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Moral Distress: Questions and Comments from the Mailbag

Last week’s show on moral distress generated quite a bit of feedback and some questions from you.

We received many emails from nurses who work on the front lines. Lisbet Rygnestad of Victoria BC sent us this:

"I was initially a pediatric nurse in the emergency department at a great children's hospital in Vancouver, BC, where I always felt fully supported and relatively well resourced. I have also worked and lived in Nepal & India, and now live on Vancouver Island where I am one of the only two Street Nurses in Victoria, working in a different world from the pediatric hospital. I love my job and I love my clients, but am unfortunately consistently disappointed by how the general public (including people close to me) view my clients sub-human, not deserving of the same care as they are, not deserving of the same empathy as the kids I worked with. To me, at the core of nursing, is that a nurse is a patient advocate. Your show helps me to continue to reflect on my practice - something I feel is absolutely key to being a good nurse - and challenge myself. I love being a RN and am passionate about my chosen career, despite the challenges. Perhaps the challenges are part of what I enjoy? For me, being a RN is a great career because of the constant learning, diversity of positions, and possibilities of growth."

Cathy Ringham, a registered nurse and PhD candidate from Vancouver Island University sent this email after hearing our show:

“I am looking at research on moral distress and compassion fatigue in neonatal intensive care nurses as that has been my area of work for many years. Hearing you speak about your own moral dilemma/distress as well as the candid sharing of the students put me right back into many times and places where I felt the same gut wrenching turmoil. What were we doing to tiny, barely viable babies, following orders barked out form a paediatrician who felt compelled to save at all costs? You are quite right that repeated experiences of moral distress would lead nurses to find something else to do. The other option is that they stop feeling, pull back from any emotional investment in their work because it hurts too much. This really concerns me. What happens to the quality of patient care when you can no longer feel your own feelings or recognize what the patient must be feeling in their vulnerable state? I do not think it is much different for physicians although as you point out it is the nurses who often carry out orders from someone in a more powerful position or follow "rules" they have had no say in. I think what nurses do, the discipline of nursing, is unique making the experience and ramifications of moral distress particular to our work. I am curious if you feel that compassion fatigue is the next step beyond moral distress or a separate entity. I agree with your guest that burnout is quite different from either of these but what about compassion fatigue? I would like to find some solutions or at least raise the awareness of moral distress and its effects on nurses and the health care system. The question is how to tackle the problem! I would love to hear your thoughts!”

Cathy, we did a show last season on burnout and compassion fatigue. The University of Alberta Hospital Ethics Service and the John Dossetor Health Ethics Centre host past podcasts of White Coat, Black Art. Click on the link immediately following, and then scroll down to the show dated November 17, 2008.

Here is the link to past podcasts.

As you know, moral distress pertains to situations in which you have a clear sense of the right thing to do but can’t because of outside constraints such as the system or a supervisor who doesn’t support your decision-making. Compassion fatigue also known as a Secondary Traumatic Stress Disorder is a term that refers to a gradual lessening of compassion over time. It is common among victims of trauma and individuals that work directly with victims of trauma. It was first diagnosed in nurses in the 1950s. Compassion fatigue does not require decision making – frustrated or otherwise – to occur.

We also heard from other people who aren’t health professionals yet encounter the problem of moral distress too.

Rev. Cal Wake, Coordinating Chaplain of the Ottawa-Carleton Detention Centre, sent us this: “I listened to your program on moral distress with great interest. As a prison chaplain, I see this all the time in the nurses who work on the front lines. They struggle in a harsh environment and my hat's off to them for how they cope. My question: Could you suggest any websites or articles that would help me as a chaplain understand more and address this with the health care professionals I care about?”

Rev. Wake, I suggest you begin by connecting with individuals who have made the study of moral distress a particular interest of theirs’. The College & Association of Registered Nurses of Alberta convened a conference last year on moral distress.

And, here is a decent article on moral distress.

