Moral Distress, Giving Voice to Values

Physician Burnout: Integrated Strategies for Diverse Stakeholders

Heather Fitzgerald, MS, RNClinical Nurse EthicistChildren’s Hospital ColoradoFacultyCU Center for Bioethics and Humanities

Disclosure

No relevant financial or commercial interests to disclose.

Objectives

1. Describe a walk with Deb2. 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.

Deep Bow

Deb Saint-Phard, MD Cynda Rushton, PhD, RNAnn Hamric, PhD, RNNorine Hemphill, MS, RNPat Givens, DHA, EdM, RNJackie Glover, PhDBrian Jackson, MD, MADan Reirden, MD

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 distressEpstein & Hamric, 2009

• Speak up• Build support networks • 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 distressRodney et al., 2013.

• Supportive colleague-to-colleague dialogue• Regular interdisciplinary team debriefings• 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 distressEpstein & 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.

Churchman & Doherty, 2010

Interprofessional collaboration in the ICU suffers:• Power dynamics• 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 - hierarchyRose, 2011

GVVwith permission, M. Gentile, 2018

Values-driven leadership developmentAssumes 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 EffectEpstein & 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-awarenessSelf-regulationMindfulnessStrong moral compassRecognition of ethical issuesEmpathy to consider others’ experience

Ethical knowledge:Ability to define the problemExperienceTrainingEducationEthical principles, precepts, theoryCodes of ethics, law, precedent cases

Lechasseur, et al. , 2016

Ethical Competence

Ethical reflection:Considering more than 1 or 2 viewpointsAwareness of personal and professional valuesProcess of inquiry vs disagreement

Ethical action:Strong problem-solving skillsAbility to speak up effectivelyOwnership, ability to work w/others to resolve issues Implementation skills

Lechasseur, et al. , 2016

Ethical Competence

Ethical behavior:Moral courageRisk-takingSelf careRespectModeling these qualitiesMoral motivation to do what is right for the pt

Ethical decision making:Judgement about which action is ethical soundOpenness to perspectivesAssure all voices are includedAbility to prioritize moral values over personal valuesAbility 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 issue2. Importance of support in addressing ethical issues3. Increased individual moral agency4. Increased knowledge/understanding of ethics5. Increased perspective, ability to include others views6. Increased utilization of ethics resources7. Made a difference by impacting clinical practice8. 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 fitnessAbout 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

Rushton, 2016

• Prioritize time and methods for reflection

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

Resources

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