Moral Distress: This Week on WCBA
Have you ever had the sick feeling you wanted to make the right decision ethically, but couldn't because your boss or the system in which you work wouldn't let you? That's called moral distress, and it's something people like me feel all the time.
Moral distress is especially common among people in health care who tend to take orders rather than give them. Studies show as many as 80% of nurses experience moral distress at work. It's one of the main reasons why nurses quit the profession.
Last winter, I had the pleasure of traveling to Nanaimo, BC, where my host was Stephanie Buckingham, a professor of Nursing at Vancouver Island University. She asked me to do a q and a with her students. After the q and a, I sat down with Stephanie and several of her students for a little q and a of my own.
What transpired was an extraordinary discussion of moral distress that affects nurses on a daily basis. You'll hear about the kinds of issues that adversely affect the care you receive, and the struggle of young nurses to reconcile that with their nursing ethics.
I wanted to extend a special note of thanks to Stephanie. She has provided a safe, inviting place where students can reflect upon the work they do and the choices their jobs force them to make.
Catch WCBA Saturday November 14 at 10 am (1030 NT) with re-broadcast on Monday November 16 at 1130 am (330 pm NT) on CBC Radio One.
Update: you can also download the podcast.
Categories: Past Episodes
Previous Comments (9)
you asked today (nov.14/09) for
one suggestion: Mine is: COMMUNICATING. (esp.between doctors and nurses in hospitals, like KGH-university hospital.
My husband was in hospital two years ago. A mistake was made and he ended up with pancreatitis and nearly died. I was told constantly "about the team", but was not told "who" the team was. It was very frustrated and when the patien advocate asked me also for ONE word to describe what was lacking I said: COMMUNICATION. From doctor to nurses to patient/caregiver like myself (family). Thanks. Joyce Groot
I hope that I never have to encounter the group of nursing students featured on your show today...not to mention their Instuctor or the various Unit Managers on whose Units they worked.
I think that a huge part of the "problem" here, is that newly minted Grads from any discipline have not been taught to "critically think".
This would also seem to apply to the "Media Doctors", who seem to "hide under the cloak" of the CBC!!!
We, as Health Care Professionals, all have the "tools"...to circumvent a lot of the problems encountered by our "morally challenged" students...read any of Margaret Sommerville's books!!!!
The crucial problem here is that....at no point, during your interviews with the various Nursing Students, was the "patient's perspective" introduced.
If a "medically trained" person loses sight of the above, all is lost!!
Mr." Black Art" is surely being Black....this was a poorly presented ,,,for want of a better term..."sound bite"!!
I suggest that you interview some Nursing Students who have been a little better educated!!
Hoping that the CBC becomes a little more sophisticated with it's "Medical Presenters"..WW
I agree that moral distress is an everyday occurrence for all nurses, not only students. The cause, in my experience is the competing imperatives of human, physical and time resources, none of which is in the nurses' authority to affect. Their numbers are authorized by the management, the supplies and equipment by the budget, the interventions, to some degree, by the doctors' orders,and time is never enough. The nurses have all the responsibility with very little authority. They are accountable, primarlly, to patients but must answer to their employers, patients' families and follow doctors' orders. Students often have wonderful suggestions, which are sometimes taken, but often the problem is not the suggestion but the availablity of time and resources to carry it out. Students sometimes forget that each Professional Nurse is responsible for many patients, some of whom might be deprived of appropriate care if the one patient receives what the student believes her/his patient deserves.Joan Richard, November 14, 2009 1:46 PM
This week you asked people to write in regarding some things that they wish were different in healthcare.
I have Type 1 diabetes and live in Manitoba. I would like an experienced health care professional not necessarily a physician who I could telphone or email and who would give me some tips for LIVING with the disease.Something more than just the introductory information. Things like adjusting insulin for exercise, new products on the market etc. as well as just some encouragement.
