Presentation on theme: "Creating an Ethical Environment Where Courage Can Flourish"— Presentation transcript:
1 Creating an Ethical Environment Where Courage Can Flourish Kate Payne, RN, JDDirector of Ethics and Palliative CareSaint Thomas HospitalNashville, TN 37205
2 Objectives Define and describe moral distress Identify contributing factors and causesIdentify strategies to address moral distress and develop moral courageDescribe why it matters
3 About the Law Protect Ethics/Reduce Liability Identify and clarify the dilemmaDemonstrate good judgmentCommunicate effectivelyFacilitate negotiationImprove decision-makingEthics is the ceiling, law is the floornumber of lawsuits against nurses since early 1990’sHard to know numbersInsurance companies required to report successful suits to NPDB.6/1000 NPs vs. 38/1000 MDsNurses actually sued….relatively smallPurpose of the lawProtect peopleKeep society functioningPromote peaceful an productive interactions between the people
5 Ethics: Why?Decision making guided by ethical decision making processesDecision making informed by ethical valuesDecrease moral distress
6 What is Ethics? It can be about resolving dilemmas. It can be about individual actions.It is also about what kind of persons we are becoming, our character and how our choices shape us.Ethics is ultimately about human flourishing, about living well, about achieving good through means that are consistent with real human values and needs.
7 What is Organizational Ethics? It can be about compliance.It can be about due diligence.It can be about resolving value conflicts.Organizational ethics is about.IntegrityDecisions/actions that are consistent with moral identity and values of the organizationHelping the organization, its associates, and the communities it serves truly flourish
8 Role of Ethics Mechanisms Improve and enhance the quality of patient careCare of employeesEducationCommittee, staff, communityAdministrativePolicy development and review.Oversight and comment on operations with ethical impactConsultation and case reviewConflict resolutionInform other institutional effortsRegulatory complianceReduction of costs (without increasing mortality)
9 Ethics Experience Elemental work: protect……..from harm Social safeguard for potential harmExamine differencesRecognize that conflicts are moreAwareness of values in play, conflicts of interestProper place of ethical theoriesEthics is a group activityUnique decisions about individuals in relationship(s)Differences: in values, desires, interests, principles, perspectives, understanding, decision making, language DIVERSITY. Each individual is uniqueEvaluate these related to TennCare—it will look a little different. Probably first place to talk about drawing lines around what sorts of issues, how to interface with legal, the contract, etc.Theories shouldn’t dominate the decisionsGroup activity:contributions needed from all disciplines including consumers. More accurate to say ethics practice benefits from a group activity
10 Principled Decision Making adapted from Robert Orr, MD FAITH BASEDSanctity of lifeCompassionServiceMeritorious sufferingRedemptive sufferingContentmentMercyGraceHopeScriptureEternityRitualSocial justiceRespect for lifeTruth tellingNon-exploitationAdvocacyBenefit/burdenFree willObedienceStewardshipFaithSovereigntyDominionGod’s purposeDiagnosisPrognosisTreatment optionsValuesGoalsWishesSocialCulturalLegalFinancialPhysicalPsychologicalSpiritualPatientPreferencesContextualFeaturesMedicalIndicationsQuality of LifeSECULARNon-MaleficenceRespect for AutonomyFidelityBeneficenceJustice
11 Health Care Models Nature of Health Care Nature of Relationship Professional’sObligationModelBusinessCommodityBuyer/SellerCommitment,SkillContractualServiceContractingequalsSupply specificserviceCovenantObligationSacred trustCommitment tolifePreventiveLife-styleUnilateraloptionN/ABeneficentNegotiatedgoodTrust(fiduciary bond)Act for good ofpatient
