PSYCHOLOGY
Managing ethical distress in community nursing practice Aysha Mendes
Freelance Journalist, specialising in health, psychology and nursing
I
t has been said that nurses are personally accountable for the actions they take or fail to take in the care of their patients, and that they should always be able to justify their decisions (Nursing and Midwifery Council (NMC), 2008). However, despite the ideal view of nursing that most newly qualified nurses enter the profession with, the complexity of the decisions they are faced with, together with the realities of a resource-strapped NHS, and the varying professional opinions and approaches within a team, make it increasingly difficult to achieve this ideal in every situation.
What is ethical distress? Ethical or moral distress happens when a nurse’s values are compromised as a result of not taking what he or she feels is the right course of action (McNamee and Sourani, 2009). This can happen for different reasons, which may include fear or circumstances beyond their control (McNamee and Sourani, 2009). Ethical distress, as the term implies, is emotionally distressing during, and in the immediate aftermath of, the decision made. However, if left unresolved, it is also associated with burnout in the long term, which interestingly and alarmingly has been linked to a lack of compassionate care delivery (Canadian Nurses Association (CNA), 2003; Vahey et al, 2004). However, nurses play a unique and valuable role within the multidisciplinary team and have the opportunity to contribute actively to collaborative and ethical decision-making (McLeod, 2014).The position of community nurses who are usually alone while visiting patients and their families, and faced with a myriad of decisions, is unique, and the importance of this role cannot be underestimated.
The causes of ethical distress Ethical distress and unresolved moral distress, sometimes referred to as moral residue (CNA, 2003), can occur in any area of nursing practice. However, there are particular areas in which these arise more frequently, and community nurses are especially impacted. Long-term conditions and end-of-life care are areas in which these issues are particularly pertinent (Baldwin, 2010). In order to pinpoint specific sources of ethical distress in nursing practice, Corley (2002) identified the following:
514
ww Harm to patients ww Treatment of patients as objects ww Policy constraints ww Medical prolongation of dying without informed choice ww Definition of brain death ww Inadequate staffing ww Effects of cost containment Decisions regarding whether to continue, withhold or withdraw life-prolonging treatment when a patient’s prognosis is poor is one of the most common sources of ethical distress in nursing (McLeod, 2014). Other common sources include a lack of staff, resources and organisational support, resulting in a lack of time to spend with patients. Also, care provision which may not be considered harmful, can fall below the standards of many individual nurses. When considering whether or not to ‘whistleblow’, nurses may fear falling out of favour with colleagues to improve the standard of care, sometimes only for their complaints to fall on deaf ears and for nothing to change. A pack attitude within some organisations can make it difficult for nurses to feel they can speak up, and some nurse managers may even perceive the reputation of their trust to be under threat with such complaints. The importance of a supportive organisational culture in which nurses feel they can safely express their concerns cannot be overlooked. Some nurse leaders may even be aware that a nurse or health care assistant is delivering care that is not quite up to standard, but managers too can feel powerless. For example, if that nurse providing substandard care is the only one available to reliably work the night shift, nurse managers faced first and foremost with the practical requirement of having staff to fill their rota may feel that worrying about gold standard care around the clock is a luxury they do not have. The added fact that approaches and cultures of care vary by local trust does not help this situation, and an active and collective compliance with the code (NMC, 2008) is as important as an individual’s compliance to maintain their nursing registration.
What can be done? Ethical distress is not a negative thing; it only demonstrate a nurse’s moral compass and a desire to deliver care that is aligned with their personal values and their professional
© 2017 MA Healthcare Ltd
[email protected]
British Journal of Community Nursing October 2017 Vol 22, No 10 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 203.029.107.054 on October 3, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
PSYCHOLOGY code of conduct (NMC, 2015). Sources of ethical distress will also always exist, as different people will always have varying opinions on what is the right thing to do in any given situation, and organisational constraints will also continue to play a role to some degree. However, resolving ethical distress so that it does not become moral residue and lead to burnout is paramount. Nurses must have an awareness of ethical distress so that they can recognise it in themselves, their colleagues or staff. A safe space for open, honest communication about nurses’ opinions is essential for teams to engage in collaborative decision-making regarding the care of individual patients. Health professionals have standards, guidelines and other resources that they can turn to for guidance about providing high-quality, evidence-based specialist care, and multidisciplinary teams will have valuable and varied expertise on which to draw from. However, as each patient’s situation will be individual, listening to their feelings and their wishes, as well as those of their families and carers, will be vital to the decisions being made about them.This, together with a nurse’s compliance with the NMC (2015) code, their willingness to
