11/13/2017 Moral Distress 2017 NACC Webinar Rod Accardi, D.Min, - - PDF document

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Moral Distress

2017 NACC Webinar Rod Accardi, D.Min, BCC Karen Pugliese, MA, BCC November 16, 2017

Northwestern Medicine

Where the Patient Comes First

• National leader in quality and

consumer preference

• 1,600+ member employed

Physicians Groups

• 1,700+ total beds among

NM’s seven-hospital system

• 30,000+ employees
• Seven hospitals and more

than 100 other sites of care in Chicago and suburbs

• Primary clinical affiliate of

Northwestern University’s Feinberg School of Medicine

Quality Recognitions

• 4 hospitals have earned recognition from U.S. News & World

Report as regional leaders with the health system’s flagship hospital, Northwestern Memorial Hospital in downtown Chicago, recognized on the Honor Roll of America’s “Best Hospitals” for five consecutive years.

• 4 Northwestern Medicine hospitals earned Magnet status:

− Northwestern Memorial Hospital − Northwestern Medicine Central DuPage Hospital − Northwestern Medicine Lake Forest Hospital − Northwestern Medicine Delnor Hospital

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Central DuPage Hospital

− 392 bed acute-care facility − Winfield, IL; western suburb of Chicago − 1,150 physicians on staff in 89 specialties − Regional destination for oncology, neurology,

• rthopedics, pediatric and cardiology

− Approximately 7,400 employees

Delnor Hospital

− 159 bed acute facility − Geneva, IL; western suburb of Chicago − 600 physicians on staff in 60 specialties − First hospital in Illinois to earn nursing Magnet status − Approximately 1,400 employees

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Moral Distress

“The pain or anguish affecting the mind, body or relationships in response to a situation in which the person is… aware of a moral problem, acknowledges moral responsibility, and makes a moral judgment about the correct action yet, as a result of real or perceived constraints, participates in perceived moral wrongdoing.” (ANA, 2008)

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Current Perspectives on Moral Distress

Moral distress has gained pervasive momentum as a topic of concern especially for nurses in in-patient settings.

(Weigland, Funk, 2012; Browning, 2011, Gallagher, 2012)

Multiple studies have focused upon the quantification of moral distress through the development of survey tools to measure the level of distress in specific populations.

(Corley, Elwick, Gorman, 2001; Hamric, Borchers, Epstein, 2012; Wocial & Weaver, 2013)

We don’t know what type of interventions are effective in reducing moral distress. Leggett, Wasson, Sincore & Gamelli, 2013 reported an increase in moral distress on a burn unit after a 6 week intervention.

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Current Perspectives on Moral Distress

“… there are varieties of ethically significant moral distress, because the

durable values implicated in ethically significant moral distress originate in both professional and individual integrity, and because there is a variety of impediments that trigger ethically significant moral distress.”

(A Philosophical Taxonomy of Ethically Significant Moral Distress. Journal of Medicine and Philosophy, 40: 103 – 120, 2015)

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Nursing Challenges

Nurses need to respond to:

• Internal environmental shifting such as continually changing

patient conditions and acuity levels (Casida & Pinto-Zipp, 2008)

• Life and death issues
• Introduction of new technology, medications and procedures
• Differing staffing models, nurse to patient ratios, work-force shortages

(Ingersoll, Wagner , Merk, Kirsch, Hepworth & Williams, 2002)

• Appropriate care delivery processes to avoid errors and patient harm

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Sources of Moral Distress

Moral distress occurs when persons know (OR believe they know) the ethically appropriate course of action, but cannot carry out that action because of:

• Lack of time
• Lack of supervisory/administrative support
• Institutional or legal constraints
• Tremendous responsibility for patient care,

but little authority

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Perceived Causes of Moral Distress

• Harm to patients – overly aggressive treatment
• Inadequate pain management
• Ineffective communication
• Unclear treatment goals
• Disrespecting, disregarding patient/family choices
• Incomplete or inaccurate disclosure
• Lack of informed consent
• Objectifying patients
• “Futile” treatment
• Authority imbalance & IDT conflict
• Inappropriate allocation of resources

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Daily Sources of Diminished Resilience - Tugging at Heartstrings

