Creating an Ethical Environment Where Courage Can Flourish Kate Payne, RN, JD Director of Ethics and Palliative Care kpayne@stthomas.org Saint Thomas Hospital Nashville, TN 37205

Objectives Define and describe moral distress Identify contributing factors and causes Identify strategies to address moral distress and develop moral courage Describe why it matters

About the Law Protect Ethics/Reduce Liability Identify and clarify the dilemma Demonstrate good judgment Communicate effectively Facilitate negotiation Improve decision-making Ethics is the ceiling, law is the floor number of lawsuits against nurses since early 1990’s Hard to know numbers Insurance companies required to report successful suits to NPDB .6/1000 NPs vs. 38/1000 MDs Nurses actually sued….relatively small Purpose of the law Protect people Keep society functioning Promote peaceful an productive interactions between the people

Ethics: Why? Decision making guided by ethical decision making processes Decision making informed by ethical values Decrease moral distress

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.

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. Integrity Decisions/actions that are consistent with moral identity and values of the organization Helping the organization, its associates, and the communities it serves truly flourish

Role of Ethics Mechanisms Improve and enhance the quality of patient care Care of employees Education Committee, staff, community Administrative Policy development and review. Oversight and comment on operations with ethical impact Consultation and case review Conflict resolution Inform other institutional efforts Regulatory compliance Reduction of costs (without increasing mortality)

Ethics Experience Elemental work: protect……..from harm Social safeguard for potential harm Examine differences Recognize that conflicts are more Awareness of values in play, conflicts of interest Proper place of ethical theories Ethics is a group activity Unique decisions about individuals in relationship(s) Differences: in values, desires, interests, principles, perspectives, understanding, decision making, language DIVERSITY. Each individual is unique Evaluate 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 decisions Group activity:contributions needed from all disciplines including consumers. More accurate to say ethics practice benefits from a group activity

Principled Decision Making adapted from Robert Orr, MD FAITH BASED Sanctity of life Compassion Service Meritorious suffering Redemptive suffering Contentment Mercy Grace Hope Scripture Eternity Ritual Social justice Respect for life Truth telling Non-exploitation Advocacy Benefit/burden Free will Obedience Stewardship Faith Sovereignty Dominion God’s purpose Diagnosis Prognosis Treatment options Values Goals Wishes Social Cultural Legal Financial Physical Psychological Spiritual Patient Preferences Contextual Features Medical Indications Quality of Life SECULAR Non-Maleficence Respect for Autonomy Fidelity Beneficence Justice

Health Care Models Nature of Health Care Nature of Relationship Professional’s Obligation Model Business Commodity Buyer/Seller Commitment, Skill Contractual Service Contracting equals Supply specific service Covenant Obligation Sacred trust Commitment to life Preventive Life-style Unilateral option N/A Beneficent Negotiated good Trust (fiduciary bond) Act for good of patient

Why Ethics? Need a moral compass to guide difficult decisions that have to be made in the health care context. N Cannot 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 review W E S

Moral Compass Mission Values Ethics Vision

Vision Defining and achieving a desired future Best hindsight and foresight for action Possibilities The best healthcare system Your best life Fat free chocolate AACN 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

Mission Mission makes us who we are Human beings are valuable It is our purpose Human beings are valuable Because they are created by God People are ends unto themselves Excellent practice, excellent care Is where mission finds form and expression

Values What is most important Priorities Worth Value set Personal values Professional values Organizational values

Virtues/Values Cardinal virtues Modern virtues Other Prudence, courage, temperance and justice Modern virtues Unconditional positive regard, charity, compassion, trustworthiness, vigilance and agility Other Dedication, loyalty, honesty, creativity, faith, family, care of the poor, competence, learning

Ethics Act in accordance with values based on universal principles External reflection of an internal moral code Actions that enhance the well being of others

“So much for moral clarity.”