tune into their personal values, and to seek support from managers and colleagues, can go a long way to providing direction and clarity on the road of community nursing practice, which is never straight. BJCN Baldwin K. Moral distress and ethical decision making. Nursing made Incredibly Easy. 2010;8(6):5 Canadian Nurses Association. Ethics in Practice for Registered Nurses. Ethical Distress in Health Care Environments. CNA: Ottawa; 2003 Corley MC. Nurse moral distress: a proposed theory and research agenda. Nurs Ethics. 2002;9(6):636–50 McLeod A. Nurses’ views of the causes of ethical dilemmas during treatment cessation in the ICU: a qualitative study. Br J Neuroscience Nurs. 2014;10(3):131–7 McNamee M, Sourani L. 2009. Ethical dilemmas, distress or courage: How do ethical responsibilities and quality work environments impact your nursing practice? 2009. http://tinyurl.com/mlnw75o (accessed 14 September 2017) Nursing and Midwifery Council. The Code. Professional standards of practice and behaviour for nurses and midwives. https://www.nmc.org.uk/ globalassets/sitedocuments/standards/nmc-old-code-2008.pdf (accessed 14 September 2017) Nursing and Midwifery Council. The Code. Professional standards of practice and behaviour for nurses and midwives. 2015. https://www.nmc.org.uk/ globalassets/sitedocuments/nmc-publications/nmc-code.pdf (accessed 14 September 2017) Vahey DC, Aiken LH, Sloane DM, et al. Nurse burnout and patient satisfaction. Med Care. 2004;42(2 Suppl):1157–66
Choose the right subscription for you PRINT EDITION WEBSITE ONLY PREMIUM PACKAGE Volume 20 Number 11
www.bjcn.co.uk
November 2015
The only monthly journal dedicated to nursing in the home
‘I can’t walk away’:
understanding the complexities in embedding a nurse role
LONG-TERM CONDITIONS Falls in adults of all ages with rheumatoid arthritis PALLIATIVE CARE Looking at palliative care from a wider perspective CARE OF THE OLDER PERSON Absorbent pads to treat urinary incontinence BJCN_2015_20_11_521_Cover.indd 1
29/10/2015 16:37
© 2017 MA Healthcare Ltd
UNIQUELY DEDICATED TO DISTRICT AND COMMUNITY NURSES ORIGINAL RESEARCH
EVIDENCE-BASED PRACTICE
CARE IN THE COMMUNITY
PROFESSIONAL DEVELOPMENT
High quality, peer-reviewed research that focuses on end-of-life and palliative care in the home
Case studies and up-to-date information on clinical developments to encourage best practice
Focus on the unique challenges faced by care workers and the complex needs of older people
Essential information for community and district nurses to support their career development
Visit www.magsubscriptions.com/bjcn or call 0800 137 201 (UK ONLY)
British Journal of Community Nursing October 2017 Vol 22, No 10
515
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 203.029.107.054 on October 3, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
Managing ethical distress in community nursing practice Aysha Mendes
Freelance Journalist, specialising in health, psychology and nursing
I
t has been said that nurses are personally accountable for the actions they take or fail to take in the care of their patients, and that they should always be able to justify their decisions (Nursing and Midwifery Council (NMC), 2008). However, despite the ideal view of nursing that most newly qualified nurses enter the profession with, the complexity of the decisions they are faced with, together with the realities of a resource-strapped NHS, and the varying professional opinions and approaches within a team, make it increasingly difficult to achieve this ideal in every situation.
What is ethical distress? Ethical or moral distress happens when a nurse’s values are compromised as a result of not taking what he or she feels is the right course of action (McNamee and Sourani, 2009). This can happen for different reasons, which may include fear or circumstances beyond their control (McNamee and Sourani, 2009). Ethical distress, as the term implies, is emotionally distressing during, and in the immediate aftermath of, the decision made. However, if left unresolved, it is also associated with burnout in the long term, which interestingly and alarmingly has been linked to a lack of compassionate care delivery (Canadian Nurses Association (CNA), 2003; Vahey et al, 2004). However, nurses play a unique and valuable role within the multidisciplinary team and have the opportunity to contribute actively to collaborative and ethical decision-making (McLeod, 2014).The position of community nurses who are usually alone while visiting patients and their families, and faced with a myriad of decisions, is unique, and the importance of this role cannot be underestimated.
The causes of ethical distress Ethical distress and unresolved moral distress, sometimes referred to as moral residue (CNA, 2003), can occur in any area of nursing practice. However, there are particular areas in which these arise more frequently, and community nurses are especially impacted. Long-term conditions and end-of-life care are areas in which these issues are particularly pertinent (Baldwin, 2010). In order to pinpoint specific sources of ethical distress in nursing practice, Corley (2002) identified the following:
514
ww Harm to patients ww Treatment of patients as objects ww Policy constraints ww Medical prolongation of dying without informed choice ww Definition of brain death ww Inadequate staffing ww Effects of cost containment Decisions regarding whether to continue, withhold or withdraw life-prolonging treatment when a patient’s prognosis is poor is one of the most common sources of ethical distress in nursing (McLeod, 2014). Other common sources include a lack of staff, resources and organisational support, resulting in a lack of time to spend with patients. Also, care provision which may not be considered harmful, can fall below the standards of many individual nurses. When considering whether or not to ‘whistleblow’, nurses may fear falling out of favour with colleagues to improve the standard of care, sometimes only for their complaints to fall on deaf ears and for nothing to change. A pack attitude within some organisations can make it difficult for nurses to feel they can speak up, and some nurse managers may even perceive the reputation of their trust to be under threat with such complaints. The importance of a supportive organisational culture in which nurses feel they can safely express their concerns cannot be overlooked. Some nurse leaders may even be aware that a nurse or health care assistant is delivering care that is not quite up to standard, but managers too can feel powerless. For example, if that nurse providing substandard care is the only one available to reliably work the night shift, nurse managers faced first and foremost with the practical requirement of having staff to fill their rota may feel that worrying about gold standard care around the clock is a luxury they do not have. The added fact that approaches and cultures of care vary by local trust does not help this situation, and an active and collective compliance with the code (NMC, 2008) is as important as an individual’s compliance to maintain their nursing registration.
