Virginia Nurses Today - August 2020

www.VirginiaNurses.com | Virginia Nurses Today August, September, October 2020 | Page 33
Practical Tips for Moral Resilience
Phyllis Whitehead, PhD, APRN/CNS,
ACHPN, RN-BC, FNAP
Clinical Ethicist; Clinical Nurse Specialist Palliative Medicine/Pain
Management
During these times of COVID-19, nurses and other clinicians throughout
the world are faced with many ethical dilemmas such as PPE shortages,
limited COVID-19 testing, and staffing challenges. Such situations can lead
to moral distress, which is defined as “the experience of being seriously
compromised as a moral agent in practicing in accordance with accepted
professional values and standards,” (Varcoe, et al., p. 488). Moral distress
occurs when we feel that we cannot do the perceived right action resulting
in our moral integrity being compromised (Hamric, 2007; Hamric, 2012).
Moral distress results in significant physical and emotional stress, which
contributes to feelings of loss of integrity and dissatisfaction with the work
environment (Jameton, 1993). Research demonstrates that moral distress
may contribute to staff leaving the work setting and profession. It can affect
relationships with patients and coworkers and the quality, quantity, and
cost of care.
Moral resilience is the important ability of nurses to cultivate a sense
of well-being and growth in response to moral and ethical challenges they
face in their stressful and rapid-paced work environments (Holtz, Heinze,
Rushton, 2018; Rushton, 2016). Nurses, organizations, and nurse leaders
need to foster the moral resilience within themselves and among their
staffs. One strategy is a Moral Distress Consultation Service. During a
Moral Distress Consult, trained facilitators provide a 45-60 minute session
in an open, safe forum to address issues related to any situation causing
moral distress - end-of-life care, cultural issues, communication, treatment
choices, etc. - or ways to prevent moral distress by dealing with power or
personality conflicts based on issues of concern on the unit. The facilitator
works with the staff to develop action plans for decreasing moral distress
on the unit or service.
Many professional nursing organizations provide helpful information
and tools to support healthy work environments. The following resources
may provide valuable support to nurses seeking to cultivate a healthier
workplace for their unit:
• Healthy Work Environment (American Nurses Association): https://
www.nursingworld.org/practice-policy/work-environment/
• Healthy Practice Environment Advocacy Guide (Academy of Medical-
Surgical Nurses): https://www.amsn.org/practice-resources/healthypractice-environment
Coming Soon!
We’re thrilled to announce the launch
of a brand-new VNA website!
Loaded with tools, resources, and
education, our new website will launch
in late summer, so be
sure to bookmark
www.virginianurses.com!
• Healthy Work Environments (American Association of Critical Care
Nurses): https://www.aacn.org/nursing-excellence/healthy-workenvironments
• Healthy Perioperative Practice Environment: Patient & Workplace
Safety (Association of perioperative Registered Nurses): https://www.
aorn.org/guidelines/clinical-resources/position-statements
• Healthy Work Environment in the Emergency Care Setting
(Emergency Nurses Association): https://www.ena.org/docs/defaultsource/resource-library/practice-resources/position-statements/
healthyworkenvironment.pdf?sfvrsn=a4170683_14
For more information about moral distress, moral resilience, and Moral
Distress Consult Services, contact Phyllis Whitehead at pbwhitehead@
carilionclinic.org.
Strategies to consider when you experience an ethically and/or morally
challenging situation:
• Get the whole story. Encourage others to do so as well
- Speak up. Encourage dialogue
- If seen as risky, that’s the first problem to tackle
• Focus on the ethical dimensions of care
- What we ought to do?
- Which obligation is primary?
- What are the goals of care? Have they changed? Do they need to
change?
• Debrief Situations with a goal of preventing the recurrence of a similar
case
- What could we have done differently?
- How can we anticipate next time?
- Include entire interprofessional team
• Interprofessional education on moral distress
- Nurture the expectation of collaboration
• Target unit/service practices that improve communication:
- Interprofessional rounds
- Unit/service conferences
- Family meetings
• Develop Proactive Systems & Processes
- Early, frequent, consistent communication with patients and
families
- Clear articulation of health team goals
- Team speaks with one voice
• Develop institutional resources that are:
- Available
- Known
- Santioned
• Develop policies/guidelines encouraging team collaboration, ethics
consultation, provider continuity
• Identify the moral distress sources operating in your unit/division/
service and target interventions there
- Then, extend to the organization if the problems are systemgenerated
• Initiate Ethics and/or Moral Distress Consults
- To reduce moral distress levels among staff
- To provide an interprofessional avenue for frank discussion and
problem solving in morally distressing situations
- To assist staff in developing strategies to address barriers to highquality
patient care
- To empower staff to raise concerns
• Identify your ethical/moral distress
- Providing inadequate or harmful pain management
- EOL futile care challenges
- Poor teamwork and challenging communication issues
• Work on strategies to improve your teamwork and communication.
(Holtz, 2018; Rushton, 2016; Varcoe, 2012; Whitehead, 2015)
References
Hamric, A.B., Blackhall, L.J. (2007). Nurse-physician perspectives on the care of
dying patients in intensive care units: collaboration, moral distress, and ethical
climate. Crit Care Med, 35, 422-429.
Hamric, A.B., Borchers, C.T. & Epstein, E.G. (2012). Development and testing of an
instrument to measure moral distress in healthcare professionals. AJOB Primary
Research, 2, 1-9.
Holtz H, Heinze K, & Rushton C. (2018). Interprofessionals’ definitions of moral
resilience. Journal of Clinical Nursing. 27(3-4):488-494. doi: 10.1111/jocn.13989.
Jameton, A. (1993). Dilemmas of moral distress: moral responsibility and nursing
practice. AWHONNS Clin Issues Perinat Womens Health Nurs, 4(4), 542-551.
Rushton, C.H. & Carse, A. (2016). Towards a new narrative of moral distress:
Realizing the potential of resilience. The Journal of Clinical Ethics, 27(3), 214-218.
Varcoe C., Pauly B., Webster G., & Storch J. (2012). Moral distress: tensions as
springboards for action. HEC Forum, 24(1), 51-62.2.
Whitehead, P.B., Herbertson, R.K., Hamric, A.B., Epstein, E.G., & Fisher, J.M. (2015).
Moral distress among healthcare professionals: Report of an institution-wide
survey. Journal of Nursing Scholarship, 47(2), 117-125.