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Healthcare Ethics and Law 2012 Conference. Decreasing Moral Distress By Implementing Within-Department Ethics Roundtables Joy Hinson Penticuff, RN, Ph.D., FAAN [email protected] Organizational Characteristics.

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Healthcare ethics and law 2012 conference

Healthcare Ethics and Law2012 Conference

Decreasing Moral Distress By Implementing Within-Department Ethics Roundtables

Joy Hinson Penticuff, RN, Ph.D., FAAN

[email protected]


Organizational characteristics

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.


Moral distress definition

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


Status quo pavlish et al 2011

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.


Gaudine et al barriers to use of hospital ethics committees

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)


Gaudine et al barriers to use of hospital ethics committees1

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)


Nurses abilities to meet their ethical obligations are affected by the

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.


Factors in nurse involvement in resolution of ethical dilemmas

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


The moral distress equation wilkinson j 1987 nursing forum 23 1 16 29

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


Effect on wholeness

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.


Effect on patient care

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.


Moral distress advocacy and burnout the relationships huard fahy 1999

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


Moral distress advocacy and burnout continued

Moral distress, advocacy and burnoutcontinued

Immediate

• Inadequacy of resources:

Staffing

Expertise

Environmental elements

• Communication milieu/lack of privacy

• Pressure of time

• Techno-rational chaos


Moral distress advocacy and burnout continued1

Moral distress, advocacy and burnout continued

The medical response

• Deflection

• Aggressive communication style

• Medical backlash


Moral distress advocacy and burnout continued2

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


Nurses involvement in dilemma resolution

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


An example of a within department ethics roundtable

An example of a within-department Ethics Roundtable:

TheNursing Ethics Roundtable at

A large general hospital

in the Southwest


Purpose

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.


Issues

Issues

Is the Hospital Ethics Committee supportive of nursing/social work/pharmacy/etc. participation?


Issues1

Issues

What is the view of the department’s administration regarding a within-department ethics roundtable?


Issues2

Issues

Do staff in the department perceive a need for more organizational ethics resources?


Functions of the nursing ethics roundtable

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


Functions of the nursing ethics roundtable1

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


Functions continued

Functions (continued)

To facilitate immediate ethics consultation

To provide prospective, retrospective, and ad hoc case review


Functions continued1

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


How does the ethics roundtable work

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.


Basics

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.


The roundtable

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.


Essentials for success

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.


Why this relationship is essential

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.


Involvement in resolving dilemmas

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.


Development of within department peer ethics resources

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.


And if the case should go to the hospital ethics committee

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.


Nursing representation on hospital ethics committees

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.


Instruments

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.


Method

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)


Research questions

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?


Neis sf

NEIS - SF

Reliability for the NElS-SF subscales:

Activism Pre-TreatmentPost-Treatment

Chronbach alpha .78 .72

Unit Characteristics

Chronbach alpha .83 .85


Healthcare ethics and law 2012 conference

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


Healthcare ethics and law 2012 conference

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


Aacn s call to action for employers

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.


Aacn s call to action for employers1

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.


Aacn s call to action for employers2

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.


Conclusions

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.


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