What can be done? Ethical distress is not a negative thing; it only demonstrate a nurse’s moral compass and a desire to deliver care that is aligned with their personal values and their professional
© 2017 MA Healthcare Ltd
[email protected]
British Journal of Community Nursing October 2017 Vol 22, No 10 © MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 203.029.107.054 on October 3, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
PSYCHOLOGY code of conduct (NMC, 2015). Sources of ethical distress will also always exist, as different people will always have varying opinions on what is the right thing to do in any given situation, and organisational constraints will also continue to play a role to some degree. However, resolving ethical distress so that it does not become moral residue and lead to burnout is paramount. Nurses must have an awareness of ethical distress so that they can recognise it in themselves, their colleagues or staff. A safe space for open, honest communication about nurses’ opinions is essential for teams to engage in collaborative decision-making regarding the care of individual patients. Health professionals have standards, guidelines and other resources that they can turn to for guidance about providing high-quality, evidence-based specialist care, and multidisciplinary teams will have valuable and varied expertise on which to draw from. However, as each patient’s situation will be individual, listening to their feelings and their wishes, as well as those of their families and carers, will be vital to the decisions being made about them.This, together with a nurse’s compliance with the NMC (2015) code, their willingness to
tune into their personal values, and to seek support from managers and colleagues, can go a long way to providing direction and clarity on the road of community nursing practice, which is never straight. BJCN Baldwin K. Moral distress and ethical decision making. Nursing made Incredibly Easy. 2010;8(6):5 Canadian Nurses Association. Ethics in Practice for Registered Nurses. Ethical Distress in Health Care Environments. CNA: Ottawa; 2003 Corley MC. Nurse moral distress: a proposed theory and research agenda. Nurs Ethics. 2002;9(6):636–50 McLeod A. Nurses’ views of the causes of ethical dilemmas during treatment cessation in the ICU: a qualitative study. Br J Neuroscience Nurs. 2014;10(3):131–7 McNamee M, Sourani L. 2009. Ethical dilemmas, distress or courage: How do ethical responsibilities and quality work environments impact your nursing practice? 2009. http://tinyurl.com/mlnw75o (accessed 14 September 2017) Nursing and Midwifery Council. The Code. Professional standards of practice and behaviour for nurses and midwives. https://www.nmc.org.uk/ globalassets/sitedocuments/standards/nmc-old-code-2008.pdf (accessed 14 September 2017) Nursing and Midwifery Council. The Code. Professional standards of practice and behaviour for nurses and midwives. 2015. https://www.nmc.org.uk/ globalassets/sitedocuments/nmc-publications/nmc-code.pdf (accessed 14 September 2017) Vahey DC, Aiken LH, Sloane DM, et al. Nurse burnout and patient satisfaction. Med Care. 2004;42(2 Suppl):1157–66
Choose the right subscription for you PRINT EDITION WEBSITE ONLY PREMIUM PACKAGE Volume 20 Number 11
www.bjcn.co.uk
November 2015
The only monthly journal dedicated to nursing in the home
‘I can’t walk away’:
understanding the complexities in embedding a nurse role
LONG-TERM CONDITIONS Falls in adults of all ages with rheumatoid arthritis PALLIATIVE CARE Looking at palliative care from a wider perspective CARE OF THE OLDER PERSON Absorbent pads to treat urinary incontinence BJCN_2015_20_11_521_Cover.indd 1
29/10/2015 16:37
© 2017 MA Healthcare Ltd
UNIQUELY DEDICATED TO DISTRICT AND COMMUNITY NURSES ORIGINAL RESEARCH
EVIDENCE-BASED PRACTICE
CARE IN THE COMMUNITY
PROFESSIONAL DEVELOPMENT
High quality, peer-reviewed research that focuses on end-of-life and palliative care in the home
Case studies and up-to-date information on clinical developments to encourage best practice
Focus on the unique challenges faced by care workers and the complex needs of older people
Essential information for community and district nurses to support their career development
Visit www.magsubscriptions.com/bjcn or call 0800 137 201 (UK ONLY)
British Journal of Community Nursing October 2017 Vol 22, No 10
515
© MA Healthcare Ltd. Downloaded from magonlinelibrary.com by 203.029.107.054 on October 3, 2017. Use for licensed purposes only. No other uses without permission. All rights reserved.
