Resolving Moral Distress in Health Care

by: Jill Ritchey BSN RN

Objectives

• Name some stakeholders that may experience moral distress

• Recognize moral distress and its impact on nursing and health care

• Identify ways to lessen the negative effects of moral distress

Who are the Stakeholders?• Patients• Families• Physicians• Nurses• Social Workers• Chaplains• Those at the bedside• Hospitals

• What are the unique burdens that they bear?

Patients

• Ethical goals: reduce suffering, preserve dignity & protect patient’s autonomy

• 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

Family of critically ill patients face:

• Extreme Stress

• Feeling solely responsible and at the same time powerless

• Difficult and timely decisions

• Grief: can be experienced even if the prognosis is good

Bedside Nurses

• Cannot physically detach from the patient like other stakeholders

• 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

Nurses, continued:

• 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).

• 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.

Physicians• Have less contact with patients thanHave less contact with patients than nurses• Ultimately carry the most legal/ethical weight which likely Ultimately carry the most legal/ethical weight which likely

explains why futility decisions are often based on positive explains why futility decisions are often based on positive prognostic forecastsprognostic forecasts

• Nurses who have constant intimate contact with patients Nurses who have constant intimate contact with patients prognosticate more accurately, but are more likely to give prognosticate more accurately, but are more likely to give negative forecastsnegative forecasts

• Nurses prognostic capabilities are based on recent Nurses prognostic capabilities are based on recent frequent experiencesfrequent experiences

• Physicians prognostic capabilities are more likely to be Physicians prognostic capabilities are more likely to be based on remote selective recall of infrequent experiencesbased on remote selective recall of infrequent experiences

Chaplains

• May view that their maximum potential is limited by roles assigned by a particular culture

• Unlike nurses, have little peer support

• Socialized to care only about others’ feelings, not to burden others with their own personal feelings

Social Workers

• May feel patient’s best interests are secondary to the family dynamics

• A profession greatly affected by moral distress

• Fewer peers to vent feelings of personal powerlessness/moral distress

Definition of moral distress

• 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”

How does it affect...• Nurses: 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.

Physical illness can occur therefore Hospitals Hospitals must deal with must deal with staffing issues due to staffing issues due to call-offs

• Magnet Hospitals have a lower incidence of MD

• Patient care: Patient care: Patients have better outcomes

• Future of nursing: 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

How can nursing leaders impact moral distress?

By empowering nurses

Magnet Force # 1Quality of Nursing Quality of Nursing LeadershipLeadership

In Magnet Hospitals, Nursing leaders “walk the talk” of the organization’s Mission goals

Nursing leaders empower nurses in many ways...

• Visibility in Leadership

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

Empowering and Inspiring Leaders...

“have connections”• Provide guidance- steer

nurses toward the right resources

• 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

are unafraid to• acknowledge and confront moral

distress in the bedside nurse, provide incentives for cultural rovide incentives for cultural change and are pchange and are powerful enough to bring even the most uninterested/’burned-out’ nurses to

the table. have an open door policy• …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.

Strong Leaders provide opportunities for:

• Nurses to participate in decisionsLeaders 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.

• Self efficacyMake staff feel that they have something valuable to add to the organization

• Growth and developmentLeaders 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

How else can hospitals impact moral distress?

Magnet Force # 2 Organizational Structure

Cultural Change

Decentralize or flatten administrative hierarchy

Shared Governance•Create forumsPerhaps nurse/physician forums to improve collaboration

•Facilitate efficacy of educational initiativesNurses 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

•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

Are Magnet Forces at play in your

unit/organization’s culture? • Is speaking up considered a low-benefit high-risk endeavor? • Is the discussion of uncomfortable subjects (inter-professional

conflicts, moral distress) supported?• Are there unspoken rules…are concerns dismissed or minimized?

• Do you feel that advice, information or guidance may be unreliable or unavailable?

• Is there fear of retaliation for speaking up on behalf of the patient?• Does inter-professional dialogue about conflict feel safe?• Is rocking the boat or making waves frowned upon?• Are there ethical resources available?

Picker Institute’s Eight Dimensions of patient centered care

Patient satisfaction, what patients want

• Respect for patient’s preferences

• Access to information

• Emotional support

• Continuity

• Physical comfort

• Provisions for education

• Involvement of family and friends

• Collaboration and coordination of care between caregivers

How visible are patient centered care values How visible are patient centered care values in your unit?in your unit?

