By Debra Wood, RN, contributor
September 12, 2013 - When nurses encounter ethical dilemmas in situations in which they cannot do what they consider “the right thing,” they experience moral distress. While some have the courage to speak up or take action, others do not.
“There is such a moral burden to witnessing the suffering of patients and trying to balance the suffering vs. the benefit, and the complexity of decisions that can be made in the acute-care setting,” said Mary K. Walton MSN, MBE, RN, nurse ethicist at the Hospital of the University of Pennsylvania. “The basic questions are ‘What is the right thing to do?’ and ‘What makes it so?’”
Part of nursing is the relief of suffering, but complex interventions often cause patients to suffer while restoring them to health.
“Being part of the implementation is a heavy weight when you are at the bedside,” Walton said.
Carol Pavlish, RN, PhD, FAAN, reported that watching patients suffer is a primary cause of nursing ethical dilemmas.
Carol Pavlish, RN, PhD, FAAN, associate professor at the UCLA School of Nursing in Los Angeles, has studied early indicators of ethical challenges nurses face and has developed some strategies for helping them.
Ethical dilemmas can take many forms
“Challenges primarily had to do with watching patients suffer, which nurses find is unnecessary suffering,” Pavlish agreed. Nursing interventions may increase the patients’ suffering without necessarily improving an outcome.
Pavlish found nurses also were concerned that patients and families were not fully informed about treatment options and their clinical prognosis and whether the patient voice was represented. For instance, advance directives were not being followed because families wanted something else.
Nurses often come to Walton with concerns about informed consent, pain and going beyond a common goal, but dilemmas in nursing ethics are not limited to end-of-life care.
Connie M. Ulrich, PhD, RN, FAAN, said when nurses think they know the correct action but cannot carry it out, they experience moral distress.
“The issue of moral distress is when they feel they know the correct action but cannot carry it out because of the organizational environment they are in,” said Connie M. Ulrich, PhD, RN, FAAN, associate professor of bioethics and nursing at the University of Pennsylvania School of Nursing in Philadelphia and author of Nursing Ethics in Everyday Practice. “It could be [from] a multitude of situations.”
Ulrich indicated that end-of-life issues arise as concerns but ethical dilemmas also extend to the day-to-day issues of caring for patients.
The American Nurses Association (ANA) responds to members’ who write in about ethical concerns and then tallies the queries to learn the themes. Martha Turner, PhD, RN-BC, assistant director of ANA’s Center for Ethics and Human Rights, reported that the work environment, integrating genomics and genetics into practice, and end-of-life issues and palliative care round out the top three nurses report.
ANA’s position statements on ethics and human rights can guide nurses and aid in their dealing with the ethical challenges they face in practice.
The work environment
Nurses report communication difficulties and workplace bullying and violence as serious work environment ethical concerns, Turner said.
“The hierarchy or work structure do not encourage conversations,” Pavlish added. She is developing models and tools to allow such discussions to take place where everyone can feel comfortable speaking up.
“We are looking for ways that it becomes a community obligation to the patient, with collaboration in answering questions and talking about issues,” Pavlish said. “The work of ethics is dialogue.”
Patient safety and staffing issues also fall into the work environment category. Pavlish found nurses reporting they do not have the time to do what they intended for patients--helping them recover or adapt, or addressing patients’ emotional needs.
“They felt compromised and that some their moral obligations were not recognized by the system,” Pavlish said.
“They just don’t have the time,” Ulrich added. “How you prioritize the needs can be very stressful.”
Therefore, she said, nurses often come away from a situation feeling they did not do good for those patients who did not receive optimal care.
“You cannot change the tragedy,” Walton said. “I try to get them to refocus: ‘Did you fulfill your obligation? Did the patient or family feel cared for? Did you learn something?’”
Walton recommended nurses reflect on how they manage competing obligations and suggested nurses call on their team members, for example to help them balance between tasks and talking with a patient who is upset. Priorities also are reset as new patients arrive and colleagues need something. As nurses develop and gain experience, they become better at that.
Turner added that nurses “can be advocates for staffing that is appropriate for the patient population and know how to resolve issues when there is inadequate staffing.”
Social media and personal boundaries also are part of the work environment concerns. Technology keeps evolving and blurring traditional values about privacy and boundaries.
“Social media and that use of technology is a far more difficult problem for nurses, as to what they post and what relationships they can have with patients,” Turner said.
Genomics and genetics
“The [genetic testing] technology should be available to all and not randomly, but the workforce is not up to speed on those topics,” Turner said. “Many nurses and physicians graduated before these things were common.”
Yet, patients may present having learned their genetic profile through an online service, putting the clinician in an awkward position.
Education about what is available and how it can be use appropriately, without causing distress to patients, can help practitioners with this ethical issue, Turner indicated.
Other ethical concerns
Cultural diversity and caring for people with different values and traditions, and accepting their rituals, can present challenges in the practice setting, Turner explained. Education can help address this type of scenario.
Access to care and affordable and equitable care present ethical challenges for nurses as they try to make that happen in their communities.
Nurses working in non-acute care settings, such as schools and prisons, have concerns related to bedside nurses but they can differ, Turner explained. For instance, some school nurses are now dealing with the fallout from legal actions in their states that now allow untrained lay people to administer insulin and other medications to students.
“That becomes an ethical issue for nurses,” Turner said.
Additionally, parents opting to not vaccinate pose a challenge for school nurses.
Dealing with ethical issues
Martha Turner, PhD, RN-BC, encouraged nurses to use resources, such as the ANA’s position statements on ethical challenges, to help them cope with dilemmas.
Where can nurses find help for their ethical and moral issues? One place is The Hastings Center, a research institution dedicated to bioethics, that offers several helpful resources; in addition, universities often post beneficial information about ethics topics that nurses can access, and topics in the ANA’s Online Journal of Issues in Nursing often cover ethical concerns.
“Ongoing education in ethics is encouraged,” Turner said. She explained that ethical concerns may change as the nurse matures in his or her role.
Ulrich discussed the importance of education in nursing programs to prepare undergraduate and graduate students for clinical practice.
The Joint Commission requires ethical resources be available--be it a committee, an individual or a community organization, Turner said. Additionally, the ANCC Magnet program requires ethics resources.
“Every hospital should have an ethics committee, and nurses need to have a voice in the decisions that are being made,” Ulrich said. “They can access an ethics committee to voice their concerns and get help.”
Ulrich also suggested providing unit-based ethics mentors who could help nurses think through the issues when facing them. She advocated for more creative solutions.
At Penn, nurses generate between one-third and one-half of the ethics consults.
“We help people refocus on the good they have done and how they fulfilled their moral obligation to the family,” said Walton, who added, “being present and letting someone share their pain is a therapeutic intervention.”
Communication is key for helping nurses work through these issues. In fact, having conversations with the health care team and holding family conferences can help ease the ethical conflict, Pavlish reported.
“A lot of the distress people feel, even if they don’t agree, is diminished if they have had an opportunity to communicate their view,” Pavlish added.
Walton made the argument for moral advocacy, speaking up and discussing options early.
“How do we talk about the hard stuff and share and invite our team members,” Walton said. “That can mitigate moral distress.”
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