Moral Distress and Model
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MORAL DISTRESS; IMPLICATIONS FOR PRACTICE Mary C. Corley, PhD, RN (email@example.com) Virginia Commonwealth University
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OBJECTIVES To articulate the relationship between working conditions and moral distress To evaluate the effect of moral distress on practice To identify three strategies for reducing moral distress
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Moral Distress Definition Painful feelings Know the morally right action to take Cannot carry out action because of institutional constraints Power structure Institution policy Legal constraints Carry out action despite the constraints
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Moral Distress Guilt, frustration Occur due to situations that involve ethical dimensions (and doesn’t most of Nursing) Health care provider feels unable to preserve all interests and values at stake Perceived violation of the person
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Initial Distress Feelings Frustration Anger Anxiety
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Reactive Distress Stress that occurs when a person does not react to the original stress. Leaves a “moral residue”
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“Incidence & Prevalence” Moral distress identified in many countries throughout the world. Sweden, Canada, Taiwan, Hong Kong, many sites throughout US. Probably every health care provider experiences it—including chaplains. Even outside health care—e.g., educators
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WHY BE CONCERNED? 26% OF NURSES SAID THEY HAD LEFT A POSITION IN THE PAST DUE TO MORAL DISTRESS IMPACT ON OTHER NURSE BEHAVIOR NO LONGER DONATE BLOOD CHANGED ORGAN DONOR STATUS AVOID BEING ASSIGNED TO CERTAIN PATIENTS MAKE MORE MISTAKES (MED. ERRORS)
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Major Sources of Moral Distress Inadequate staffing Level of health professional’s expertise Physical layout of organization Size of unit/acuity of patients Support from other disciplines Decisions related to ending aggressive treatment in the ICU
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Decision Making—Dying? Patient—Code Status RNs and MDs focus on different ethical problems when caring for the same patients Ways of reasoning differ Major source of moral distress—lack of agreement on code status Patient/family expectations raised by ER and other TV shows that recovery will occur
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Pain Management Reflects lack of agreement on part of health professionals Patient input may not be obtained
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How would you want the health professionals involved in your care to related to you and each other if you were terminally ill? Consider the many uncertainties 1 in 5 patients in ICU die
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Organizational Culture Leadership Structure Communication Change Finance Human resource management
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Administration Perspective How valuable do they perceive nurses to be Do they listen? Provide support? Has the administration provided changes for the better over a period of time?
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“Toxic” Work Environment Oppression of nurses Powerlessness, exploitation, cultural imperialism, marginalization, violence Oppressed people inhibited in developing and exercising their needs, thoughts, feelings Environment dominated by values of others Where does responsibility begin and end
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How Do Organizations Stand? Two medical centers had scores of 3.23 out of 5.0 Most nurses said they had access to an ethics committee (M=3.97) Lowest score on being involved in deliberations addressing ethics concerns about work (M=2.51)
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Ethical Environment How concerned is administration about ethical practice, providing ethics guidance ,making money Is ethical practice rewarded (or is a whistle-blower punished?) Provides opportunities for ethics deliberation Ethics committee available
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Strategies to Consider for Morally Habitable Environment Whistleblowing—protest about conditions E.g. being “floated” to Pediatrics from OR “Nobody else to go” E.g. nurse anesthetists prescribing doses higher than usual for pediatric patients Nurses refused to give medication, documented and reported to Administration E.g. delegation of evaluation of neuro patients to the untrained. Documented it and reported to Administration; reviewed policies on delegation
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What can nurse do to influence the moral environment? Assertiveness & collective action Self-care strategies that acknowledge own moral worthiness Acquire more education in ethics Organize a forum for discussion of ethically troubling situations experienced in daily practice of care—ethics of the ordinary Ethics rounds with interdisciplinary participation
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Nursing Shortage/Moral Distress Burnout Increased turnover Poorer quality of patient care Inadequate peer support Inadequate care for self No breaks, inadequate time for meals, no down time because of overtime requested.
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Nursing Shortage--Strategies Greater use of technological support Thermometers that take temperatures at a distance Cell phones as small pins on uniform Handheld computers Patient data PDA Clinical resource www.centerforamericannurses.org Software 40% off on Principles of Internal Med., etc
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Technological Changes to Improve Work Environment Design of patient rooms that facilitates care E.g. lifts in every room obtained at a flick of the wrist Voice activated entry of patient data
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Social Support—Role in Moral Distress Nurses usually have support network in work environment Physicians identify the lack of support in ethical conflict (e.g. ICU or NICU) Can better social support network be developed to benefit all during an ethical conflict Needs to be readily accessible
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Source of Conflicts in Values Organization: Greatest good for the greatest number Individual nurse value: Greatest good for my patients Commitment to care versus caring for self
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Being on the Boundary Nurses—the one with continual presence. On boundary among all involved in patient care (e.g., intensivists, other medical specialties, patients and families, social workers, managerial-administrative personnel Lack power and resources to impact outcomes Lack confidence in managing family conflict Cannot manage the different approaches and solutions of physicians
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