Nursing Community - A Response to Moral Distress
In the last Issues Update, moral distress was defined by Alvita Nathaniel MSN, RNCS, as:
..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 judgement about the correct action; yet as a result of real or perceived constraints, participates in perceived moral wrongdoing.
Retrieved July, 28, 2002, from Issues Update Vol. 1.
The purpose of this article is to express, through true stories, the development and use of strategies to combat moral distress which contributes to loss of personal and professional integrity. The first story is a true story with two endings. The reader is asked to decide which is the true ending. The second story is evolving. It is my personal quest to deepen my understanding of potential causes of moral distress and identify strategies to resolve ethical dilemmas encountered by nurses in their day to day practice. During this search, I discovered the writings of a nursing leader in South Africa who inspired me to take a fresh look at the meaning and power of community.
The story with two endings
A 21 year old female presented to the ER on a Friday at about midnight with gross hematuria. She was accompanied by her fiancé, and both were in quite a bit of distress over the sudden onset of symptoms a few days earlier, and the increasing severity of the hematuria. The patient was worked up for a Urinary Tract Infection (UTI), a three-way Foley was inserted and her bladder was irrigated. In spite of continuous irrigation over a 6 hour period, the hematuria did not resolve. The nurse caring for the patient spoke with the patient's parents by telephone, with the patient's permission. They were very concerned, but were about 4 - 5 hours away by car. The nurse assured them that their daughter was receiving competent care, that the urologist on call was being consulted, and that everything would be done to determine the cause of the problem. Immediately after this phone conversation, the nurse left the patient's room and was shocked and dismayed to find orders to discharge the patient on oral antibiotics with instructions to follow up with the urologist on Monday. By now it was 7 AM, and change of shift for both the ER doctors and the nurses.
Which of these two endings is true? Which one is more likely?
I. The nurse took the chart and went to the day shift charge nurse and the nurse who would be relieving her. She gave report on the patient, and stated that she could not, in good conscience, discharge the patient in her present condition. She asked if she had the charge nurse's and day shift nurse's support in this position, and they both stated that they would support her. The nurse then went to speak to the ER doctor, who was giving report to day shift. When he came to the patient in question, the nurse interrupted report to state that she refused to discharge the patient, and so would the day shift. The doctor stated that the urologist had not felt admission was necessary, even though he had not examined the patient. The nurse replied that since none of the nurses would discharge the patient, the doctors would have to do it themselves, if they really felt that this was the right thing to do. The doctor, when confronted, decided that he would ask the urologist to reconsider. The urologist then agreed to come in and see the patient, who was subsequently admitted, and after extensive diagnostic testing, was transferred to Johns Hopkins with a rare and potentially fatal kidney condition.
II. The nurse took the chart and gave report on the patient to the nurse who would be relieving her and stated that she didn't feel right about discharging this patient, but she would leave it up to day shift. She had talked to the doctor about it already, and he had stated that the urologist had not felt admission was necessary, even though he had not examined the patient. He stated that his hands were tied, since he did not have the ability to admit patients. The day shift nurses then discharged the patient to home. Her parents, meanwhile, were on their way to be with their daughter. They took her to Johns Hopkins, where she was diagnosed with a rare and potentially fatal kidney condition.
The Evolving Story
As a practicing nurse in a small health care system having graduated from an Associate Degree nursing program in 1980, I did not receive formal ethics education. Over the years I continued my education in college with science and business courses. When I enrolled in the Registered Nurse (RN) to Masters in Nursing program, I became interested in ethics in nursing. While reviewing the ethics literature for a nursing leadership class, I frequently noted the terminology "moral distress". A preponderance of the literature suggested nurses are burning out, dropping out, or numbing out (passive compliance, alcohol, drugs) in order to relieve the moral distress they face in their daily practice(Corley, Elswick, Gorman & Clor, 2001; Hamric, 2001; Jameton, 1993; Oberle & Hughes, 2001; Raines, 2000; Sundin-Huard & Fahy, 1999; Tiedje, 1999; Volker, 2001; Wocial, 1996). Ethics research, education, and supportive services for nurses were encouraged and supported by the literature. What strategies could I implement in my practice to avoid the complications of ethical stress described in the literature?
I began to read books describing ethics theories and principles. Through my reading, I began to question whether nurses can be ethical because they are not autonomous, have multiple fidelities, and are increasingly forced to witness pain and suffering without the ability to care freely. I was also questioning the justice of the inappropriate distribution rather than scarcity of health care resources. As a nurse, I make decisions every day about who gets health care, and who does not. These choices are painful and can have cumulative effects on nurses. Could we afford to forget the individual human being in need of care, in order to provide for the needs of society? If the community and society are an extension of the self, we would have to be prepared to forget ourselves and our loved ones in this process.
I began to question whether nurses might dare to attempt to deinstitutionalize and develop an ethical vision for nurses. An article written by a nursing leader in the Republic of South Africa encouraged nurses to build on both justice and care ethics. This leader suggested incorporating 'Ubuntu' which enfolds a person with significance and meaning; and asked if Africa or nursing could bring this ethic to birth (Haegert,2000).
According to Haegert, it is through listening we engage with individuals and communities. Stories are used in Africa to explore complex issues, as opposed to case studies in the American health care culture. This author used true stories in her article to support her claim that "forgetfulness of the person had led to a crisis in modern ethics, an inability to relate morally and spiritually and to act ethically toward another." (p.494).
