Presentation Transcript

1. Healthcare Ethics and Law2012 Conference

   Decreasing Moral Distress By Implementing Within-Department Ethics Roundtables Joy Hinson Penticuff, RN, Ph.D., FAAN joy.penticuff@concordia.edu
2. Organizational Characteristics The structure and processes of an organization determine the degree to which employees can carry out their moral decisions. There is ample literature to document that situational constraints and pressures influence the ability of nurses, in particular, to carry out moral decisions.
3. Moral Distress Definition The psychological disequilibrium and negative feeling state experiences when a person makes a moral decision but does not follow through by performing the moral behavior indicated by that decision – Judith Wilkinson (1987) Nursing Forum
4. Status Quo (Pavlish et al. 2011) Until advocacy strategies become more clearly defined, educational and work settings enrich nurses’ moral deliberation, and nurses implement more evidence-based, ethics-specific nurse actions, many nurses will continue to just bear witness and experience lingering regrets, and team conflicts will continue to erupt and erode quality care.
5. Gaudine et al.: Barriers to use of Hospital Ethics Committees 1. Lack of knowledge about committee 2. Lack of experience or expertise in managing ethical issues 3. Reactions of others 4. It is my responsibility 5. Lack of expertise on committee (MDs)
6. Gaudine et al.: Barriers to use of Hospital Ethics Committees 5. Lack of expertise on committee (MDs) 6. Fear that others may intervene with the patient/family (MDs) 7. Not my role 8. Problematic process for ethics consultations 9. Lack of informal and formal supports (RNs)
7. Nurses' abilities to meet their ethical obligations are affected by the: Extent to which a professional role for nurses is valued within the organization, Influence of nurses in the design of patient care, Representation of a nursing perspective in policy making and patient care decisions.
8. Factors in nurse involvement in resolution of ethical dilemmas Individual Nurse’s Role Definition Institutional Definition of Nurses’ Roles Competence of Nursing Staff = Degree of Influence on Medical Plan of Care Characteristics of the Patient Population: Education Age Social Status Severity of illness Dependence Vulnerability = Need for Nurse Advocacy
9. The Moral Distress EquationWilkinson, J. (1987).Nursing Forum 23 (1), 16–29. Experience MoralMoral Decision Perceived Painful Situationabout Right Action Inability Feelings and to Act Psychological Disequilibrium Effect CopingFrequency of Cases
10. Effect on Wholeness- a. Successful coping behaviors, maintaining an acceptable level of wholeness and ability to give patient care or b. Unsuccessful coping behaviors, resulting in increasing damage to wholeness and decreasing ability to give patient care-often with the nurse leaving the patient care setting or leaving nursing altogether.
11. Effect on Patient Care- a. Immediate effect on care of the patient involved in the case. b. Long-term effect on nurse's wholeness and care of other patients.
12. Moral distress, advocacy and burnout: The relationships (Huard & Fahy,1999) Triggering elements • Life-threatening illness • Perceived inappropriate medical treatment Cultural elements • Disparity in goals of medicine and nursing • Philosophy: care vs cure • Conflicting legal and moral obligations • Perceived obligation to cope: avoid criticism; avoid shame • Power differentials
13. Moral distress, advocacy and burnoutcontinued Immediate • Inadequacy of resources: Staffing Expertise Environmental elements • Communication milieu/lack of privacy • Pressure of time • Techno-rational chaos
14. Moral distress, advocacy and burnout continued The medical response • Deflection • Aggressive communication style • Medical backlash
15. Moral distress, advocacy and burnout continued The nursing response • Nursing infidelity • Nursing silence • Scapegoating • Relocation of the nurse The aftermath Nursing suffering Moral outrage Burnout
16. Nurses’ Involvement in Dilemma Resolution Penticuff, J. & Walden, M. (2000). Influence of practice environment and nurse characteristics on perinatal nurses’ responses to ethical dilemmas. Nursing Research 49(2), 64-72 Results suggest that nurses are more likely to be involved in dilemma resolution activities when they perceive themselves to have higher levels of influence in their practice environments and higher levels of concern about the ethical aspects of clinical situations
17. An example of a within-department Ethics Roundtable: TheNursing Ethics Roundtable at A large general hospital in the Southwest
18. Purpose The Nursing Ethics Roundtable is a means to develop ethics expertise among nursing staff and to support nurses' participation in ethical decision making and dilemma resolution.
19. Issues Is the Hospital Ethics Committee supportive of nursing/social work/pharmacy/etc. participation?
20. Issues What is the view of the department’s administration regarding a within-department ethics roundtable?
21. Issues Do staff in the department perceive a need for more organizational ethics resources?
22. Functions of the Nursing Ethics Roundtable To develop ethics expertise among nursing peers To assist staff nurses to feel more comfortable using organizational ethics resources To provide information
23. Functions of the Nursing Ethics Roundtable To support increased nursing role in resolving dilemmas To enhance ethics continuing education To develop in-unit ethics expertise and in-unit consultation
24. Functions (continued) To facilitate immediate ethics consultation To provide prospective, retrospective, and ad hoc case review
25. Functions (continued) To link with the chair of the hospital ethics committee To facilitate resolving dilemmas within the unit To support nurses' requests for meeting of the medical ethics committee
26. How Does the Ethics Roundtable Work? The Roundtable is open to any nurse interested in ethical issues. It is chaired by a nurse and meets once a month to discuss cases and to explore both level one ethical reasoning and level two strategies.
