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09Moral Distress


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Moral Distress/Work Environment/Magnet

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09Moral Distress

  1. 1. Resolving Moral Distress in Health Care by: Jill Ritchey BSN RN
  2. 2. Happy Nurses Happy patients Moral Distress Patient Satisfaction
  3. 3. Inspiration Vision/Mission Goals Infrastructure Relationship Based Care Education Magnet Forces Evidence Patient/Nurse Satisfaction
  4. 4. Objectives <ul><li>Name some stakeholders that may experience moral distress </li></ul><ul><li>Recognize moral distress and its impact on nursing and health care </li></ul><ul><li>Identify ways to lessen the negative effects of moral distress </li></ul>
  5. 5. Who are the Stakeholders? <ul><li>Patients </li></ul><ul><li>Families </li></ul><ul><li>Physicians </li></ul><ul><li>Nurses </li></ul><ul><li>Social Workers </li></ul><ul><li>Chaplains </li></ul><ul><li>Those at the bedside </li></ul><ul><li>Hospitals </li></ul><ul><li>What are the unique burdens that they bear? </li></ul>
  6. 6. Patients <ul><li>Ethical goals: reduce suffering, preserve dignity & protect patient’s autonomy </li></ul><ul><li>Patients are often unable to participate in EOL decision making processes, therefore, their wishes are at risk of becoming secondary to other stakeholders, usually family </li></ul>
  7. 7. Family of critically ill patients face: <ul><li>Extreme Stress </li></ul><ul><li>Feeling solely responsible and at the same time powerless </li></ul><ul><li>Difficult and timely decisions </li></ul><ul><li>Grief: can be experienced even if the prognosis is good </li></ul>
  8. 8. Bedside Nurses <ul><li>Cannot physically detach from the patient like other stakeholders </li></ul><ul><li>Must respond to limitless and unpredictable human needs…they are like the ball boy at a tennis match who also must serve snacks in the audience </li></ul>
  9. 9. Nurses, continued: <ul><li>Wear many hats, but carry no title of authority: nurses are still viewed in a subservient role, not as part of an autonomous profession. Nursing can be described as a semi-profession that is responsible for everything but has no authority over anything. “Nurses have little experience with positive credit but have a great deal with negative accountability”. (Buresh and Gordon). </li></ul><ul><li>Nurses straddle their priorities with the priorities of others and the nurses’ priorities ultimately take a back seat: The stress of not being able to spend time at the bedside is one source of moral distress. </li></ul>
  10. 10. Physicians <ul><li>Have less contact with patients than nurses </li></ul><ul><li>Ultimately carry the most legal/ethical weight which likely explains why futility decisions are often based on positive prognostic forecasts </li></ul><ul><li>Nurses who have constant intimate contact with patients prognosticate more accurately, but are more likely to give negative forecasts </li></ul><ul><li>Nurses prognostic capabilities are based on recent frequent experiences </li></ul><ul><li>Physicians prognostic capabilities are more likely to be based on remote selective recall of infrequent experiences </li></ul>
  11. 11. Chaplains <ul><li>May view that their maximum potential is limited by roles assigned by a particular culture </li></ul><ul><li>Unlike nurses, have little peer support </li></ul><ul><li>Socialized to care only about others’ feelings, not to burden others with their own personal feelings </li></ul>
  12. 12. Social Workers <ul><li>May feel patient’s best interests are secondary to the family dynamics </li></ul><ul><li>A profession greatly affected by moral distress </li></ul><ul><li>Fewer peers to vent feelings of personal powerlessness/moral distress </li></ul>
  13. 13. Definition of moral distress <ul><li>According to the American Association of Critical Care Nurses; “a situation when the ethically appropriate action to take is known, but one is unable to act upon it; or when one acts in a manner contrary to his or her personal and professional values, which undermines that individual’s integrity and authenticity” </li></ul>
  14. 14. How does it affect... <ul><ul><ul><li>Nurses: Have you ever worked with a nurse you privately labeled as 'lazy'? Moral distress can manifest as a nurse who limits time with patients to point of barely meeting their most basic needs . </li></ul></ul></ul><ul><ul><li>Physical illness can occur therefore Hospitals must deal with staffing issues due to call-offs </li></ul></ul><ul><li>Magnet Hospitals have a lower incidence of MD </li></ul><ul><li>Patient care: Patients have better outcomes </li></ul><ul><li>Future of nursing: Nurses are leaving the bedside by the droves. Moral distress is a priority issue with Association of American Critical Care Nurses, as well as other organizations </li></ul>