Aaron Smith, a listener from Northern Vermont, suggested that health professionals would feel less moral distress if they took a moment to put themselves in the position of the patient. He writes: “Remind health professionals of the "Golden Rule". Ask, "How would they feel or what would "they" want done in the situation, were they the patient". This as helped everyone involved, patients and staff, in my many hospital experiences. May sound like common sense, but you'd be surprised how many times folks forget these things."

And finally, Simon Qiggaittuq sent this wonderful post that was directed specifically to me.

“Your opening statement of tubing was a very excellent introduction, and coming from a blind individual my reaction. You were mentioning on the last day you had to learn how to do "tubing," and you also mentioned that you had trouble doing it. Then your instructor pushed you aside and did it in a matter of 20 seconds. Which tells me, he or she wasn't watching you carefully enough to observe to watch out for: where you were having trouble inserting the tube, and therefore wasn't able to tell you where you were having your problems inserting the tube. The instructor is supposed to be a teacher, coach, trainer, and most of all observers, to see where you're having trouble with anything. Your instructor sounded like the Wayne Gretzky of the medical field, and not all the hockey players of the game can be Gretzky. And that also means in any work related job, we need to be efficient.”

Simon, thank you for that observation. I wish I’d received it long ago, when I found the experience of learning to intubate a patient so frustrating and so traumatic.

And, thanks to all of you for sending in your comments and questions.


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On Monday morning, November 2, 2009, I listened intently to your Moral Distress podcast on CBC radio. I was sitting in Stephanie Buckingham’s class on Influencing Change in Nursing. Rob McGibbon, a student who spoke on the show was sitting near by. While I was proud of the Vancouver Island University (VIU) students for speaking up and raising awareness about the moral distress nurses face every day, I could not help but think that it painted a grim picture of the nursing image – one that I do not agree with. I felt that the examples somewhat negatively portrayed a student’s ability to deal with morally distressing situations.
The students in my fourth year nursing class are between the ages of 22 to 45 years of age and they are not immature 20 somethings. They do have life experience, many have children, some have prior degrees, many have left other careers for nursing, many volunteer abroad or closer to home for their child’s hockey team. The podcast was right in citing that students present a fresh perspective.

Through out our entire nursing education we have learned methods and steps to take when resolving an ethical dilemma or a situation that was morally distressing. I can confidently report that my fellow students can share numerous anecdotal stories of inspiration- where they coped and solved morally distressing situations every day. To me, coping with or preventing moral distress or an ethical dilemma is as important to the foundation of nursing as starting an IV or performing a dressing change. Further, nurses are leaders, policy makers, politicians and activists, not just people who are plagued only with worries about an ativan order or pain management. Even as students, we work on multi-disciplinary teams to create a care plan or motivate a team of health professionals to work in conditions often beset with limited resources.

In our Biomedical Ethics class last year with Dr. Pepper-Smith and in our Relational Practice class with Julie Bishop, we were asked to share just one of our many morally distressing situations and then outline the steps we took to resolve the issue.

The following is my story. I hope it provides evidence that nursing students are taught to cope efficiently with morally distressing situations and that it sheds positive light on the nursing image. Canadians can feel confident that nursing students are well prepared for their role in the medical system.

I was in second year. I started my practicum on paediatrics that morning and had no idea what to expect. I clutched my care plan, medication cards, and a cheat sheet on nasogastric (NG) tube feedings. My patient was a five month old infant who had been born prematurely, with his twin brother, at 24 weeks old. The other twin had been discharged home, a 45 minute drive away. Up until this point, the twin’s life on earth had consisted of the Children’s Hospital and the neonatal unit, attached to endless monitors and tubes. It was a mother and father’s worst nightmare. At the nursing station in morning report, the Registered Nurse (RN) labelled the mother as “single, dishevelled looking, demanding, and condescending,” and my patient as “a lot of work.” The mother phoned to say that she was to arrive that morning to meet with the paediatrician. She was also commuting back and forth to breast feed both of her infants.