The cost of treating patients with complications from diabetes is expensive and I think a service such as this would be cost effective in the long run.Margaret McCallum , November 14, 2009 4:54 PM
I listened with great interest to your program this AM on Ethical/Moral distress. I graduated from Respiratory Therapy in the early 70's. I practiced in various hospitals and settings throughout the world until 1999. At that time I decided to leave acute care and return to school. My decision came after a confrontation with a physician about removing a patient from a ventilator. The patient had been airlifted out of central BC and was quite combative. During the flight the patient was given muscle relaxants and several other narcotics so we could adequately manage the airway until we were in a more controlled environment. Upon arriving at the hospital the receiving physician decided to remove the patient from life support. As the patient's temperature was below 33degrees I strongly objected and would not place the patient on any other form of therapy. I subsequently ended up contacting the director of the Intensive Care voicing my strong objections. The director came into the ICU and assumed care of the patient. The patient's temp was brought up to normal and after several days succumbed to the disease process. Upon further discussion with the ICU Director I was reminded that my assessment of the situation was correct BUT that in the end I did not have an FRCS behind my name.. This event stands out for me among many situations that I witnesssed over thousands of shifts in 25+ years of work in Acute Care as a Respiratory Therapist. Our training does not prepare us for the ethical and moral dilemmas which we will face nor are we always supported when we draw attention to the inconvenient truth within the system.
I left acute care and am now a computer analyst assisting health care providers at the end of the telelphone. I am still able to utilize my clinical skills at times but I am removed for the most part from the increasing day to day struggles that represent working within todays difficult health care environment
You asked for what I want from my doctors. I was a controlled BiPolar for years until menopause caused intense emotional, physical and cognitive disruption. Every month my doctors say "it's slow in coming, but you'll get better". It's been 5 years and a dozen treatments. I'd rather hear some advice on how I can just cope with today.Gabrielle Duval, November 16, 2009 12:32 PM
I very much enjoyed this particular program. I try to listen to your program as I think it is very good,
I am someone who for whatever reasons is a frequent user of the medical care system with multiple medical complicated problems as i hit age 64. One thing just gets piled onto another over a lifetime of surgeries and medications.
I have been fortunate to have had an excellant GP since 1971 and the same rheumatologist since 1986 who follows me closly. I think I lucked out to get that high level of care. Referrals to other specialists are consistently good and helpful, which is a reflection of my GP reputation.
March 2008 I had surgery hemiclolectomy in 2008. This was the first time I was in a hospital where nursing students were being trained on a surgical unit. For once actually i was overwhelmed with the amount of time and care I received. Some students were very anxious when their teacher was watching them do a procedure like a changing a dressing (I had a drainage tube where my large bowel was removed) and as a patient it was hard not to react and tell the student to relax. I don't have a problem with students as they do have to learn and I like to give them feedback. One student talked to himself out loud the steps he had to take to maintain the sterile field etc and was told to do that silently that a patient didn't need to hear the details.
I don't think anyone faced any moral delinmas' dealing with me - I was in for 10 days since I was quite lucid and able to articulate my needs. The one thing that drove me nuts was this pain scale of 1 to 10 and being asked constantly what number I was. I have chronic pain at a normally high levels which requires alot of meds to keep things to a dull roar so I would have to explain to the student that with me 5 to 8 is my normal so the number had to be expanded to fit a person like me.
One thing I have found is many medical people don't understand chronic pain. I have a finely tuned routine of taking several medications for pain so my body is used to that schedule. When you throw in a surgery (my hospitalizations seem to all be related to surgeries about 17) then things get out of whack and my body goes nuts. It is not understood that that med schedule has to be maintained and pain meds, antibiotics etc added on are for the surgical situation.
I was lucky this last time which was an emergency situation (my bowel twisted in 3 places and gangrene was found) as the surgeon, the internist and the pharmacists listened to me and understood. I had a tube done my nose to pump stuff out and 2 of my regular meds could not be given IV so we tried having me take by mouth and that was fine . We just ignored the protocal for nothing by mouth which I appreciated. When I had been given a regular pain med for me ie for nerve pain then I would have a nurse for pain med for the surgical and the answer would be "but we just gave you something for pain". I talked to the surgeon, internist and pharmacists and asked them to explain to the nursing staff that there was a difference, that I knew my body and if I asked for a nacrotic i needed it. I think it is important that a patient be listened to and an attempt made to try and understand what they were saying. In this situation this listening happened and I was understood and that got passed onto the nursing staff. All 3 regularly checked with me that I was happy with my care regarding my medications.
My only difficulty came with an OT who arrived without notice wanting me to get out of bed and walk. It was just the wrong time and while I understood why I needed to walk and was walking, that time was not a ggod time. I was pressured to obey but I just insisted that I knew my body and now was not the time my body was going to be able to handle a walk without major pain. The OT never came back and she probably thought whatever??? but I would not be pressured. I have to say experience has taught me to speak up as a patient and know I can say no also.
Thank you again for the program. My idea is to talk about the issues surrounding listening to the patient - sometimes we understand our bodies and how it feels better than the "professionals".