  15. 15. How can nursing leaders impact moral distress? By empowering nurses <ul><li>Magnet Force # 1 Quality of Nursing Leadership </li></ul><ul><li>In Magnet Hospitals, Nursing leaders “walk the talk” of the organization’s Mission goals </li></ul><ul><li>Nursing leaders empower nurses in many ways... </li></ul><ul><li>Visibility in Leadership </li></ul><ul><li>Being present by listening to the stories of nurses creates the capacity to appreciate fully the temporal-spatial relationship between patients and the bedside nurse….in this sense, we are all leaders. Having access to the nurse-narrative gives leaders access to the patient, thus fulfilling an aspect of their altruistic mission goals </li></ul>
  16. 16. Empowering and Inspiring Leaders... <ul><li>“ have connections” </li></ul><ul><li>Provide guidance- steer nurses toward the right resources </li></ul><ul><li>Nurses can access Power through their leaders to help patients…leaders may be able to cut through the “red tape” that automatically comes with a large and unwieldy vertical organizational structure </li></ul><ul><li>are unafraid to </li></ul><ul><li>acknowledge and confront moral distress in the bedside nurse, p rovide incentives for cultural change and are p owerful enough to bring even the most uninterested/’burned-out’ nurses to the table. </li></ul><ul><li>have an open door policy </li></ul><ul><li>… staff feel welcome and safe to seek clarification if they are unsure (or feel intimidated by other stakeholders) of their ethical duties and leaders utilize this as a learning opportunity for staff development. </li></ul>
  17. 17. Strong Leaders provide opportunities for: <ul><li>Nurses to participate in decisions </li></ul><ul><li>Leaders can help by facilitating nurses with identifying and articulating their ethical problems…nurses who are experiencing moral distress may have difficulty with this stage of problem-solving….it’s possible that there is a quick and easy solution. </li></ul><ul><li>Self efficacy </li></ul><ul><li>Make staff feel that they have something valuable to add to the organization </li></ul><ul><li>Growth and development </li></ul><ul><li>Leaders allow nurses to access their power while re-learning to exercise their own new sense of empowerment…leaders then support nursing autonomy once it is acquired </li></ul>
  18. 18. How else can hospitals impact moral distress? Magnet Force # 2 Organizational Structure Cultural Change <ul><li>Decentralize or flatten administrative hierarchy </li></ul><ul><li>Shared Governance </li></ul><ul><li>Create forums </li></ul><ul><li>Perhaps nurse/physician forums to improve collaboration </li></ul><ul><li>Facilitate efficacy of educational initiatives Nurses should decide what they want and need to learn…a vertical governance model is likely to make assumptions of what nurses need and want…nurses learn better when they are engaged and fully invested in the issues of patient care </li></ul><ul><li>Participate in policy... with power and autonomy comes responsibility…therefore nurses must make the commitment to participate with the implementation and evaluation as well …and adjust current initiatives accordingly </li></ul>
  19. 19. Are Magnet Forces at play in your unit/organization’s culture? <ul><li>Is speaking up considered a low-benefit high-risk endeavor? </li></ul><ul><li>Is the discussion of uncomfortable subjects (inter-professional conflicts, moral distress) supported? </li></ul><ul><li>Are there unspoken rules…are concerns dismissed or minimized? </li></ul><ul><li>Do you feel that advice, information or guidance may be unreliable or unavailable? </li></ul><ul><li>Is there fear of retaliation for speaking up on behalf of the patient? </li></ul><ul><li>Does inter-professional dialogue about conflict feel safe? </li></ul><ul><li>Is rocking the boat or making waves frowned upon? </li></ul><ul><li>Are there ethical resources available? </li></ul>
  20. 20. Picker Institute’s Eight Dimensions of patient centered care Patient satisfaction, what patients want <ul><li>Respect for patient’s preferences </li></ul><ul><li>Access to information </li></ul><ul><li>Emotional support </li></ul><ul><li>Continuity </li></ul><ul><li>Physical comfort </li></ul><ul><li>Provisions for education </li></ul><ul><li>Involvement of family and friends </li></ul><ul><li>Collaboration and coordination of care between caregivers </li></ul><ul><li>How visible are patient centered care values in your unit? </li></ul>