The paediatrician met with me while I was taking the infant’s vitals. I was directed to closely keep track of his in and out record, boil his soother to decrease his oral yeast infection, keep his head raised and also keep him in the crib rather than his car seat. The RN, also present, advised me on the infant’s gavage feeds, every two hours, his medications, how to soothe his crying, diaper changing, and weighing him. I passed on the message to the paediatrician that the infant’s mother was coming at 0930 to meet with her. The paediatrician then warned me “to watch out because the mother was very demanding and to remove my student pin because she preyed on young inexperienced nurses.”

The mother came in shortly afterwards, crying and carrying the other twin. She abruptly started to pack up all of the infant’s supplies. I stood in the corner with my classmate from VIU, trying to do the gavage feed as the mother cried, yelled, and swore that no one cared, no one knew what they were doing, and she was taking her infant home. Apparently, the mother had met the paediatrician in the hallway where she told the mother that she did not have time to meet with her that morning. While my classmate held the infant, I went to get help from the RN. Nursing students are taught to never feel alone and that “two minds are better than one.” While waiting for the RN, I was impressed with my classmates and I’s open communication with the mother. As we calmly listened to the mother, I could almost hear Leigh Blainey, our mental health instructor’s guiding words, “just listen.”

Soon the RN arrived, the floor leader arrived, and the social worker arrived. Not exactly what nursing students are taught to expect, but we are taught to be prepared for the unexpected. A stressful confrontation in the small hospital room erupted with my classmate and I shaking in the corner, feeding the infant. After some interesting conflict management, everyone left and I was asked to meet with the nurse leader on the floor. From there, I was told not to go into the infant’s room, to let the mom “screw up” and realize that she was not competent enough to have both infants at home. I was advised that if she did try to take the infant home, the social worker was ready to have the infant removed from the mother’s custody.

Everything happened so quickly. Within a blink of an eye, I was left still holding my care plan and NG tube cheat sheet, millions of thoughts racing through my head. It was a typical nursing student situation. What had me so emotionally torn against just listening to the nurse leader, the RN, and the pediatrician? I had faced many moral dilemmas in my life outside of nursing, but each one is unique and each one can tear apart anyone’s heart.

In Biomedical ethics, Dr. Pepper-Smith taught nursing students steps involved in making decisions in morally distressing situations.

First, we are taught to think for ourselves. We gather information such as in the health records. What happened in the last five months? What was the culture on the paediatric floor? The mother was capable of making decisions for her twins – She had the ability to understand and communicate relevant information, ability to think and choose with independence, ability to assess the potential for benefits, risks or harms as well as to consider the consequences and multiple options, and she had values. We are taught to avoid appeals to the authority and consider using the existing capacities such as the social worker. We are taught to treat people with impartiality where like people in like circumstances are treated in a like manner. Each patient’s interests are equally important and from a moral point of view, there are no privileged patients, and everyone’s life has the same value. This guides nursing students not to treat one person differently than another when there is no good reason to do so.

Second, we are taught to examine our feelings and those of others, and to listen without judgement.

Third, we are taught to keep still and avoid subjective certainty or only paying attention to evidence that confirms what we want to hear. We are taught to avoid false moral dilemmas and that they arise when there seems to be only 2 options presented, ie. the mother keeps the infant or she does not. The mother had many options that day. Dialogue is vital to decreasing moral distress.

Fourth, we are taught to stand in relation, think outside the box and not be bound to iron laws simply because it is familiar. We need to consider uniqueness, mutuality, and trust.

Lastly, while remaining confidential, we are taught to debrief and seek guidance from instructors and colleagues. Similarly, according to the College of Registered Nurses of British Columbia (CRNBC) Professional Standards, RN’s in the have to ccommunicate, collaborate and consult with nurses and other members of the health care team about the provision of health care services.