12 Why Ethics?Need a moral compass to guide difficult decisions that have to be made in the health care context.NCannot just focus on the technical aspects of planning. Must also attend consciously and conscientiously to the ethical underpinnings of planning.Ethical Guide developed based on 2003 SARS experience together with more recent stakeholder input in relation to pandemic influenza planning – in particular, the Ontario Ministry of Health, Sunnybrook & Women’s College Health Sciences Centre, clinical ethicists in 14 health care organizations affiliated with the Joint Centre for Bioethics, two public health units. It underwent both an internal & external reviewWES
14 Vision Defining and achieving a desired future Best hindsight and foresight for actionPossibilitiesThe best healthcare systemYour best lifeFat free chocolateAACN is dedicated to creating a healthcare system driven by the needs of patients and families where critical care nurses make their optimal contribution.To be the premier spiritually based health care system as seen through the eyes of the patient
15 Mission Mission makes us who we are Human beings are valuable It is our purposeHuman beings are valuableBecause they are created by GodPeople are ends unto themselvesExcellent practice, excellent careIs where mission finds form and expression
16 Values What is most important Priorities Worth Value set Personal valuesProfessional valuesOrganizational values
17 Virtues/Values Cardinal virtues Modern virtues Other Prudence, courage, temperance and justiceModern virtuesUnconditional positive regard, charity, compassion, trustworthiness, vigilance and agilityOtherDedication, loyalty, honesty, creativity, faith, family, care of the poor, competence, learning
18 Ethics Act in accordance with values based on universal principles External reflection of an internal moral codeActions that enhance the well being of others
20 Ethical Dilemmas Conflict between two ‘rights’ Principles, decision making frameworks, or tools help clarify what is importantEthics processID areas of conflictID (other) resourcesProvide support, understandingHelp move toward resolutionGoal/hope: a 3rd way forwardSomething besides two extremes
21 Ethical Components of Moral Distress Obligations of selfObligations of othersBoundariesRisks and benefits of actionCritical thinking/responseKnowledge, skills, resources neededAnticipationManagementAction
22 Care Giving: A Moral Endeavor Roots of the caring professionsPromotion of ideal for patient careRespect for personsConduct by advocacySafe and best careCare giver role/relationshipFundamentally ethicalCare giver role/relationship is complexPatient/client focused caringSome distress is unavoidableRoots are in care of the poor by men and women religious, poor women, widows, fallen women. Medevel hospitals were there to care for pilgrims, the poor, the sickIdeal of pt. care comments relate to both history, what the moral profession strives for and these ideas and others are contained in codes of ethics for nurses and specialty societies.
23 Moral Distress Defined… “Painful feelings and/or the psychological disequilibrium that occurs when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.”Jameton A.Nursing Practice: The Ethical Issues. NJ:Prentiss-Hall. 1984
24 …defined 1993 Jameton distinguished: 2000 Webster and Baylis included Initial: frustration, anger and anxiety due toInstitutional obstaclesInterpersonal conflict about valuesReactive: due to failure to address initial distress2000 Webster and Baylis includedFailure to pursue “right” course of action due toError in judgmentPersonal failingCircumstances beyond controlMay feel cherished beliefs violatedCompromised integrity
25 ….defined“..the pain or anguish affecting the mind, body or relationships in response to a situation in which the person is aware of a moral problem, acknowledges moral responsibility, and makes a moral judgment about the correct action; yet as a result of real or perceived constraints, participates in perceived moral wrongdoing.”Alvita Nathaniel MSN, RNCSIn Nursing World, July 28, 2002
26 Other/Related Distress… JadingA process leading to exhaustion from being overdriven to perform long, continued labor and/or severe or tedious tasks.Burn outIndividual or group stress related to one’s relationship with the work environmentGrief outRepeated, sustained and often unresolved grief and loss