  21. 21. Nurses experience less moral distress when they can advocate on behalf of their patients Magnet Force # 5 Professional Model of Care Relationship based or patient-centered care models promote patient and nursing autonomy
  22. 22. … it is well documented that nurses experience moral distress when they are given too much to do and too little to do it with <ul><li>Nursing models of care can guide the efficacy of providing care through quality initiatives based on evidence-based and resource-driven care practices </li></ul><ul><li>Nurses who are involved in policy-making decisions can utilize research to eliminate non-value added practices and improve upon the care they do practice </li></ul>
  23. 23. Nursing advocacy-power is important for: Vulnerable Patient/Family Populations <ul><li>Distrust...Bad experiences with health system in the past lead to poor outcomes </li></ul><ul><li>Low health literacy…may require more time from caregivers </li></ul><ul><li>Poor coping skills </li></ul><ul><li>Religious and cultural influences </li></ul><ul><li>all families can recognize compassion….competence of caregiver is not so easily recognized…therefore, families may construe uncaring behavior to be incompetence or caring behavior as competence…caregivers can affect the cycle of trust through their behavior </li></ul>
  24. 24. Magnet Force # 8 Consultations/ Resources Utilizing Hospital Ethics Committee can help stakeholders in addressing ethical issues, thus reducing moral distress
  25. 25. Catholic Health has begun an initiative to reintegrate ethics at the point of care The Next Generation Ethics Model <ul><li>What does this ethics’ model do for hospital ethics’ committees? </li></ul><ul><li>Increases visibility and utilization </li></ul><ul><li>Promotes pro-action versus reaction </li></ul>
  26. 26. Re-integrating ethics at the point of care <ul><li>Austin, et al, envisions “...ethics committees as ‘architects of moral space within the health care setting as well as mediators in the conversation taking place within the space’…are in the unique position of being able to seek out ethical discussion and educate healthcare staff to better articulate their own ethical problems…”. </li></ul>
  27. 27. Helping Nurses Reclaim their Traditional Role as Patient Advocates (otherwise known as the Professional Practice of Nursing) <ul><li>At Bon Secours it was felt that nurses needed to re-create their role in ethics. The goal was to promote proactive, practical integration between health care ethics and nursing care by front-line nurses </li></ul><ul><li>Developed a set of core competencies for nurses </li></ul><ul><li>Communicated the expectation that nurses advocate for patients and the profession </li></ul><ul><li>Education and resource development </li></ul><ul><li>Increase awareness of resources available to them </li></ul>
  28. 28. “ Ethics is Everyone’s Business” <ul><li>St. Joseph Health System is developing an ethics strategy by involving Risk Management and Legal to aid in education </li></ul><ul><li>Feeling supported by policy regarding information-giving (and other Picker Institute dimensions) can improve stakeholders ability to advocate </li></ul>
  29. 29. Integration of Ethics with Patient Centered Care <ul><li>Supports a culture that protects patient autonomy through communication and collaboration </li></ul>
  30. 30. Grand Rounds Interdisciplinary daily rounds conducted in a manner that ensures input from non-physicians is one way to promote... <ul><li>Having a voice reflects aspects of this Magnet Force (# 9) </li></ul>Autonomy
  31. 31. Magnet Force # 12 Image of Nursing <ul><li>Experience (years) affects moral sensitivity. Individuals may be unwilling to identify moral distress in themselves…may prompt caregivers to assume a ‘tough guy’ persona or eventually result in “EDD”-Empathy Deficit Disorder </li></ul><ul><li>Socialized roles have perpetuated the perception of powerlessness </li></ul><ul><li>Caregivers perceived lack of power stems from feeling…. </li></ul>
  32. 32. Dis-empowered <ul><li>Unaware </li></ul><ul><li>Uneducated </li></ul><ul><li>‘ Burned out’ uninterested </li></ul><ul><li>Unguided </li></ul><ul><li>Inarticulate </li></ul><ul><li>Out of the loop </li></ul><ul><li>Unsupported </li></ul>
  33. 33. Magnet Force # 13 Collegial Nurse/Physician Relationships <ul><li>Collaborative relationships between medical directors and nursing directors improve patient outcomes </li></ul><ul><li>Improve structural support at the unit level to empower those at the bedside… for example, mechanisms that trigger automatic palliative, ethics or physician/patient-family conferences </li></ul><ul><li>Collaboration and communication will dictate the ethical climate… goal of therapy should be widely known </li></ul>