Regardless, we are also taught that what happens in theory is often different than what happens in the “real world.” Sitting in that room, holding the infant, all I could think of was the quote from my third year Health Psychology professor, Dr. Wayne Mitic, “Health is the crown that healthy people wear on their heads, but only unhealthy people may see.” (Mitic, 2005, lecture). We are taught that our own personal phenomenon of concern can signal or attune us to what is important and meaningful. Nursing students are taught to sit in patient’s shoes. I knew she was exhausted, both emotionally and physically. I could feel her heart being ripped apart. She was probably feeling alone, scared, and frightened. Later I found out that the mother was a long term care aid at a facility I worked at. Later I found out that she was actually viewed as a wonderful, caring person. Later, I found this out because her coworkers attended the funeral for one of the twins that did not make it. Later, I knew that I had done the right thing by disobeying the nurse leader, the RN, and the paediatrician. Just like we are taught in school and like my fellow classmates, I faced the morally distressing situation head on.

Nursing students are taught to follow the heart’s instincts to shape their own personal art of nursing, and to guide them through morally distressing situations. I tiptoed back into the hospital room, still wearing my student pin, ironically pinned over my heart. What had I been thinking by clearly not following directions? Doane and Varcoe (2005) discuss how nurse’s need to tread lightly as they enter a relationship because they never know the impact they might have on a family’s relational flow. I simply went by my gut feeling, using every ounce of emotional intelligence I had that morning, deciding that I was thinking clearly because I had enough sleep the night before, I had a healthy breakfast, and knowing that I had a strong cup of coffee in my stomach.

Even though I empathized with her pain, no one, not even me, could ever understand exactly what she was going through because I could not see all of her culture, history, or family memories. I knew how I had felt in the last few months, so ill. It was not my role to just walk away. My classmate and I brought the mother her infant’s formula, her infant’s medications, a cup of tea, and a warm blanket. By bringing her these supplies, we empowered her to let her look after her own infant. Then I sat and listened. Nursing students are taught to value listening. We are taught to use the art of nursing, or “nursing’s own science” (Doane & Varcoe, 2005, p 45), to guide a relationship: to know that every single family is unique and can not be moulded into a theory or a care plan (the one that I had spent hours making the night before). I love nursing because I choose my actions based on how my heart feels. I was lucky that morning; some morally distressing situations do not have happy endings. But, nursing students are taught “nothing ventured, nothing gained.” She opened up and beneath my critical lens, I saw much more underneath the surface façade of angry mother.

Nursing students are taught not to make assumptions, but rather, to remain mindful and take in “the big picture.” Assumptions can lead to moral distress. Our instructors teach us to speak up even though we have been raised in a Canadian culture where students are traditionally taught to bow down to superiors. Initially, I wrongly assumed that the RN would be difficult to talk to since she had labelled the mother with derogatory stereotypes. However, that morning, despite my unbecoming second year student pin, I was able to keep in mind that each person involved had “qualitatively different concerns and priorities” (Doane & Varco, 2005, p 59). Surprisingly, when I approached the RN afterwards, I stayed completely calm, curious, and neutral, and so did she. I greatly valued that the RN took the time for a student that day. I compare my relational way of being that day to Doane and Varcoe’s (2005) discussion on complexity theory. I utilized the same interview system I had learned with Leigh Blaney in mental health and could literally feel Leigh’s calming positive protons working. Quantum matter was maintaining my mindfulness.

I asked the RN how she was feeling. Surprisingly, she opened up and reported that she was feeling worried, overwhelmed, and scared. The previous day she reported feeling emotionally abused by the mother. Now she said that she was literally shaking and had not wanted to come to work that morning. She discussed how the team did not really want the mother to “screw up,” it was just that they wanted her to have some time to settle down. Also, the team cared about the infant because they were the ones that stayed up at night feeding him every two hours. They were acting as advocates for the patient, not the mother. For example, in the Canadian Nurse’s Association (CNA) Code of Ethics, nurse’s advocate for persons in their care if they believe that the health of those persons is being compromised by factors beyond their control, including the decision making of others.

The RN and I discussed everything we had learned in mental health, such as therapeutic interviewing. The RN felt that repeatedly, due to numerous factors such as time constraints, she was “… positioned as the legitimate questioner, and the mother [was]…meant to follow [her lead] (Doane & Varcoe, 2005, p 47).” We both realized that this was not client centered care and the mother had no internal locus of control. It should have been that the mother was just of much a patient as her children were. In order for the relationship with the mother to improve, the health care team needed to focus on the mother’s capacities and potential. This meant that as a health care team, we needed to continue to use a critical lens to see beneath the surface façade, dispose of our assumptions, listen to our hearts, and use the art of nursing to help build on the patient’s and the team’s strengths.

