Moral DistressMoral DistressPatricia (Paddy) Rodney, RN, MSN, PhDPatricia (Paddy) Rodney, RN, MSN, PhD

Associate Professor Associate Professor

& Undergraduate Program Coordinator,& Undergraduate Program Coordinator,

UBC School of NursingUBC School of Nursing

Faculty Associate, UBC Centre for Applied Faculty Associate, UBC Centre for Applied Ethics Ethics

PHC Ethical Reflection ConferencePHC Ethical Reflection Conference

April 2, 2009April 2, 2009

This presentation is based on research and writing done This presentation is based on research and writing done by P. Rodney, C. Varcoe, J. Storch, B. Pauly by P. Rodney, C. Varcoe, J. Storch, B. Pauly

and G. Hartrick Doaneand G. Hartrick Doane

Ethical Musings…Ethical Musings…

IS

OUGHT

Moral AgencyMoral Agency

• Personal enactment of ethical responsibilitiesPersonal enactment of ethical responsibilities• Action is intentional and directed towards “the Action is intentional and directed towards “the good”good”• Action is experienced as embodiedAction is experienced as embodied• Action and reflection hold significant meaning for Action and reflection hold significant meaning for the moral agentthe moral agent• Effective moral agency requires authenticity, Effective moral agency requires authenticity, connectedness and trust connectedness and trust

Health Care Workplaces Health Care Workplaces Over the Past Decade Over the Past Decade

Growing shortages of providers and Growing shortages of providers and resourcesresourcesIncreasing patient acuity, family stressIncreasing patient acuity, family stressGrowing workloads, casualizationGrowing workloads, casualizationOngoing restructuring and Ongoing restructuring and reorganization, loss of practice leadersreorganization, loss of practice leadersIncreasing stress, illness, injury, and Increasing stress, illness, injury, and attrition of nurses and other providersattrition of nurses and other providersDecreased patient satisfactionDecreased patient satisfactionIncreased morbidity and mortalityIncreased morbidity and mortality

Moral ClimateMoral Climate

Patient SafetyPatient Safety

Provider SafetyProvider Safety

Safe Moral ClimateSafe Moral Climate

The safety of patients is The safety of patients is linked tolinked to the safety of the safety of nurses and other members of the health-care nurses and other members of the health-care team. team.

Both depend on a safe moral climate in which Both depend on a safe moral climate in which the required the required organizational, material and organizational, material and interpersonal resourcesinterpersonal resources are available and the are available and the values for safe, competent, ethical carevalues for safe, competent, ethical care are in are in place. place.

(Rodney, Doane, Storch, & Varcoe, 2006)(Rodney, Doane, Storch, & Varcoe, 2006)

The Moral Context of PracticeThe Moral Context of Practice

Moral ChoiceMoral Choice

Moral ActionMoral Action

MoralMoral

DistressDistress

Moral distress “is when there is Moral distress “is when there is

incoherence between one’s beliefs and incoherence between one’s beliefs and

values and one’s actions, and possibly values and one’s actions, and possibly

also outcome”.also outcome”.

(Webster and Baylis, 2000)(Webster and Baylis, 2000)

Moral residue “is that which each of usMoral residue “is that which each of us carries with us from those times in ourcarries with us from those times in our lives when in the face of moral distresslives when in the face of moral distress

we have seriously compromisedwe have seriously compromised ourselves or allowed ourselves to be ourselves or allowed ourselves to be

compromised”compromised”

(Webster and Baylis, 2000)(Webster and Baylis, 2000)

Environment:Environment:

Structural and Structural and Interpersonal Interpersonal

Challenges (unit, Challenges (unit, agency, region)agency, region)

Self:

How People See Themselves and Their Own Action

Self in Relation to Environment: How People Respond to Others and to

the Challenges in Their Environment

SITE FOR ACTION AND EVALUATION

WHAT WE HAVE LEARNED…

Leadership for Ethical Policy and Leadership for Ethical Policy and Practice:Practice:

Using an Ethics Lens to ImproveUsing an Ethics Lens to ImproveHealthcare Workplaces (2004-2007)Healthcare Workplaces (2004-2007)

