9/22/14

The Silver Lining of Moral Distress: An Opportunity For Progress in Patient Care

Every day nurses make decisions regarding patient care. Nurses want to relieve patient suffering, provide useful care, and be an advocate for their patients. They want to do these to the best of their ability, knowledge and caring.



Yet often nurses are prevented from reaching their ideal level of care by circumstances not of their own making. Some researchers have suggested that one component of moral challenges is conflict, whether that conflict is internal or between two or more parties. Conflict is such an important factor in health care that the Joint Commission has made conflict resolution a priority in improving the quality of patient care. For example, a nurse must discontinue care because of hospital policy when the patient cannot pay. What about nurses who assist a doctor in medical procedures when the doctor has not obtained informed consent? There have also been cases where a nurse’s clinical judgment has not been taken into account when the patient’s condition was deteriorating. The result of the inaction of the other medical staff has caused medical emergencies. How does the nurse feel in a situation like that?

These ethical challenges and unresolved conflict cause nurses moral distress, which can be on their minds for years after the situation has passed. Nurses have various ways of coping with moral distress such as getting angry, blaming themselves or their bosses, switching units or employers, working less hours, getting a position where they are not involved with patients, or quitting. None of these are helpful to anyone. Yet there are examples in the health care system where recognition of moral distress in nurses has led to progress in patient care. In response, what innovations have medical centers put in place? It starts with productive collaborative communication among all stakeholders. Nurses have reported less moral distress in medical centers that have structures in place that allow nurses to communicate concerns before they become a moral dilemma or challenge. If there is dedicated time after a situation where nurses can debrief, discuss, and reflect this goes a long way towards relieving moral distress. Another important avenue is to include nurses in the planning of the workflow to help prevent moral challenges and detect situations that could lead to conflict. A significant number of these problems arise due to organizational barriers that nurses must work around, for example, staffing levels and staff composition.

 Some medical centers have established nurse manager support. Nurse managers can be critical in helping nurses deal with moral distress if they are properly trained and have experience. Some workplaces have established ethics committees which include different members of the care team. Typically these committees deal with the most challenging and difficult cases. Some medical centers have created a nurse ethicist position.

One innovation that other employers could benefit from studying is the partnership created by Clarian Health, Indiana University School of Nursing, and the Fairbanks Center for Medical Ethics. In 2006 they decided to combine their resources to create a program in nursing ethics that would operate in their hospitals, provide education to upcoming nurses, and conduct research as well. They created a nurse ethicist position.

 This position allows a bridge between nurse and leaders in administration. The program ensures that nurses are able to access the attention and resources they need to provide ethical care. This journey begins with helping nurses at the bedside recognize and cope with ethical conflict and moral distress.

 The clinical component of the program has two parts, a formal structure of the nurse ethicist being part of the ethics committee which provides follow up for nurses who were involved with ethics consultation. There is also the subcommittee which nurses can consult less formally to help them cope with peer interaction or moral distress, and to obtain ethical advice. Nurses can also access a monthly column in the nursing newsletter. Every other month they can submit questions. This column also might report on informal discussion with nurses. The other month of the bimonthly rotation deals with workplace policies that have an ethical component.

 The nursing ethics program also includes a fellowship program that the staff can participate in which is open to all staff. The focus of the fellowship is clinical ethics. Each year six applicants are chosen for the nine month part time program.

 The program also created unit based Ethics Conversations. These Conversations are a therapeutic space where discussions are facilitated on ethical dilemmas. These conversations are where participants can gain confidence in their ability to positively cope with ethical challenges. This is a key pillar of the program to give nurses the tools to cope independently when these situations arise to help them become self sufficient in resolving moral distress.

 The nurse ethicist also follows up with new nurses shortly after they are hired in the form of journal clubs and in services. Examples of the topics chosen by nurses for these in services are dealing with a noncompliant patient, advance directives, and whether family should be present during CPR. Reaction to the program has been so positive that Clarian Health had their first nursing ethics conference which also had positive feedback. The nurse ethicist is also responsible for evaluating nursing ethical health system wide, through surveys and interviews. Part of this evaluation includes assessing how much moral distress nurses experience and the power and authority dynamics of nurse doctor relationships.

 Nurses who take action as opposed to not doing anything will experience less moral distress. Successful resolution of moral dilemmas can lead to a strengthening of character and professional values, and a sense of accomplishment. Successful resolution can also help a nurse become more aware of their own values and increase determination which can lead to personal and professional growth. It is important to view ethical dilemmas as learning opportunities and to find meaning in them. Of all medical professionals, nurses are in the best position to initiate closure, progress, and resolution in these situations to gain insight for the future. The employers that support nurses in this endeavor will provide the best care. The nurse administrator can both encourage nurses to bring up ethical concerns and provide crucial insight into the daily challenges that nurses face at the bedside. Organizational culture can support nurse advocacy. Employers that assist nurses to use the language of ethics in manner that fosters progress in nursing care will be the leaders in patient care quality.