Nursing students are taught to use a critical lens in a morally distressing situation. Just like we are taught in school, the RN and I used a critical lens to understand upstream causal factors of the escalating situation and to determine how to build on strengths, ultimately decreasing moral distress. According to Doanne and Varcoe (2005), “nurse’s need an ecocentric view…where everything is understood to be connected to everything else….Nurse’s attend not just to individuals and families-in-context, but to individuals and families as situated in, shaped by, and continuous with their social, economic, historical, political, and physical contexts” (p 50). There were many contributing factors leading up to morally distressing situation. For example, we discussed how the infant was often crying. What about a mobile? Volunteers? Teddy bears? Could the mother stay close to the hospital? Where was funding? The infant needed feeding or medications or vitals taken every hour. We decided that there should be a schedule posted in the infant’s room. There was no time for breaks. The staff had a new rotation where one nurse could be with the same family for weeks at a time. The RN thought that the nurse’s could cover each other during breaks but then she was worried that the other nurse would not know the infant’s medical history. Because of the incident, the RN suggested changing the schedule to the nurse leader. The nurse leader had been on vacation. Some of the nurse’s needed more education on infant care, such as the latest evidence based research on properly treating the oral yeast infection. I put information on gavage feeding and oral yeast infection treatments in the Medication Administration Record (MAR). The social worker was overworked. If enough nurses raise their voice advocating for the importance of social work, policy can change. There was no care plan, no discharge planning, no case manager, no communication book, and sadly, similar situations had occurred through out the last 5 months. Nursing students are taught to raise their voice and let others know when change needs to occur.

However, rather than continuing to place blame or finding problems in the health care system, similarly to finding strengths of the mother, nursing students are taught to focus on the capacity and potential of the health care team. We cannot fix the health care problems like a machine, but we can build on strengths by looking at the environment, contexts, situations, and processes surrounding the health care system (Doane & Varcoe, 2005). I wrongly assumed that it was out of my student scope to advocate for change on the paediatric floor. But…If a butterfly could create a tornado, a second year student could find strength and create change on a paediatric floor (Doane & Varcoe, 2005).

I have written this because I feel passionate about the image of nursing and our ability to influence change. My message to Canadian nurses from a student: Nursing can be morally distressing, but, please, just like we are taught in school, keep the flame burning that got you started as a nurse in the first place, take risks, do not be afraid to make mistakes, take a stand for what you believe in, and have faith in future nurses. Those we care for will only benefit.

Thank you for your excellent topics on your show…keep them coming

-Rebecca Manson,BSc Biology/Psychology from the University of Victoria, LPN and BSN Year 4 from Vancouver Island University

References:

Doan Hartrick, G., Varcoe, C. (2005). Family Nursing as relational inquiry: Developing health-promoting practice. Philadelphia: Lippincott Williams & Wilkins.
Mitic, W. (2005). University of Victoria. Health Psychology Lecture.

Rebecca Manson, November 18, 2009 4:17 PM

I'm so impressed by this young nurse's comment, by the scope of a Canadian nurse's education and her character and obvious gift for her chosen profession.

I wonder if nurses from other countries, who nurse here, have as wonderful and patient-centred an education?

Recently I spent six days in hospital cared for by a bewildering rotation of nurses, only two of whom were RN, mother-tongue English speakers. (If you don't think that latter is an important point, then you need to spend time medicated and sedated, without your eye-glasses, and have a heavily-accented foreign-trained night nurse demand to know, at 2 a.m. in near dark, if "this is your needle".

The majority of the nurses whose name-plate I saw were LPNs and Nursing Aids (or Assistants). They wouldn't have anything like Rebecca's education.

Only two older Canadian trained RNs, and a superbly efficient and nurturing Mexican RN nursed and behaved as though they had a similar education and dedication to their profession, and particularly, to understanding what their role is.