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

…it is well documented that nurses experience moral distress when they are given

too much to do and too little to do it with

• Nursing models of care can guide the efficacy of providing care through quality initiatives based on evidence-based and resource-driven care practices

• 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

Nursing advocacy-power is important for:

Vulnerable Patient/Family PopulationsVulnerable Patient/Family Populations

• Distrust...Bad experiences with health system in the past lead to Distrust...Bad experiences with health system in the past lead to poor outcomespoor outcomes

• Low health literacy…may require more time from caregiversLow health literacy…may require more time from caregivers

• Poor coping skillsPoor coping skills

• Religious and cultural influencesReligious and cultural influences

• all families can recognize compassion….competence of caregiver all families can recognize compassion….competence of caregiver is not so easily recognized…therefore, families may construe is not so easily recognized…therefore, families may construe uncaring behavior to be incompetence or caring behavior as uncaring behavior to be incompetence or caring behavior as competence…caregivers can affect the cycle of trust through their competence…caregivers can affect the cycle of trust through their behaviorbehavior

Magnet Force # 8 Consultations/ Resources

Utilizing Hospital Ethics Committee can

help stakeholders in

addressing ethical issues, thus reducing moral distress

Catholic Health has begun an initiative to reintegrate ethics at the point of care

The Next Generation Ethics Model

• What does this ethics’ model do for hospital ethics’ committees?

• Increases visibility and utilization

• Promotes pro-action versus reaction

Re-integrating ethics at the point of care

• 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…”.

Helping Nurses Reclaim their Traditional Role as Patient Advocates (otherwise known as the

Professional Practice of Nursing)

• 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

• Developed a set of core competencies for nurses

• Communicated the expectation that nurses advocate for patients and the profession

• Education and resource development

• Increase awareness of resources available to them

“Ethics is Everyone’s Business”

• St. Joseph Health System is developing an ethics strategy by involving Risk Management and Legal to aid in education

• Feeling supported by policy regarding information-giving (and other Picker Institute dimensions) can improve stakeholders ability to advocate

Integration of Ethics with Patient Centered Care

• Supports a culture that protects patient autonomy through communication and collaboration

Grand RoundsGrand Rounds Interdisciplinary daily rounds conducted in a Interdisciplinary daily rounds conducted in a

manner that ensures input from non-physicians manner that ensures input from non-physicians is one way to promote... is one way to promote...

• Having a voice reflects aspects of this Magnet Force (# 9)Having a voice reflects aspects of this Magnet Force (# 9)

Magnet Force # 12Image of Nursing

• Experience (years) affects moral Experience (years) affects moral sensitivity. Individuals may be sensitivity. Individuals may be unwilling to identify moral distress in unwilling to identify moral distress in themselves…may prompt caregivers themselves…may prompt caregivers to assume a ‘tough guy’ persona or to assume a ‘tough guy’ persona or eventually result in “EDD”-Empathy eventually result in “EDD”-Empathy Deficit DisorderDeficit Disorder

• Socialized roles have perpetuated the Socialized roles have perpetuated the perception of powerlessnessperception of powerlessness

Caregivers perceived lack of power stems from feeling….

Dis-empowered

• UnawareUnaware

• UneducatedUneducated

• ‘‘Burned out’ Burned out’ uninteresteduninterested

• UnguidedUnguided

• InarticulateInarticulate

• Out of the loopOut of the loop

• UnsupportedUnsupported

Magnet Force # 13Magnet Force # 13Collegial Nurse/Physician Collegial Nurse/Physician

RelationshipsRelationships• Collaborative relationships between medical Collaborative relationships between medical

directors and nursing directors improve patient directors and nursing directors improve patient outcomesoutcomes

• 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 • Collaboration and communication will dictate the ethical Collaboration and communication will dictate the ethical

climate…climate…goal of therapy should be widely knowngoal of therapy should be widely known

More about collaborationMore about collaboration

• Magnet hospitals have a high level of collaboration Magnet hospitals have a high level of collaboration between physicians and bedside caregiversbetween physicians and bedside caregivers

• By definition, it is not collaboration unless all/both By definition, it is not collaboration unless all/both parties agreeparties agree

• Physicians are 3-4 times more likely than nurses to Physicians are 3-4 times more likely than nurses to believe that physician/nurse experiences of collaboration believe that physician/nurse experiences of collaboration is good is good

• High levels of doctor/nurse collaboration is associated with decreased mortality & hospital length of stay

Empower by…Communication

• Documentation of DPOA or appropriate Documentation of DPOA or appropriate surrogate so staff relay information consistently surrogate so staff relay information consistently

–Routine for updating surrogates who are court appointed

–Set a precedent for use of interpreting services

–Don’t “dummy down” information

–Education for vulnerable populations so that care is proactive

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

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