  •  Bailey M. Aulisio M. The Nurse Administrator on the Ethics Committee: A Collaborative Approach. Nursing Management December 2011 p.52-54 
  •  McCarthy Deady R. Moral Distress Reconsidered Nursing Ethics Vol. 15 No 2 
  •  Pavlish C. Early Indicators and Risk Factors for Ethical Issues in Clinical Practice Journal of Nursing Scholarship Vol. 43 No. 1 2011 p 13-21 
  •  Wocial L. et al Nurse Ethicist: Innovative Resource for Nurses. Journal of Professional Nursing Vol. 26 No 5 Sept. 2011 p 287-292.
  •  Zuzelo P. Exploring the Moral Distress of Registered Nurses Nursing Ethics Vol. 14 No, 3 2007, p 344-359

9/9/14

The Unnamed Frustration, Fatigue, and Anxiety (1)

Consider these medical situations that nurses have been involved in:

A child is admitted to ER with possible symptoms of abuse. A doctor allows the patient to be discharged despite the nurse’s intuition about the situation. The child returns to the ER 2 days later dead on arrival. (2)


A patient was in severe enough pain to be crying out. Increased ammonia levels caused him mental confusion. The doctors wanted to monitor his mental state and ordered that pain medication be withheld. Twelve hours later he died. (3)


Readers could list many more situations like this in the various settings where nurses practice. These situations involve peers, patients, caregivers, and administration. The resultant feelings of frustration and helplessness have given rise to the term moral distress. Factors included in this phrase are cognitive dissonance, and psychological disequilibrium. But behind those fancy scientific terms lie the real crux of the matter. The nurse feels helpless, angry, and dissatisfied. Moral distress occurs when a nurse reaches a moral decision but is unable to execute her values, training, and knowledge. In other words the nursing goal is stymied and now a less than ideal outcome must be accepted. The nurse is impacted because she/he is the most involved in care, sees the consequences first hand, and because ethics are the basis of the nursing profession.


There are many reasons why a nurse might be unable to carry out maximum nursing care. Some factors are external, some internal. Nurse must collaborate with doctors and other professional colleagues. Nurses must deal with employer policy and sometimes consider cost of care. Another factor contributing to constraint are advances in technology which can increase life expectancy, but also affects the trajectory of chronic disease. Health care is expensive and medical centers have budget requirements which affect staffing levels. Nurses are pressed for time. There could be culture and values mismatch or challenges between patients, caregivers and nurses.


Moral distress in nurses is often created when there are 2 conflicting principles. For example, nurses must often choose between honoring patient autonomy and giving the best nursing care which to some extent relies on patient compliance. What if the patient is non compliant? Nurses must sometimes weigh legality and morality, for example, doctors might order tests because of the perceived possibility of legal action, but the nurse believes they are unnecessary.


Nurse researchers have developed a way to measure moral distress in nurses using the Moral Distress scale. It measures frequency and intensity of moral distress, using a Likert scale of 0-6. The most frequent situation that causes moral distress in nurses is unnecessary patient suffering, or circumstances that constrain action to relieve patient suffering.


One study researched risk factors and early warning signs of situations that could lead to possible moral distress. The researchers reasoned that if the situation could be identified early enough it could be solved in a proactive instead of an after the fact reactive manner. Moral distress in nurses would be avoided and the quality of care would be better. Medical centers would benefit from dealing with moral distress of medical staff to increase the likelihood of better work engagement and job satisfaction.


In the study the risk factors that can lead to moral distress were classified in the following categories: Individual risk factors were patient vulnerability listed as decreased mental functioning or psychiatric condition, elderly or very young, developmentally delayed, English as a second language, no relatives, homeless. End of life, suffering, and failed treatment are also individual risk factors.


Family risk factors can include the family being against the treatment plan, family uncertainty, stubbornness or unrealistic expectations, caregiver disagreement, caregivers not honoring patient wishes, denying comfort care or family indifference.


There are risk factors at the professional level which include team conflict, unethical behavior, over optimism by peers, stubbornness, fear of litigation, ignoring patient wishes or advance directives.


Risks exist at the system level as well with polices either vague or strict, limited resources, and lack of professional collaboration.


Helping nurses identify risk factors and early indicators of situations that could escalate into ethical dilemmas will avert moral distress. As indicated in this space in a previous article, nursing intuition is a scientifically valid phenomenon. Empowering nurses to proactively manage patient situations where moral distress can occur would be beneficial to everyone involved.