In some ways it is too bad that they used the lead in about tubing the patient, that was all about the doc (white night) riding to the rescue. I am also not entirely sure which of them had the moral distress, the doc who was trying to learn, or the anesthetist who was trying to teach him how to do it and having to balance the value of the teaching moment with the risk to the patient.
Now we switch to your students who introduce themselves as first or fourth year students and no background on the experience they have, so a critic looks at it and says “What can a first year know about….”
That aside the issue is about the individual nurses moral (ethical) reaction to work. Not everyone will have an experience of saving (or losing) a life in an ER – and that has lots of appeal given the TV shows that have been around. Your nurses talked about real, believable everyday stuff and the impact it had on them. Anyone who failed to grasp the moral distress issue in the cases of how seniors were being treated (at least I am assuming the fellow in the sling relieving himself was a senior) isn’t worth your time or concern … maybe they will understand if they are unfortunate enough to get the quality of care they deserve.
Your comments about age bringing us the maturity, wisdom and security to speak out was right on the mark. If the phenomenon accounts for only 10% of the turnover in the profession, it needs to be addressed - I suspect the 10% is a very conservative number.
As I have been crafting this reply, it has occurred to me that there are parallels in my business world. Not everyone who works in finance will be a forensic auditor working on a popularized example like Enron; buy what about the young person starting their career who spots that the boss is cheating on his expense account. Oh my, what to do!! How shall they deal with the Moral Distress?
I am guessing that it does not matter if you are a nurse or an accounting type; if you are mired and lost in the moral distress and have no supports, you are bound for the mental health clinic.Stew Churlish, November 20, 2009 4:04 PM
Last week I listened with interest to the discussion with the nursing students and their ethical dilemmas. As I am a clinical facilitator in year three of a four year nursing program, I can understand where and how these situations happen and I assure you that they happen on a daily basis. Most students come into the program in their mid to late twenties and older so they have a decent amount of life experiences and usually already have pretty good people skills.
They are not graduating from the nursing program with critical thinking skills intact, but are developing those skills. I see evidence of this at the end of year three when they start to question and look for rationale to support decisions that are made on behalf of their patients. This is knowledge seeking behavior and the students need to be delivering competent and safe nursing care in an informed way. This is the information and knowledge that they communicate to patients and their families. To not question and ask for rationale to further understand the plan of care and to deliver care (follow orders blindly) without a clear understanding of what outcomes or goals we are trying to reach for a patient would be negligent under the standards of best practice set out by the Canadian Nurses Act and the provincial regulatory body. Not to mention that it is just not morally right. In today's world we focus on teamwork. That is many health care disciplines working together to achieve the desired outcomes for their patients. Whether that be a focus on wellness and recovery or comfort and dignity in dying. Contrary to one nurse's view that nurses are only following doctor's orders and that they have no voice in any decision-making and as such, she is basically washing her hands of any accountability with regards to negative patient outcomes as it was never clearly her fault: To this nurse, I must ask "what century are you living and working in?" We no longer practice this way, (and many of us never have) and to not advocate for your patient and ask questions to ensure you are knowledgeable in your health care delivery is shameful and you are clearly not in the profession for the right reasons. Team discussions are welcomed and occur many times over in any given shift. To be part of a cohesive health care team is paramount to the best health care delivery approach with ultimately better outcomes for the patients. I see this every day in the large tertiary care hospital and I am proud to be a part of it. I am equally honored to have a part in helping to teach and mentor soon to be graduate nurses and newly graduated nurses. This keeps me focused on the newest and best ways of learning and delivering nursing care. In fact, what a lot of the more experienced nurses say is that having students in their work area and helping them learn also helps them stay focused and makes them think about some of the decisions we experienced nurses make to save time and money but may not necessarily be in the best interests of the patients, nor ethically right. I also work at several hospitals in acute care areas and I am please to say that in virtually every area I go, I see former students from years past working and in turn mentoring others. And so goes the continuum of learning. There will always be people who take short cuts, only do what they are told, in any profession. My small part in this all is to try to facilitate the critical and ethical thinking and safe nursing care practice in the up and coming nursing professionals in hopes of achieving a more forward thinking group of health care professionals. Over the last twenty-five years, this is ultimately my best contribution to the nursing profession.
Kudos to those nursing students who shared their thoughts with us on your show! They need to know that they are not alone in this.gayle anderson-harrow, November 23, 2009 11:31 AM