27. Basics The Nursing Ethics Roundtable is within a nursing shared governance framework. It meets once a month on the second Monday. It encourages discussions and case analyses relevant to nursing ethical practice. All you need is a room, a chairperson, and a way to let nursing staff know when the Roundtable will be held.
28. The Roundtable: Is an ongoing series. As issues arise, they can be dealt with. Nurses can continually improve their understanding of clinical ethics: how to recognize and be involved in resolving clinical dilemmas.
29. Essentials for success An essential part of the success of the Roundtable is the relationship between the chairperson of the Nursing Ethics Roundtable and the chairperson of the Hospital Ethics Committee. These two people need to have an excellent collegial relationship.
30. Why this relationship is essential This can mean that when nurses have a concern, the chairperson of the Nursing Ethics Roundtable may choose to describe the case to the Hospital Ethics Committee chairperson, who then often will contact the other key professional involved and say for example, "Look, Lee, the nurses are concerned and I've discussed the case with them and I think that you and I need to sit down and talk about it." We have had dilemmas quickly resolved with this strategy.
31. Involvement in resolving dilemmas The Roundtable supports the staff nurse's role in resolving dilemmas. It increases the legitimacy of nursing involvement and the recognition of a nursing perspective within the hospital. Usually every unit in the hospital will have at least one nurse who goes regularly to the Roundtable meetings. So you have in essence an in-house consultant who is known to the rest of the nurses in each unit. You can have immediate ethics consultation in that way.
32. Development of within-department peer ethics resources Nurses who consistently attend the Roundtable usually come to be known as in-unit resource persons to whom other staff can go for initial consultation about dilemmas. In this way, the Roundtable provides bedside nurses with nursing peers in their units who can help them in their decision making about ethics concerns.
33. And if the case should go to the Hospital Ethics Committee . . . If a dilemma can't be resolved within the department, then with the consultation and support from the Nursing Ethics Roundtable, the bedside nurses involved can feel more comfortable in going to the Hospital Ethics Committee to ask for consultation on the case, or at least to present the nursing perspective.
34. Nursing representation on hospital ethics committees Constitution of Hospital Ethics Committees Who represents nursing? Should be able to articulate a nursing perspective on ethical dilemmas. Someone who is an influential, well respected representative of nursing. Willing to go into the units and talk with the nurses involved in problem cases, find out what the nursing perspective is and represent that at the meetings of the Hospital Ethics Committee.
35. Instruments: Data about organizational climate and nurse self­ reported responses to ethical dilemmas were obtained using the Nursing Ethical Involvement Scales Short Form (NElS-SF) (Penticuff, 1992) Self­ administered 26-item instrument consisting of Activism and Unit Characteristics subscales.
36. Method: Sample: The sample included staff nurses involved in direct patient care in a large general hospital in the Southwest. (pre-treatment=335, post-treatment =329)
37. Research questions: 1. Is the Nursing Ethics Roundtable effective in increasing nurses' self-reported willingness to be involved in processes of ethical dilemma resolution in a large general hospital in the Southwest? 2. Is the Nursing Ethics Roundtable effective in increasing nursing influence within the practice climate of a large general hospital in the Southwest?
38. NEIS - SF Reliability for the NElS-SF subscales: Activism Pre-Treatment Post-Treatment Chronbach alpha .78 .72 Unit Characteristics Chronbach alpha .83 .85
39. Table 1T-Test Comparison of NElS-SF Unit Characteristics SubscalePre-Treatment and Post-Treatment Group Means (One-Tailed) Pre-treat Group n Mean St. Dev. F value p 335 45.07 9.01 1.07 .26 ns Post-Treat Group 327 45.08 9.34
40. Table 1T-Test Comparison of NElS-SF Activism SubscalePre-Treatment and Post-Treatment Group Means (One-Tailed) Pre-treat Group n Mean St. Dev. F value p 335 32.48 7.02 1.20 .047 Post-Treat Group 329 32.61 6.40
41. AACN's Call to Action for Employers Implement interdisciplinary strategies to recognize and name the experience of moral distress. Establish mechanisms to monitor the clinical and organizational cli­ mate to identify recurring situations that result in moral distress. Develop a systematic process for reviewing and analyzing the system issues enabling situations that cause moral distress to occur and for taking corrective action.
42. AACN's Call to Action for Employers Create support systems that include: o Employee assistance programs o Protocols for end-of-life care o Ethics committees o Critical stress debriefings o Grief counseling Create interdisciplinary forums to discuss patient goals of care and divergent opinions in an open, respectful environment.
43. AACN's Call to Action for Employers Develop policies that support unobstructed access to resources such as the ethics committees. Ensure nurses' representation on institutional ethics committees with full participation in all decision making. Provide education and tools to manage and decrease moral distress in the work environment.
44. Conclusions Each nurse in the institution has ethical obligations that are met or failed within a context of organizational realities. A within-department Ethics Roundtable may facilitate professional staff’s involvement in resolution of ethical dilemmas, leading to Decrease in moral distress and improved patient care.