How do I know this? Over a period of days, I watched several of these nurses verbally and emotionally abuse and treat with thinly veiled contempt a patient dying of a disease that is tantamount, today, to having Leprosy. This was a person who was not only sedated much of the time, but entirely vulnerable, and dependent, and calm and respectful to them.

So while Rebecca (and her classmates, I assume) has a top notch education and seems admirably suited to become an amazing nurse, I wonder, how many of the patients in our average Canadian hospital will see a nurse with anything near her education, understanding of a patient's needs, and her motivation?

riv, November 18, 2009 7:50 PM

After listening to your show re: "Moral Distress", I have been inspired to act on an issue that has troubled me during my 4 years nursing in long term care: violence experienced by special care aides, personal support workers, nurses' aides (they have many names depending on facility and province).

They are those that have the most contact with residents/patients, the least paid & have the least influence on care decisions. "Team nursing" is the common approach in long term care. RN's usually work as manager delegates (charge nurses), LPN/RPN's administer medications & treatments & care aides provide direct patient care: bathing, feeding, dressing, transferring, etc. Therefore, not surprisingly, care aides are the individuals usually in closest proximity to the residents, so are most likely to experience violence.

The actions I have taken thus far are societal research, research regarding procedures for dealing with violence in facility, posting pertinent results of my research on my unit, talking to staff that have experienced violence to inform them of my findings and offering to assist them with necessary action.

I will also be signing up to be a union rep. I used to work in Ontario. Unfortunately, I didn't conduct much research in this area then. Although, filing a complaint with the Ministry of Health came up a few times in conversation with colleagues. However, dealing with the Ministry of Health is very daunting. It is unlikely that staff will make a complaint to them.

I currently work in Saskatchewan. I have discovered what may prove to be a very useful path. A Labour Relations Consultant! In the Abuse/Harassment Policy in my region, victims are encouraged to attempt to resolve issues with the respondent (offender) first. However, the policy does "recognize" persons may find this confrontational and are uncomfortable with that approach. Instead, he/she may opt to advance to the next step. Four steps in, one discovers the use of a Labour Relations Consultant. Fax off a 'Free of Harassment Form' and voila! A confidential investigation begins. I have yet to see this in action but I have a good feeling it is only a matter of time.

No one I talked to heard of this option and I could not find the forms on the unit. It took a little more research to uncover one. Grieving with union support is always an option, but any one who has taken this route, also knows that it is usually extremely confrontational. I would hope that readers would suggest other actions that might or have been effective.

The prevalence of actual physical violence uncovered is shocking. One of the more thorough studies I have found stated 89.7% of care aides have experienced violence in their careers. 43% of those that have experienced violence, experience it virtually every day! This does not include threats of violence, unwanted sexual attention, racist comments, etc. (Banerjee, Albert et al. "'Out of Control': Violence Against Personal Support Workers in Long-term care"; Collaborative Study by York & Carleton Universities, 2008) The conclusion of this study was "working in [Canadian] long-term care is dangerous". Moreover, that violence is NOT inherent in long-term care as evidenced by the far lower rates of violence in Nordic countries. The study found an overwhelming connection to poor working conditions and work relations.

After confirming that my experiences are not exceptional, but likely systematic of Canadian health care I began to research what positive action is available to staff. There are many beautiful, full-color posters with slogans such as "Patients First, Safety Always", but not a great deal of information of what to do if one has experienced violence. In orientation, we are told to consult our immediate supervisor(s) or unit managers. But to be honest, it takes very little time on a long term care unit to experience first hand or be informed of the negative experiences other staff have had approaching management or even physicians regarding "care concerns" that are behavioural in nature. Suspect someone has a urinary tract infection (UTI's)-- no problem. For "behaviours" a urine test is usually the extent of intervention that is taken. UTI's, especially in the older population, can cause confusion, sudden balance issues, loss of appetite, etc. Managers are rarely on the unit. They are either in their office or at a "committee meeting". There is a huge disconnect between those performing the care and those making policy decisions regarding care.