  34. 34. More about collaboration <ul><li>Magnet hospitals have a high level of collaboration between physicians and bedside caregivers </li></ul><ul><li>By definition, it is not collaboration unless all/both parties agree </li></ul><ul><li>Physicians are 3-4 times more likely than nurses to believe that physician/nurse experiences of collaboration is good </li></ul><ul><li>High levels of doctor/nurse collaboration is associated with decreased mortality & hospital length of stay </li></ul>
  35. 35. Empower by…Communication <ul><ul><ul><li>Documentation of DPOA or appropriate surrogate so staff relay information consistently </li></ul></ul></ul><ul><ul><ul><ul><li>Routine for updating surrogates who are court appointed </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Set a precedent for use of interpreting services </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Don’t “dummy down” information </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Education for vulnerable populations so that care is proactive </li></ul></ul></ul></ul>
  36. 36. Moral distress can be a catalyst for change In part, vulnerability of patients and families bestows caregivers privilege of caring for another fellow human being in need
  37. 38. Buresh, B & Gordon, S. From Silence to Voice: What Nurses Know and Must Communicate to the Public . 1 st edition. Ottawa, Ontario: Canadian Nurses Association, 2000. California Thoracic Society. “End-of-Life in the Hospital: Strategies to Improve Quality Life-Sustaining Treatments and Limit Conflict through Identifying and Following Patient Wishes.” Position Paper- American Lung Association of California 2005. Corley, Mary Ph.D. RN et al. “Development and Evaluation of a Moral Distress Scale.” Methodological Issues in Nursing Research 33.2 (2001): 250 Davidson, Judy E RN FCCM et al. “Clinical Practice Guidelines for Support of the Family in the Patient-Centered Intensive Care Unit: American College of Critical Care Medicine Task Force 2004-2005.” Critical Care Medicine 35.2 (2007): 605 Duval, Gordon SJD et al. “A National Survey of U.S. Internists’ Experiences with Ethical Dilemmas and Ethics Consultation.” Journal of General Internal Medicine 19.3 (2004): 251 Elpern, Ellen and Silver, Michael. “Improving Outcomes: Focus on Workplace Issues.” Current Opinion in Critical Care 12.5 (2006): 395 Frick, S, Uehlinger DE and Zuercher, Zenklusen RM. “Medical Futility: Predicting Outcome of Intensive Care Unit Patients by Nurses and Doctors—A Prospective Comparative Study.” Critical Care Medicine 31.2 (2003): 456
  38. 39. Giganti, Ed. “A New Center for Spirituality and Leadership at Bon Secours Richmond.” Health Progress 87.1 (2006): 4 Hamric, Ann B Ph.D., RN, FAAN and Blackhall, Leslie J. MD, MTS. “Nurse-Physician Perspectives on the Care of Dying Patients in Intensive Care Units: Collaboration, Moral Distress, and Ethical Climate.” Critical Care Medicine 35.2 (2007): 422 Khatri, et. al. “Relationship between management philosophy and clinical outcomes.” Health Care Management Review 32.2 (2007): 128 McClendon, Heather RN, BSN and Buckner, Ellen B. DSN, RN. “Distressing Situations In the Intensive Care Unit-A Descriptive Study of Nurses’ Responses.” Dimensions of Critical Care Nursing 26.5 (2007): 199 McManis and Monslave Associates. “Healthy Work Environments: Striving for Excellence.” http://www. aone .org/ aone /docs/ hwe _excellence_full. pdf Murphy, Kevin Ph.D. “A ‘Next Generation’ Ethics Committee.” Health Progress 87.2 (2006): 26 Peter, Elizabethand Liaschenko, Joan. “Perils of Proximity: A Spatiotemporal Analysis of Moral Distress and Moral Ambiguity.” Nursing Inquiry 11.4 (2004): 218
  39. 40. Ray, Daniel MD et al. “Integrating Palliative Medicine and Critical Care in a Community Hospital.” Critical Care Medicine 34.11 (2006): S394 Schmalenberg, Claudia, MSN, RN et al. “Excellence through Evidence-Securing Collegial/Collaborative Nurse-Physician Relationships, Part 2.” Journal of Nursing Administration 35.11 (2005): 507 Silow-Carroll, Sharon, T. Alteras and L. Stepnick. “Patient-Centered Care for Under Served Populations: Definition and Best Practices.” Economic and Social Research Institute . Washington DC. January, 2006. www. esresearch .org Spence Laschinger et al. “ , A longitudinal analysis of the impact of workplace empowerment on work satisfaction.” Journal of Nursing Administration 35 (2003): 410 Taylor, Carol, RN Ph.D. “Dealing with Tough Situations: When Families and Caregivers Disagree.” telecom Lecture MCSA Columbus, OH 2007 Treece, Patsy D RN, MN et al. “Integrating Palliative and Critical Care: Description of an Intervention.” Critical Care Medicine 34.11 (2006): S380