27 …distress Compassion fatigue Secondary Traumatic Stress (STS) Gradual lessening, over time of ability to be compassionate.The price one pays for caring.Emotional stress experienced from exposure to the suffering of others.Secondary Traumatic Stress (STS)Presence of Post-Traumatic Stress Disorder (PTSD) in the caregiver.Both STS and CF are caused by exposure to patients who have been traumatized or are suffering, not to the traumatic event itself.Vicarious traumatization
29 Personal Psychological/emotional Closeness/identification with patient/clientBoundariesIsolationFeelings of powerlessness or helplessnessCompromise of one’s standards of careFeelings of failure or guiltInability to talk about itGrief and lossLack of time to processAccumulated grief and lossLack of closureSustained proximity contributes to sense of responsibilityMORAL DISTRESS FOR ALLDR. COOPER “I NEVER LEARNED TO DO THIS”IS FRAUGHT WITH CONFLICTS/THREATS TO ONE’S SELF IMAGE“MAYBE I SHOULD HAVE DONE MORE” DR. G./DR. B“ANGEL OF DEATH” DR. B“I PRAY THAT SHE DOES SOMETHING, POSITIVE OR NEGATIVE, SO I’LL KNOW WHAT TO DO” DR. C“HE LOOKED UP AT ME AND SAID ‘DON’T LET ME DIE’” TONYANEED TO FEEL FORGIVEN--DR. PC, DR.F“I’VE LOST 3 PATIENTS THIS WEEK AND I CAN’T STOP TO CRY”NEED ONE ANOTHER, CAN’T DO IT ALONE; SAFE PLACES TO TALK; CONVERSATIONS AN ANTIDOTEAS CHAPLAINS POSSESS THE SKILLS TO RESPOND
30 Professional Barriers StaffingSo low, care is inadequateLack of time, skillNovice staffMultiple deaths in close successionHigh patient/client acuityOrganizational changeQuality, safetyCost cutting: Doing more with lessLeadership dynamicsNature of relationshipsCloseness/IdentificationPatient and/or family issuesEffectiveness of teamPower imbalanceLack of collaborationTo talk about this related to organizational, professional or personal constraints. These are different lens. The next two slides are what comes into focus with these different lens.Note they all also impact each other.These are just SOME of many.
31 ….professional Role/Relevance questions Communication failures Limited role in decision makingBelief that decisions contradict best interestsConfusion about planToo many partners or consultantsCommunication failuresIn team, between teamsPatient or familySustained proximity when others walk awayTechnological imperative/futilityDoing everything vs. the right thingBelief “doing everything” a sign of faithfulnessDeath a failureDiscomfort with own mortality
32 ….professional Conflict Outside pressures Assertive/aggressive patients/clients and familiesIntra or interdisciplinary conflictOutside pressuresOrganizational, professional, personalEconomyPandemicPolitics
33 Symptoms of Moral Distress Emotional/psychologicalIntrusive thoughtsDisturbing dreamsSense of reliving traumaCued psychological distressDifficulty concentratingHypervigilanceAnxietyFrustrationDepression
35 ….symptoms Distancing oneself Poor or inappropriate care Detachment from othersAvoidance of others, places, activitiesAbsenteeismEmotional numbingForeshortened futurePoor or inappropriate careInability to recall patient/client informationLoss of integrity and authenticityLoss of meaningCrisis of faith
36 Organizational Barriers Hospitals/other settingsCure orientationDeath as failureBiomedical focusTechnologyLack of timeFailure of teamLeadership dynamicsLack of collaborationConflictPatient/client with sudden, critical illnessWishes unknownSustained proximity when others walk away
37 Organizational Inhibitors Culture(s) thatStifle discussion regarding unethical behaviors and/or tolerate unethical actsWilling to compromise personal and professional standardsto avoid social isolation from peersto secure a promotion/favoritism within the organizationGroup think to turn the other wayUnwillingness to face the tough challenge of addressing unethical behaviorsRedefine unethical behaviors as acceptableIndifference to ethical valuesApathy of bystanders
38 Work Place Culture Pathologic culture Bureaucratic culture Generative cultureComponentsInformed/informingJustFlexibleLearningWhat does your culture look like?