The early indications of a possible ethical dilemma are categorized as follows: Signs of conflict, which can include arguing between family members or medical staff, family expressing anger and mistrust of the staff, and nurses objecting to either prescribed treatment or family decisions. Patient suffering is another indication, for example unrelieved discomfort, or pain from different treatments and their complications, anxiety, and labored breathing.


Poor communication and unrealistic expectations from either patient or family are also early indications of possible ethical challenges. Ethical violations include not honoring patient autonomy, right to information, and standard of care. If the patient is treated without respect, or fraud is committed these are also signs of an ethical challenge.
Signs of nurse distress include the nurse believing treatment is futile, expressing concern over patient suffering, feeling powerless in the organizational structure of the medical center, and feeling regret that the nurse didn’t advocate enough for the patient.


Moral distress must be addressed both at the institutional and individual level.  For institutions moral distress is a factor in nurse burnout, turnover, and nurse retention. This can only exacerbate the upcoming lack of health care providers in the near future. But more importantly, moral distress affects nurses’ perception of themselves and the care they provide. Could it alter a nurse’s professional self image?  Can nurses compartmentalize self perception so that moral compromise in one’s professional life does not impact one’s ‘true’ self? Can nurses end up acting for pragmatic reasons alone due to moral distress?


The purpose of this space is always to end on a hopeful note, however. There is hope that nurses are identifying and coping positively with moral distress. Moral distress situations can prompt nurses to take action and become more assertive in changing their workplace to increase understanding of these situations. The self awareness that comes from reflection on one’s practice can lead to professional self development, and strength of character. Of course this is not going to occur without some changes at the employer level. Part 2 will deal with those innovative people and institutions that have pioneered the nursing professional championing ethics in the workplace.

9/8/14

Which Nurse Would You Choose To Care For Your Loved One?

Here's a post for those non-nurses that frequent our blog.

One factor that distinguishes a profession from other careers is by its goal to advance society though making a positive difference in peoples’ lives. In nursing this is reflected in healing, caring, and encouragement of a lifestyle that enable well being, among other actions.

What are the specific characteristics of excellence in nursing that can be articulated? The National League for Nursing states that excellence is a core value:” It is a commitment to continuous growth, improvement and understanding. It is transformation, moving beyond the status quo and mediocrity.”(1)

Caring, knowledge, and skill are the foundation of excellence in the nursing profession.  Nurses demonstrate excellence by preventing suffering and complications, they promote health and well being, they save lives and money, they are innovators and leaders. These are accomplished through such skills as patient centered care, evidenced based practice, and collaboration.

There are many nurse led initiatives and examples of attributes of excellence. Simply listing characteristics is not as meaningful as real life examples of nurses who are longstanding professionals. What is their view of excellence? How did they get there? What common themes emerge from their decades long experience as nurses caring for patients?

One theme that surfaced in more than one instance is that the nurse patient relationship is mutually beneficial. Patient experience of the healing process is valid and nursing care can foster progress in effective therapies. For example, the field of pharmacogenetics started from nurse observations of patients’ reaction to medication. Longtime nurses also expressed the attitude that there is always more to learn and education is life long. Not only do nurses learn from patients but they learn from their peers. Lifelong learning and ongoing professional development instill confidence in nursing as the ‘caring science whose knowledge is distinct from the other sciences’(2)

Another way that nursing excellence is demonstrated is when nurses become involved in creative ways to improve their workplaces. Nurses are experienced in effective and courageous communication. Board member Jean Logan and others, facilitated input from staff at Broadlawns Medical Center in Des Moines, Iowa. Because of this open communication the medical center was transformed from a so called poor people’s hospital with frequent ED visits to a primary care center focusing on prevention. In the same vein, Ann Marie Pinkham as a board member with the Free Medical Clinic in Columbia, South Caroline assigned to work with the publicity committee, enabled positive change. The committee felt their input was ignored and she was faced with hostility. Through persistent and dedicated communication they were able to forge a marketing strategy where the community was informed that for every dollar donated $8 in health care was provided. This awareness brought increased donations which encouraged the committee to become more engaged.

Nursing excellence is also demonstrated when nurses advance in leadership and are recognized outside of the nursing profession. One example is the appointment in late 2011 of the first nurse and woman to the rank of Surgeon General and Commander of the US Army.Medical Command, Major General Patricia Horoho.