Ethical Dilemmas Conflict between two ‘rights’ Principles, decision making frameworks, or tools help clarify what is important Ethics process ID areas of conflict ID (other) resources Provide support, understanding Help move toward resolution Goal/hope: a 3rd way forward Something besides two extremes

Ethical Components of Moral Distress Obligations of self Obligations of others Boundaries Risks and benefits of action Critical thinking/response Knowledge, skills, resources needed Anticipation Management Action

Care Giving: A Moral Endeavor Roots of the caring professions Promotion of ideal for patient care Respect for persons Conduct by advocacy Safe and best care Care giver role/relationship Fundamentally ethical Care giver role/relationship is complex Patient/client focused caring Some distress is unavoidable Roots 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 sick Ideal 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.

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

…defined 1993 Jameton distinguished: 2000 Webster and Baylis included Initial: frustration, anger and anxiety due to Institutional obstacles Interpersonal conflict about values Reactive: due to failure to address initial distress 2000 Webster and Baylis included Failure to pursue “right” course of action due to Error in judgment Personal failing Circumstances beyond control May feel cherished beliefs violated Compromised integrity

….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, RNCS In Nursing World, July 28, 2002

Other/Related Distress… Jading A process leading to exhaustion from being overdriven to perform long, continued labor and/or severe or tedious tasks. Burn out Individual or group stress related to one’s relationship with the work environment Grief out Repeated, sustained and often unresolved grief and loss

…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

Personal Psychological/emotional Closeness/identification with patient/client Boundaries Isolation Feelings of powerlessness or helplessness Compromise of one’s standards of care Feelings of failure or guilt Inability to talk about it Grief and loss Lack of time to process Accumulated grief and loss Lack of closure Sustained proximity contributes to sense of responsibility MORAL DISTRESS FOR ALL DR. 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’” TONYA NEED 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 ANTIDOTE AS CHAPLAINS POSSESS THE SKILLS TO RESPOND

Professional Barriers Staffing So low, care is inadequate Lack of time, skill Novice staff Multiple deaths in close succession High patient/client acuity Organizational change Quality, safety Cost cutting: Doing more with less Leadership dynamics Nature of relationships Closeness/Identification Patient and/or family issues Effectiveness of team Power imbalance Lack of collaboration To 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.

….professional Role/Relevance questions Communication failures Limited role in decision making Belief that decisions contradict best interests Confusion about plan Too many partners or consultants Communication failures In team, between teams Patient or family Sustained proximity when others walk away Technological imperative/futility Doing everything vs. the right thing Belief “doing everything” a sign of faithfulness Death a failure Discomfort with own mortality

….professional Conflict Outside pressures Assertive/aggressive patients/clients and families Intra or interdisciplinary conflict Outside pressures Organizational, professional, personal Economy Pandemic Politics

Symptoms of Moral Distress Emotional/psychological Intrusive thoughts Disturbing dreams Sense of reliving trauma Cued psychological distress Difficulty concentrating Hypervigilance Anxiety Frustration Depression

….symptoms Irritability, anger, insults, blaming Physical Cued physiological reaction Fatigue Somatic concerns Diminished activity level Difficulty sleeping Feelings of inadequacy Personal, professional Feeling victimized

….symptoms Distancing oneself Poor or inappropriate care Detachment from others Avoidance of others, places, activities Absenteeism Emotional numbing Foreshortened future Poor or inappropriate care Inability to recall patient/client information Loss of integrity and authenticity Loss of meaning Crisis of faith

Organizational Barriers Hospitals/other settings Cure orientation Death as failure Biomedical focus Technology Lack of time Failure of team Leadership dynamics Lack of collaboration Conflict Patient/client with sudden, critical illness Wishes unknown Sustained proximity when others walk away

Organizational Inhibitors Culture(s) that Stifle discussion regarding unethical behaviors and/or tolerate unethical acts Willing to compromise personal and professional standards to avoid social isolation from peers to secure a promotion/favoritism within the organization Group think to turn the other way Unwillingness to face the tough challenge of addressing unethical behaviors Redefine unethical behaviors as acceptable Indifference to ethical values Apathy of bystanders

Work Place Culture Pathologic culture Bureaucratic culture Generative culture Components Informed/informing Just Flexible Learning What does your culture look like?

