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Creating an Ethical Environment Where Courage Can Flourish

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Creating an Ethical Environment Where Courage Can Flourish Kate Payne, RN, JD Director of Ethics and Palliative Care kpayne_at_stthomas.org Saint Thomas Hospital – PowerPoint PPT presentation

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Title: Creating an Ethical Environment Where Courage Can Flourish


1
Creating an Ethical Environment Where Courage Can
Flourish
  • Kate Payne, RN, JD
  • Director of Ethics and Palliative Care
  • kpayne_at_stthomas.org
  • Saint Thomas Hospital
  • Nashville, TN 37205

2
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

3
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

4
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5
Ethics Why?
  • Decision making guided by ethical decision making
    processes
  • Decision making informed by ethical values
  • Decrease moral distress

6
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.

7
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

8
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)

9
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)

10
Principled Decision Making adapted from Robert
Orr, MD
Non-Maleficence
Respect for Autonomy
Fidelity
Beneficence
Justice
11
Health Care Models
Professionals Obligation
Nature of Relationship
Nature of Health Care
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
12
Why Ethics?
  • Need a moral compass to guide difficult decisions
    that have to be made in the health care context.

N
W
E
S
13
Moral Compass
14
Vision
  • Defining and achieving a desired future
  • Best hindsight and foresight for action
  • Possibilities
  • The best healthcare system
  • Your best life
  • Fat free chocolate

15
Mission
  • Mission makes us who we are
  • 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

16
Values
  • What is most important
  • Priorities
  • Worth
  • Value set
  • Personal values
  • Professional values
  • Organizational values

17
Virtues/Values
  • Cardinal virtues
  • 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

18
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

19
So much for moral clarity.
20
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

21
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

22
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

23
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.
    NJPrentiss-Hall. 1984

24
defined
  • 1993 Jameton distinguished
  • 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

25
.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

26
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 ones
    relationship with the work environment
  • Grief out
  • Repeated, sustained and often unresolved grief
    and loss

27
distress
  • Compassion fatigue
  • 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

28
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29
Personal
  • Psychological/emotional
  • Closeness/identification with patient/client
  • Boundaries
  • Isolation
  • Feelings of powerlessness or helplessness
  • Compromise of ones 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

30
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

31
.professional
  • Role/Relevance questions
  • 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

32
.professional
  • Conflict
  • Assertive/aggressive patients/clients and
    families
  • Intra or interdisciplinary conflict
  • Outside pressures
  • Organizational, professional, personal
  • Economy
  • Pandemic
  • Politics

33
Symptoms of Moral Distress
  • Emotional/psychological
  • Intrusive thoughts
  • Disturbing dreams
  • Sense of reliving trauma
  • Cued psychological distress
  • Difficulty concentrating
  • Hypervigilance
  • Anxiety
  • Frustration
  • Depression

34
.symptoms
  • Irritability, anger, insults, blaming
  • Physical
  • Cued physiological reaction
  • Fatigue
  • Somatic concerns
  • Diminished activity level
  • Difficulty sleeping
  • Feelings of inadequacy
  • Personal, professional
  • Feeling victimized

35
.symptoms
  • Distancing oneself
  • 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

36
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

37
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

38
Work Place Culture
  • Pathologic culture
  • Bureaucratic culture
  • Generative culture
  • Components
  • Informed/informing
  • Just
  • Flexible
  • Learning
  • What does your culture look like?

39
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

40
Crescendo Effect
Solid lines indicate moral distress Dotted lines
indicate moral residue
Moral Distress
Moral distress crescendo
Moral residue
Time
41
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42
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

43
.strategies
  • Story telling
  • Self-care
  • Balance
  • Appropriate boundaries
  • Spiritual practice
  • Find own voice/advocacy
  • Courage
  • Develop sources of support
  • Professional
  • Referral sources
  • Social
  • Play

44
Hard to tell from here. Could be buzzards. Could
be grief counselors.
45
Organization Prozac?
  • Insight-top down
  • Shock therapy
  • Organizational soul
  • Admit there is a problem
  • Re-inspire
  • Re-invigorate
  • Re-energize
  • Re-discover roots

46
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.
19997714-26 (1999).
47
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

48
Ethics Resources
  • Mission, Vision, Values
  • Code of Ethics
  • Ethics Consultation, Ethics Committee
  • Organization Ethics Committee
  • Compliance
  • Conflict of Interest Committee
  • Institutional Review Board

49
ethics resources
  • Pastoral care
  • Palliative care
  • Employee Assistance Program
  • Patient advocate
  • Quality improvement
  • Outcomes management
  • Patient safety
  • Risk management

50
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

51
Healing Teams
  • Interdisciplinary/ collaborative
  • 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

52
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

53
Community Resources
  • Grief counseling (through hospice, other)
  • Agencies
  • Crisis lines/centers
  • Counselors, therapists
  • Clergy in the community
  • Who/what have you found helpful?

54
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

55
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

56
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