picture of sign with directions & words (moral integrity, etc)
Nurse’s moral integrity is threatened by the
devastating phenomenon of ‘moral distress’. 80% of RN’s experience moral distress (Corley, 2002). The major ethical dilemma for RNs is that they are unable to practice nursing (Curtin in Peter & Liaschenko,
2004). Purpose of Presentation: ·
Examine concepts within moral distress
|
Vignettes: 1.
Due to a heavy patient load, the palliative nurse does
not have to time to companion her patient in his
spiritual pain. 2.
Teary-eyed, the nurse recollects an event years ago.
An
ICU patient was transferred to the unit due to ICU bed
shortages. The nurse expressed her fears & concerns
re: lack of expertise & equipment in the event of a crisis
to the unit manger and ICU. ICU
nurses labeled the
nurse as a “whiner”. An emergent situation did arise
& the nurse was unable to resuscitate the patient. The
patient died needlessly. 3.
The new long-term care nurse witnesses abuse of the
geriatric patients; the manager ignores her concerns. |
Definitions: ·
Moral integrity
– “a focal virtue that relates to soundness, Reliability,
wholeness, an integration of character, and Fidelity
in adherence to moral norms” (Burkhardt & Nathaniel, 1998,
p. 391) ·
Moral distress
– “the reaction to a situation in which there are moral
problems that seem to have clear solutions, yet one is unable
to follow one’s moral belief because of external constraints”
(Burkhardt & Nathaniel, 1998, p. ??) ·
Moral residue
– carry with us a time of moral distress that one
compromised oneself or allowed oneself to be comprised. (CNA,
2003). ·
Moral outrage
– emotional turbulence and rage when an Attempt
to solve the moral problem is denied to preserve The status quo of submarginal performance (Johnstone, 1999). |
Moral Distress Model Corley, M. (2002). Nurse moral distress: A proposed
theory & Research agenda.
Nursing Ethics, 9(6), p. 644. Picture of boxes with words “figure 1 model for a
theory of moral distress” |
Sources of Moral DistressPreconditions: 1.
Sensitive to patient vulnerability, lack autonomy,
disregard patient choice 2.
External factors prevent what think is best 3.
No control over situation 4.
No regards to patient personhood Examples: ·
Powerlessness due to low level in hierarchy ·
Nurse-patient relationship devalued ·
Clash with institutional policies, corporate values ·
Lack staff ,resources & legal support ·
Cost containment ·
Personal inhibition, fear judgment of others ·
Lack interdisciplinary recognition &
collaboration (Austin, Bergum & Goldberg, 2003; Burkhardt
& Nathaniel, 1998; CNA 2003, Corley,
2002; Georges & Grypdonck, 2002;Lutzen, Cronqvist, Magnusson & Anderson, 2003; Peter & Liaschenko, 2004; Redman & Hill, 1997) |
Consequences of Moral Distress·
Anger, frustration, job dissatisfaction, poor
performance ·
Erode confidence, self worth, depression, nightmares ·
Embarrassment, shame ·
‘Psychological doubling’ (disengage, disconnect
from self) ·
increased absenteeism & disability (burn out) ·
increased cardiovascular disease, diarrhea,
headaches, etc. ·
dehumanization ·
increases errors due to distress fatigue ·
silence, apathy ·
job loss, leave profession of nursing ·
moral residue, moral outrage (Austin, Bergum & Goldberg,
2003; Burkhardt & Nathaniel, 1998; Holly, 1998; Lutzen, Cronqvist, Magnusson & Andeson, 2003; MacPhail, 2003; Rowe, 2003) |
Picture of screaming woman in this big space
Recommendations to Ameliorate or Resolve Moral Distress1.
Personal
– reflect & examine values & how arrived at,
refer to professional code of ethics to clarify 2.
Education
– courses to address institutional realities, legal aspects
of nursing, professional issues, teach reflective skills/strategies
to label feelings, political implications of social space
that RNs occupy. 3.