Co-PIs:Co-PIs: Jan Storch, Paddy Rodney Jan Storch, Paddy Rodney

CoIs:CoIs: Colleen Varcoe, Rosalie Starzomski, Colleen Varcoe, Rosalie Starzomski,Bernie Pauly, BC CNOs, National Nurse Leaders, Bernie Pauly, BC CNOs, National Nurse Leaders,

BC Nurse Leaders & Direct Care Nurses, BC Nurse Leaders & Direct Care Nurses, Other Health Care Professionals Other Health Care Professionals

RAs:RAs: Kara Schick Makaroff, Lorelei Newton, Cherry Kara Schick Makaroff, Lorelei Newton, Cherry Curry, Gladys McPherson, Laura Housden, Elaine Curry, Gladys McPherson, Laura Housden, Elaine

Moody, Olecia KlotchkovaMoody, Olecia Klotchkova

OUR THANKS TO FUNDERS…OUR THANKS TO FUNDERS…

Canadian Health Services Research Canadian Health Services Research Foundation (CHSRF) Foundation (CHSRF)

Health CanadaHealth Canada Associated Medical Services, IncAssociated Medical Services, Inc Each CNO & Region/AgencyEach CNO & Region/Agency Providence Health CareProvidence Health Care First Nations and Inuit Health BranchFirst Nations and Inuit Health Branch

BC CNOs/Leaders Fiona Bees Heather MassLynnette Best Amy McCutcheonAnne Cooke Barbara MildonKim Dougherty Lynne StevensonTom Fulton Cathy Ulrich

National Nurse LeadersSandra MacDonald-RenczJudith Shamian

PLUS CONSULTANTS AND NUMEROUS

PROJECT SITE LEADERS!

Sample Strategies…Sample Strategies…

Yearly conference with regions togetherYearly conference with regions together Site-based retreats/workshopsSite-based retreats/workshops Unit-based councilsUnit-based councils Interdisciplinary networkingInterdisciplinary networking Formal research proposalsFormal research proposals Links to other initiatives (eg. patient safety)Links to other initiatives (eg. patient safety) Changes to related structures/processes (eg. Changes to related structures/processes (eg.

rounds, staff meetings)rounds, staff meetings) Involvement of other resource people (eg. Involvement of other resource people (eg.

ethicists)ethicists)

Our InsightsOur Insights………..……….. An ethical lens can enhance research on An ethical lens can enhance research on

health care workplaces health care workplaces The moral climate shapes patient and health The moral climate shapes patient and health

care safetycare safety Nurses and other health care providers need Nurses and other health care providers need

support to use the language of ethicssupport to use the language of ethics Including other disciplines in this proactive Including other disciplines in this proactive

work is importantwork is important Nurses in advanced practice and other Nurses in advanced practice and other

leadership positions are crucialleadership positions are crucial

Our Insights continuedOur Insights continued………..……….. Nurses and other health care providers in Nurses and other health care providers in

direct care roles MUST be able and enabled to direct care roles MUST be able and enabled to be more actively involvedbe more actively involved

Health care providers from every facet of their Health care providers from every facet of their profession need more time for self-reflectionprofession need more time for self-reflection

There is a pressing need to move away from There is a pressing need to move away from “us-them” stances“us-them” stances

Collective action from all facets of health care Collective action from all facets of health care professions is essentialprofessions is essential

(Rodney, Doane, Storch, & Varcoe, 2006)(Rodney, Doane, Storch, & Varcoe, 2006)

PROJECT ACTIONS to PROJECT ACTIONS to consider………..consider………..

Start with hopeStart with hope Create an initial steering groupCreate an initial steering group Negotiate leadershipNegotiate leadership Reflect on power dynamicsReflect on power dynamics Seek support from others who can helpSeek support from others who can help Convene an initial retreat/workshopConvene an initial retreat/workshop Work out short-term and long-term goalsWork out short-term and long-term goals Expect skepticism and be honestExpect skepticism and be honest Build in regular evaluationBuild in regular evaluation Share with other providers and agenciesShare with other providers and agencies Consider research fundingConsider research funding Maintain hope!Maintain hope!

(Storch & Rodney, 2007)(Storch & Rodney, 2007)

Building RelationalBuilding RelationalCapacityCapacity

(Hartrick Doane & Varcoe, 2005)(Hartrick Doane & Varcoe, 2005)

Individual, Individual, Organizational, Organizational,

Regional, National, Regional, National, InternationalInternational