Organization Symptoms Depression, psychosis screening Hopeless about the future Difficulty making decisions Loss of interest Agitation Feeling trapped Negative vision, risk-avoidance, downplay threats Lack of care, cause harm

Crescendo Effect Solid lines indicate moral distress Dotted lines indicate moral residue Moral Distress Moral distress crescendo Moral residue Moral residue crescendo Time

Strategies to Address Moral Distress… Causal analysis Self awareness/self monitoring Limits, issues Address issues in real time Debriefing “Talk about it” Ethical dialog Referral Skill-building Grief work Engage in work of “letting go” At the bedside Funerals, journal, phone calls Sacred/holy

….strategies Story telling Self-care Find own voice/advocacy Balance Appropriate boundaries Spiritual practice Find own voice/advocacy Courage Develop sources of support Professional Referral sources Social Play

“Hard to tell from here. Could be buzzards. Could be grief counselors

Organization “Prozac”? Insight-top down Shock therapy Organizational soul Admit there is a problem Re-inspire Re-invigorate Re-energize Re-discover roots

safety, infection control, facility, others Cost control, safety, infection control, facility, others Organizational awareness, performance improvement, information management Customer service, patient rights, communication, and teamwork Professionalism/self-development/respect and rational decision making Accountability, self-control, and resilience Self esteem/self confidence Decker 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).

Resources to Address Moral Distress Opportunities for breaks Places of “sanctuary” Real time interventions One on one Huddles Rituals of letting go Consults Internal, external Support Groups CISM Other forums Rounds, grand rounds Round table, journal club Schwartz Center Rounds Consults EAP Ethics consults/directed conversations Pastoral care consult Psych nurse liaison consult

Ethics Resources Mission, Vision, Values Code of Ethics Ethics Consultation, Ethics Committee Organization Ethics Committee Compliance Conflict of Interest Committee Institutional Review Board The 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, Values Who 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 consultation Usually 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 issues Policy, education, review of consultations System Mission and Ethics Committee (system) Ethics Review Board for Research Ethical conduct of research Meets at STH, BH reviews all research

…ethics resources Pastoral care Palliative care Employee Assistance Program Patient advocate Quality improvement Outcomes management Patient safety Risk management Pastoral Care Palliative Care Employee Assistance Program Quality Outcomes Management Compliance Ethical conduct of business, HIPAA Patient Relations Complaint management, patient rights Risk Management Legal liability focus

Interventions Ethics mechanisms Round table Grand rounds Facilitated ethics conversations Follow up education after consultation Curbside conflict management Mediation Informal, curbside education Monthly brown bags

Healing Teams Interdisciplinary/ collaborative Conversation Blessing Role modeling Mentoring Skill building/capacity Education Conversation Affirmation of positive Encouraging when negative Blessing Flexible and creative Trusting environment Safe place to talk Bereavement Effective leadership

Effective Organizations Recurring and systemic causes identified and monitored Correct the problem Targeted interventions Adequate financial and people resources Ethics resources Palliative care Conflict resolution Interdisciplinary forums to discuss complex “situations” Mechanisms to address issues Accountability for practice and behavior Skill building, education, mentoring Bereavement mechanism Where death is frequent

Community Resources Grief counseling (through hospice, other) Agencies Crisis lines/centers Counselors, therapists Clergy in the community Who/what have you found helpful?

Leadership Responsibility Take bold steps to engage interdisciplinary colleagues to create solutions, monitor progress Develop and implement targeted strategies and evaluate their effectiveness Involve medicine, nursing, social work, pastoral care, ethics consultants, mental health professionals, palliative care, and other disciplines that have relevant expertise Recognize the symptoms of distress and create opportunities to explore the behaviors and coping strategies

…leadership Communication forums, modeling of good communication Engage in systematic review of cases Develop and use support systems Build a trustworthy community, with rewards and recognition, development of strategies for resilience, self-care, renewal, and personal growth Reach out to community Leverage resources and relationships