Loyola University Hospital in Chicago wanted to develop a program to recognize nurses who demonstrated excellence in their work. Unable to locate a useful definition through research of the literature they composed their own attributes by reflecting on a variation of the title of this article: ”What kind of nurse would you want to take care of your mother?” Their first list contained the following: outstanding in care and communication,  problem solver,  lifelong learner, advocate and collaborator. The list was refined using the Delphi technique into 10 concrete characteristics which included the following: clinical expert, patient advocate, role model, coach/mentor, innovator, researcher and leader. Clinical expertise was demonstrated for example, by critical thinking skills, independence in practice, anticipation of patient needs, and patient education. Role model attributes were exhibited in part by the ability to influence peers and department communication, and having a positive personality. Teamwork and innovation were demonstrated by the ability to establish goals, being proactive, humble, and altruistic.

The promotion of the program detailed the 14 Forces of Magnetism to allow those nurses who wished to nominate their peers to reflect on the demonstrable characteristics of an excellent nurse. These included image of nursing, nurse as teacher, nurse leadership, quality, and autonomy. The 14 characteristics were refined by the American Nurses Credentialing Center into the 5 components of transformational leadership, exemplary professional practice, structural empowerment, and new knowledge, innovation, improvement, which will lead to the fifth, quality outcomes.  These factors are interdependent and build on each other to create quality outcomes.

In the first year of the recognition program the committee decided to award 20 nurses which would represent 1% of the nursing staff. They also created the Nurse of the Year Award. The scoring system was a rank of 5 with 5 being the highest score shown by good examples from the nominee’s practice. The article did not give much detail on how the Nurse of the Year was selected. More detail on the selection of Nurse of the Year would have been interesting.

One of the most important aspects of the development of the recognition program was the fact that positive outcomes are a result of excellent nursing. To this end there are many important nurse led initiatives that have increased the quality of care that patients receive and which are a demonstration of nurse excellence. The American Academy of Nursing has their Edge Runners program through their Raise the Voice campaign. Quality and Safety Education for Nurses is a resource that helps new nurses acquire the knowledge, skills, and attitudes that can allow them to positively impact the safety and quality of their workplace.  TCAB is a well known nurse led initiative. This partial list only scratches the surface of nursing excellence in the nation.

Every day nurses demonstrate qualities of excellence that make a difference in patients’ lives and inspire their peers. There are nurses who are mentors, who take advantage of teachable moments, and are adaptable. Nurses are patient advocates, defend patient rights and empower them and their caregivers. Nurses are compassionate and culturally aware and sensitive. Nurses have the spirit of inquiry and are supportive emotionally and spiritually. There are many, many unpublicized instances of excellence in nursing that can be found everywhere nurses are employed.



Hassmiller, S. Nurses on Boards American Journal of Nursing. Vol.112 No. 3 March 2012  pp61-66

Jasovsky, D. et al How Do You Define Nursing Excellence? Nursing Management, Vol.41 No. 10 Oct 2010. pp19-24






9/7/14

Vent your day away - it's therapy

If you have a story about your day in the ER and need to get it off your chest then send us an email and we'll post it! ernurseyblog@gmail.com

We'll post it anonymously, be sure to change up some pertinent details ;). You may even get some valuable feedback!

8/12/13

Alarm Fatigue in the Hospital

Pagers, phones, beepers, beeping lanyards, computers, intercoms.... the beeps, alarms, reminders, are not in short supply in the ER (or elsewhere in the health center). At some point there appears to be a level of fatigue, or perhaps a 'boy who cried wolf' syndrome. Repeated alarming may in fact diminish healthcare as providers become immune to the consistent barrage. How does your workplace manage alarms and do you find you're starting to suffer from 'alarm fatigue'?

7/8/13

The Most Disgusting Thing in the ER

Resurrecting one of our popular posts (and most disgusting/gross) from the archives. Nothing's changed, nurses face some of the grosses, weirdest, and seemingly normal functions of humanity.

What's the most disgusting thing you've had to do / seen in your travels as a nurse?

Addition:
Some interesting and disgusting submissions, thanks....I think. A recent submission from a nurse working ICU. --- We had a patient who had an undiagnosed mental illness on top of the reason why he was admitted to ICU. We were doing routine visits to his room when we noticed the patient was coughing due to obstruction(s). As he was hacking up out comes numerous scabs from the sores on this body. Well if that wasn't enough, he sat in the bed as he, and we, looked at his discharge in his hand, and instead of inquiring where he could dispose of his....sores....he promptly slurped them back into his mouth and ate them.... Yes, I've seen many things, but that made us yell out, "come on man!"

6/3/13

Special training for victims of crime

What kind of special training is offered in your workplace to help identify and treat victims of crime. For example, any special training to help individuals who have been victims of a sexual assault? Perhaps victims of human trafficking? Share your opportunities and tips.