Research
– create nursing theoretical validation as nursing has
borrowed from other disciplines, create theory base to construct
interventions and discuss contributing factors, test concepts
to add to nursing knowledge (eg. ethical knowing), longitudinal
tracking of issues and how resolved, clinical significance
of moral distress, phenomenological experiences
and coping strategies, studies to include greater variety
of practice settings, role of emotion in moral decision-making, 4.
Create
Moral community – appoint staff nurses to ethical committees, contribute
to policy-making and decision-making of institution, gain support
from other RNs to reduce oppressive silence, management create
supportive environment for divergent opinions, increase dialogue
& story-telling to explore experiences to reduce isolation &
silence, interdisciplinary meetings, consider relational ethics/emotions/ethics
of care in patient care. (Brighid, 1998; CNA, 2003; Corley, 2002; Holly,
1993; Krishasamy, 1999; Peter & Liaschenko, 2004; Redman & Hill, 1997; Rumbold, 1999). |
Moral Distress Scale ExerciseRefer to the following condensed ‘moral distress
scale’. Corley, et al, (2000) discovered that the greatest
number of RN responses were to : “the number of staff is so low
that care is inadequate” and “carrying out physician orders for
unnecessary tests and treatments for terminally ill patients”. Do you
agree with Corley, et al? Check off the items that you have experienced in
your career: ___ Work in a situation where the number of staff is
so low that care is inadequate ___ Carry out the physician’s orders for
unnecessary tests and treatments for terminally ill patients ___ Assist the physician who is your opinion is
providing incompetent care ___ Work with ‘unsafe’ levels of nurse staffing ___ Follow the physician’s request not to discuss
death with a dying patient who asks about dying ___ Carry out the physicians order for unnecessary
tests and treatments ___ Follow the physician’s request not to tell the
patient the truth when he/she asks for it ___Observe without intervening when health care
personnel do not respect the patient’s dignity ___ Carry out a work assignment in which I do not
feel professionally competent ___ Ignore
situations of suspected patient abuse by care givers ___ Ignore situations in which I suspect that
patients have not been given adequate information to insure
informed consent ___ Avoid taking any action when I learn that a
nurse colleague has made a medication error and does
not report it ___ Give medication intravenously to a patient who
refused to take the medication orally Corley, Elswick, Gorman & Clor (2000, p.254). |
Questions1.
What is the moral duty of nurses when faced with choices to
follow policy or to follow patient request/good nursing care? 2.
Why is moral distress not openly discussed? 3.
Are emotions a part of moral integrity? 4.
What do you believe to be the most effective way
to ameliorate, resolve or cope with moral distress
& moral residue? 5. Are there benefits to moral distress/moral residue? |
Picture of man standing at road signs goes beside the reference box
References
Austin, W., Bergum, V., & Goldberg, L. (2003).
Unable to answer the call of our patients: Mental health
nurses experience of moral distress.
Nursing Inquiry, 10 (3), 177-183. Brighid, K. (1998). Preserving moral integrity: A follow-up study with new
graduate nurses. Journal of
Advanced Nursing, 28 (5), 1134-1145. Burkhardt, M & Nathaniel, A. (1998).
Ethics & Issues in Contemporary Nursing. Albany, NY:
Delmar
Publishers. Canadian Nurses Association (2003).
Ethical distress in health care environments.
Retrieved
March 25, 2005 from
http://cnaaiic.ca/cna/documents/pdf/publications/Ethics_Pract_Ethical_Distress_Oct_2003_e.pdf
_
Corley, M. (2002).
Nurse moral distress: A proposed theory & research agenda.
Nursing Ethics,
9 (6), 636-650. Corley, M., Elswick, R., Gorman, M. & Clor, T.
(2001). Development and
evaluation of a moral distress
scale. Journal of
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Moral problems experienced by nurses when caring for terminally
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and
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Western
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The suffering of the healer.
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