39 Organization Symptoms Depression, psychosis screeningHopeless about the futureDifficulty making decisionsLoss of interestAgitationFeeling trappedNegative vision, risk-avoidance, downplay threatsLack of care, cause harm
40 Crescendo Effect Solid lines indicate moral distress Dotted lines indicate moral residueMoralDistressMoral distress crescendoMoral residueMoral residue crescendoTime
42 Strategies to Address Moral Distress… Causal analysisSelf awareness/self monitoringLimits, issuesAddress issues in real timeDebriefing“Talk about it”Ethical dialogReferralSkill-buildingGrief workEngage in work of “letting go”At the bedsideFunerals, journal, phone callsSacred/holy
43 ….strategies Story telling Self-care Find own voice/advocacy BalanceAppropriate boundariesSpiritual practiceFind own voice/advocacyCourageDevelop sources of supportProfessionalReferral sourcesSocialPlay
44 “Hard to tell from here. Could be buzzards. Could be grief counselors
45 Organization “Prozac”? Insight-top downShock therapyOrganizational soulAdmit there is a problemRe-inspireRe-invigorateRe-energizeRe-discover roots
46 safety, infection control, facility, others Cost control,safety, infection control,facility, othersOrganizational awareness, performance improvement, information managementCustomer service, patient rights, communication, and teamworkProfessionalism/self-development/respect and rational decision makingAccountability, self-control, and resilienceSelf esteem/self confidenceDecker PJ. The Hidden Competencies of Healthcare: Why Self-Esteem, Accountability, and Professionalism May Affect Hospital Customer Satisfaction Scores. Hospital Topics. 1999;77:14-26 (1999).
47 Resources to Address Moral Distress Opportunities for breaksPlaces of “sanctuary”Real time interventionsOne on oneHuddlesRituals of letting goConsultsInternal, externalSupport GroupsCISMOther forumsRounds, grand roundsRound table, journal clubSchwartz Center RoundsConsultsEAPEthics consults/directed conversationsPastoral care consultPsych nurse liaison consult
48 Ethics Resources Mission, Vision, Values Code of Ethics Ethics Consultation, Ethics CommitteeOrganization Ethics CommitteeComplianceConflict of Interest CommitteeInstitutional Review BoardThe point of this slide is to show and hopefully start them off connecting what all is available to support them in doing the right thing. This is an overview slide.Call to Action is also a vision and way to guide actions. What would it really mean to have care that leaves no one behind, in the community, nation, here in the hospital? How do our own people make ends meet, deal with medical needs? What if they weren’t born in this country are there special needs?Mission, Vision, ValuesWho we are, our goals, what matters—already talked about this last slide. This would be the starting sentence. “In addition to MVV, which as I said tells you who we are, what we want to do, what is important there are other supports.” Other resources also include your supervisor, leaders in the organization and your colleagues.Ethics consultationUsually has a patient care focus, work place issues (organization ethics)Ethics Committee (generally describe when it meets, generally who is on it)Clinical and organization issuesPolicy, education, review of consultationsSystem Mission and Ethics Committee (system)Ethics Review Board for ResearchEthical conduct of researchMeets at STH, BH reviews all research
50 Interventions Ethics mechanisms Round table Grand rounds Facilitated ethics conversationsFollow up education after consultationCurbside conflict managementMediationInformal, curbside educationMonthly brown bags
51 Healing Teams Interdisciplinary/ collaborative Conversation Blessing Role modelingMentoringSkill building/capacityEducationConversationAffirmation of positiveEncouraging when negativeBlessingFlexible and creativeTrusting environmentSafe place to talkBereavementEffective leadership
52 Effective Organizations Recurring and systemic causes identified and monitoredCorrect the problemTargeted interventionsAdequate financial and people resourcesEthics resourcesPalliative careConflict resolutionInterdisciplinary forums to discuss complex “situations”Mechanisms to address issuesAccountability for practice and behaviorSkill building, education, mentoringBereavement mechanismWhere death is frequent
53 Community Resources Grief counseling (through hospice, other) Agencies Crisis lines/centersCounselors, therapistsClergy in the communityWho/what have you found helpful?
54 Leadership Responsibility Take bold steps to engage interdisciplinary colleagues to create solutions, monitor progressDevelop and implement targeted strategies and evaluate their effectivenessInvolve medicine, nursing, social work, pastoral care, ethics consultants, mental health professionals, palliative care, and other disciplines that have relevant expertiseRecognize the symptoms of distress and create opportunities to explore the behaviors and coping strategies
55 …leadership Communication forums, modeling of good communication Engage in systematic review of casesDevelop and use support systemsBuild a trustworthy community, with rewards and recognition, development of strategies for resilience, self-care, renewal, and personal growthReach out to communityLeverage resources and relationships