My first year as a nurse, working in long term care, a resident was assaulting staff & other residents, as well as sexually molesting multiple female patients. This is an environment where room doors do not have locks & many residents are completely dependent and therefore, defenseless. One of his victims was blind, nearly deaf & bedridden. There were no security guards and on evening & night shifts there are no management. Not to mention that the only intervention sanctioned & provided to us via "in services" is make sure to talk in a soft, pleasant tone of voice and if that does not work, return later when he (usually a male) may be in a better mood.

We did as we were told: reported to management, documented in patient notes and completed incident reports. We also initiated our 'own' intervention. Although stretched to the limit with staff & often short staffed, we assigned one aide to follow him around. This was grossly insufficient. To be honest what is one person, not trained to intervene in a violent situation going to do if the 6'3" 230 lbs, independent male insists on charging into some little old lady's room. But we had to do something. Finally, after months of documenting & informing management of his conduct, when the administrator of the building was present in the facility, he was attempting to get into residents' rooms. A few of us got in his way, so he threatened us & we asked for the administrator to attend. She did. He said to her, "I fucking kill you". He was arrested & in an inpatient unit for violent, psychiatric patients within 1/4 of an hour. I learned a lesson that day, get a manager in harms way and things happen!! She wasn't even punched or spit at.

The above is not an isolated case; it is merely the first I had experienced. It's very easy to believe that something is "part of the job" when one is exposed to it over and over. It is not and should not be part of the job in long term care. Maybe if I accepted a job on an inpatient, psych ward for violent offenders, then I would not have good reason to comment. But I am sure that unit is better served. When I went to school, violence was barely mentioned. It is unfair for an individual who devoted 1 yr, 2 yrs & 4 yrs of their life and financial resources to not be informed of something that is so prevalent and significant to one's personal safety. Should they just be expected to "find another job"? I used to want to be a police officer, even went to university with that in mind. But students of policing or corrections are prepared for violence: subduing or restraining persons with limited force, they have many, many tools in addition to their training: handcuffs, batons, pepper spray, guns, etc. & they have the autonomy & discretion to use them as he/she deems necessary. Nursing staff have little to no training regarding violent behaviour intervention & usually have to wait for a "doctor's order" before he/she can perform most interventions, even to preserve an individual's personal safety. Many places I worked, doctors only had to be on-site once every 2 weeks. Their sense of urgency is lot less than the care aide that is being assaulted.

Personally, I will likely leave long term care shortly. Interesting that if someone, demented or not, walked over to their neighbour's home and punched the neighbour or assaulted a home care aide, the plumber, meter reader technician, etc. the authorities would respond, but why the moment a person enters through "the doors" of a long term care facility the criminal justice system ceases to apply? Home care seems safer.... hmmm.. & it pays the same in Sask, unlike Ont.....

Randy dos Santos, November 24, 2009 3:52 PM

In response to Cathy Ringham's question above, I want to offer a slightly different perspective than the one that was offered by WCBA to her question.

Compassion fatigue can indeed result from moral distress. Compassion fatigue (CF) and secondary traumatic stress also known at Vicarious Trauma (VT) are companion problems but are not the same: CF refers to a gradual emotional and physical exhaustion that helpers develop over time. It is often caused by a large volume of work, absence of proper referral resources, witnessing pain and suffering daily without always being able to help and many other related factors.

One can see how moral distress would fit into this picture and lead to an atmosphere of discouragement and hopelessness as well as eventually impact patient care. VT is related to secondary traumatic exposure: when we bear witness to difficult stories, those stories can eventually contaminate our own world view and lead to symptoms that are similar to PTSD.

So, a helper could develop CF without having VT and vice versa. Moral distress fits squarely into the contributing factors of CF.

I would invite you to read Charles Figley's work "Treating Compassion Fatigue" (2002).

For more information and resources on both CF and VT, I invite you to visit my website: www.compassionfatigue.ca where there is ample reading material on this topic.

Best regards,

Françoise Mathieu, M.Ed., CCC. Compassion Fatigue Specialist.

Françoise Mathieu, December 3, 2009 8:03 AM
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