Haegert described the traditional African thinking about humanity as community based. The individual is considered as important to the community as the thumb to a hand. The community embodies the individual human being and the human being symbolizes the community. 'Ubuntu', found in the South African constitution, refers to "the quality of being human and so also humane."(p.496). Characteristics of 'Ubuntu' include gentleness, compassion, and use of strength on behalf of the weak and vulnerable as described by Archbishop Tutu (p. 496).
Haegert(2000) also asserts that in order for a person to behave ethically and make ethical decisions, one must be free
(p.499). For Haegert, "Caring is in the balance" for without the freedom to care ethically, "..compassion fatigue or burnout.." will result(p.497). Haegert's concern is with a justice that looks at what a person would want for themselves or their loved one and she describes the "person as central to ethics".(p.499).
An African ethic which includes justice, care and the human community could be an evolutionary experience for the professional nursing community.
I have come to the realization that I need to be more involved and supportive of my nursing community. As a member of the American Nurses Association (ANA), I have expanded my nursing community. Weekly e-mails from ANA keep me informed about what is happening nationally and internationally. The ANA code of ethics(2001) makes many references to community. These references are not just to the patient as community; but also the nurse and the profession as community. Collaboration, interdisciplinary partnerships, as well as community, national, and international partnerships are promoted within the code. This code offers nurses empowering guidance in their practice. It specifically addresses relationships with self and colleagues, and collaboration and membership in the larger professional nursing community. My new ethical vision for nursing encompasses justice, care, and the human community. My journey continues and I feel empowered by my growing nursing community.
Back to the story with two endings
The nurse is shocked and dismayed about the discharge order. These feelings are the first clue she may be faced with an ethical dilemma. The applicable ethical principles are beneficence and nonmaleficence. Using critical thinking the nurse assesses that discharging the patient is not in the patient or family's best interest and could endanger the patient's life. The dilemma revolves around her real or perceived lack of autonomy and issues of multiple fidelity. It is shift change which compounds the problem of Time "the scarce commodity" in health care(Wocial,1996,p.151).
If you chose the second ending, you are not alone. Everyone in my leadership class chose the second ending based on their personal experiences as practicing nurses. However, the first ending is the true ending. The success of this nurse was multifactorial. This nurse and her colleagues had a strong ethics education foundation and were committed to each other and their profession. They were able to identify and analyze the morally-relevant facts surrounding the dilemma of discharging a patient with a precarious clinical condition. They interpreted their primary fidelity according to the nursing code of ethics provision #2- The nurses primary commitment is to the patient whether individual, family, group, or community. Sundin-Huard and Fahy(1999) described a phenomena called "nursing infidelity" to describe how nurses typically act toward each other in hierarchal power structures, such as our current health care system.(p.11). These nurses collectively took the time to collaborate, discuss the issues and develop and implement a strategy to advocate for themselves and their patient. Fidelity to the patient, family and the nursing community empowered these nurses which minimized isolation and moral distress for the individual nurse and the nursing community. This nursing community made a positive difference in the life of a patient and family; and protected their community hospital and physicians from negative publicity and possible legal repercussions.
Many nurses may feel overwhelmed by their current responsibilities. They may say they do not have time or energy to become involved in their nursing community. I would compare involvement in your nursing community with exercise. It takes energy to get started in a program; but once you commit to it you begin to see the benefits of increased energy and better fitting clothes. Taking the time and energy to be involved in your nursing community will increase your energy and strengthen your personal and professional integrity. As demonstrated in the preceeding ethical dilemma confronting the end-of-shift, nurses viewing a patient under ones care as possessing 'Ubuntu' and listening to the patient, her family, and co-workers is an effective strategy for ethical decision making. I invite my colleagues to share vignettes of the potential moral distresses they have encountered and share with the nursing community the strategies they have used to prevent moral distress.
References
American Nurses Association (ANA).(2001). Code of Ethics for Nurses with interpretive statements. Washington, DC: ANA.
Corley, M., Elswick, R., Gorman, M., & Clor T.(2001). Development and evaluation of a moral distress scale. Journal of Advanced Nursing, 33, 250-256.
Jameton, A.(1993). Dilemmas of moral distress: Moral responsibility and nursing practice. Clinical Issues in Perinatal and Womens' Health Nursing,4, 542-551.
Haegert, S.(2000). An African ethic for nursing? Nursing Ethics, 7, 492-502.
Hamric, A.(2001). Reflections on being in the middle. Nursing Outlook, 49, 254-257.
Oberle, K., & Hughes, D.(2001). Doctors' and nurses' perceptions of ethical problems in end-of-life decisions. Journal of Advanced Nursing, 33, 707-715.
Raines, M.(2000). Ethical decision making in nurses: Relationships among moral reasoning, coping style, and ethics stress. JONA's healthcare law, ethics, and regulation, 2, 29-41.
Sundin-Huard, D. & Fahy, K.(1999). Moral distress, advocacy and burnout: Theorizing the relationships. International Journal of Nursing Practice, 5, 8-13.
Tiedje, L.(1999). Moral distress in perinatal nursing. Journal of Perinatal Neonatal Nursing, 14, 36-43.
Thorne, S.(1999). Are egalitarian relationships a desirable ideal in nursing?
Western Journal of Nursing Research, 21, 16-34.
Volker, D. (2001). Oncology nurses' experiences with requests for assisted dying from terminally ill patients with cancer. Oncology Nursing Forum, 28, 39-49.
Wocial, L.(1996). Achieving collaboration in ethical decision making: Strategies for nurses in clinical practice. Dimensions of Critical Care Nursing, 15, 150-159.