self-regulation Moral courage Self-care Rushton & Kurtz, 2015
RESOURCES Rushton & Kurtz, 2015 Job and Organizational resources Social support Autonomy Professional standards and guidelines Feedback and appreciation Training opportunities Infrastructure and professional equipment Adequate staffing Policies: guiding vision Support measures Supportive leadership style
MORAL RESILIENCE HOUSE FRAMEWORK Moral resilience Self-knowledge, self-reflection, self-care Our team (self) Appreciation Kindness/compassion Putting things into perspective Moral courage Values / meaning BEARING SURFACE
ACTION MODEL Dectecting making discussable coping with
ACTION PLAN Carrying capacity, carrying load- en suport/bearing surface interventions
ACTION PLAN Carrying capacity-interventies = personal resources of individual employees and teams Resilience (moral courage, appreciation, ) Ethical reflection capacity- clarifying values Team development See www.morelestress.be (Dutch only) Workshops
ACTION PLAN Carrying load-interventions = Focus on work demands and factors that contribute to MD Detection of situations that evoke MD Prevention of moral distress by changing the working environment Vb. reorganization of care Vb. hiring staff Vb. re-evaluating work load Vb. transfer of patients
ACTION PLAN Support/carrying surface-interventies = Focus on work-and organizational resources and support measures Autonomy-supporting measures Inspiring vision Installing a feedback culture See www.morelestress.be Guide for management: from moral distress to moral resilience
INDIVIDUAL STRATEGIES Reflect upon (situations that cause) moral distress Speak up Find (emotional) support Focus on changeable aspects Look for resources
STRATEGIES FOR HEAD NURSES/TEAM LEADERS Inform yourself on moral distress Detect moral distress & identify causes Lower the threshold for discussions on moral distress Focus on team development, social support systems and a positive, appreciative, growth-oriented team climate Hold a coaching and empowering attitude Facilitate ethical reflection Enhance participation and shared decision making
ORGANIZATIONAL STRATEGIES Anchor moral distress in HRM Provide learning possibilities and detect learning needs Focus on changes in the organization of care Develop supportive policies Focus on interdisciplinarity and team gatherings on ethical aspects of care Hold an integrated vision: moral distress as core concept in employee engagement quality of care efficiency retention
FUTURE New 2y- project: Flanders Innovation & Entrepreneurship (VLAIO) From moral distress to moral resilience in health care organizations Goal: To raise awareness on moral distress in health care organizations To create consultancy and supporting systems within occupational health consultancy agencies/occupational safety & health practitioners and External Prevention Services: e.g. risk-analysis modules on moral distress Knowledge transfer / aligning supply and demand Contact: onderzoekvpk@howest.be
E thics i n care / M oral d i s tress THE YEARS PROVIDE YOU WITH A WRINKLED SKIN BUT IF YOU LOSE YOUR PASSION YOU GET A WRINKLED SOUL