• Emergent needs and fast pace
• Minimal (or lack of) extended interactions
• Belief that professionals must learn to control and hide feelings
• Unresolved unhappiness and emotional pain in personal

and/or professional life

• Emotional burden of neutrality
• Jumping from crisis to crisis; needing to deny or minimize the emotional strain or pain
• Difficulty in setting realistic priorities and boundaries, and in asking for help
• Exposure to psycho-social-spiritual distress in addition to other stressors
• Decreased sensitivity to one’s own stressors
• Inability to bond or connect with those in one’s care

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Empirical Evidence of the Implications of Moral Distress

Consequences in nurses’ lives: Stress, burnout, job dissatisfaction; departure from the work environment and from nursing

(Hamric & Blackhall, 2007; Elpern, Covert, Kleinpell, 2005)

Immediate effects: Anger, cynicism, silent withdrawal and depression (hitting the wall and feeling nothing…“whatever”)

(Wilkinson, 1988)

Long-term effects: Self worth is jeopardized; personal and professional relationships may be affected; psychological changes, behavioral manifestations and physical symptoms occur

(Corley, 1995)

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Empirical Evidence of the Implications of Moral Distress

1 in 3 nurses have experienced moral distress

(Redman & Fry, 2000)

Almost 50% of nurses studied left their work unit

• r the profession due to moral distress

(Millette, 1994)

The intensity of moral distress was even greater than the frequency

(Corey et al. 2001; 2005; Pauly et al; 2009; Rice et al. 2008)

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Impact of Moral Distress: Painful Feelings and Psychological Disequilibrium

Reactive Symptoms: Guilt, a sense of compromised integrity, becomes “Moral Residue” Moral Residue: “that which each of us carries with us from those times in our lives when in the face of moral distress we have seriously compromised

• urselves, or allowed ourselves to be compromised.”

(Webster and Baylis, 2000)

“Crescendo Effect:” Cumulative moral distress + moral residue

(Epstein and Hamric, 2010)

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(Hamric, 2011)

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It’s in the headlines… Hospital Patient Punched Employees in Head, Urinated on Another: Report

By Scott Viau(Patch Staff) - August 12, 2016 11:02 pm ET

NAPERVILLE, IL — A patient at Edward Hospital allegedly punched two employees in the head and urinated on the leg of another. (Name withheld), 28, of the 2200 block of Donegal Drive, assaulted the employees July 17th, according to a report from the Chicago Tribune. He also reportedly threatened to kill one of them. It is unknown what prompted the attack.

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Moral Distress Reflection

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Pre-Moral Distress Interventions

Group and 1:1 Debrief Sessions facilitated by Chaplain and Employee Assistance Program (EAP)

• Standard and proactive for any issue, not only Moral Distress
• Rituals created from and embedded in organizational culture

Schwartz Rounds implemented in 2012

• Monthly, interdisciplinary forum to discuss emotional aspects
• f being a care provider
• Co-facilitated by EAP Coordinator and Chaplain

Spiritual Care & Employee Assistance Program

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Research Study Purpose and Question

PURPOSE Gain understanding of existing hospital unit-based levels

• f moral distress.

Determine if a defined intervention produces quantifiable results related to changes in distress levels. QUESTION Do nursing unit employees exposed to supportive interventions exhibit an improvement in moral distress?

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Project Road Map

Conduct MDS Survey Jan 2012

Quantitative

• Launch survey
• Provide results to

leadership

• Provide results to staff

Develop and Trial Implementation Plan Develop & Implement Interventions

Qualitative

• Develop an action

plan including 3 prong intervention (Counseling, Ethics Committee Consult, & Cognitive Learning)

• Roll out education to

staff Qualitative

• Begin offering Ethics

Committee Consults, Counseling and Cognitive Interventions

• Conduct debriefings to

validate effectiveness Quantitative

• Compare pre and

post survey responses

• Recognize situational

challenges

Repeat MDS Survey April- July 2012 Aug/Dec 2013 Jan 2014

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Survey Process

Moral Distress was defined as occurring when professionals perceive that they cannot carry out what they believe to be ethically appropriate actions because of internal or external constraints. The survey tool (MDS) measured the frequency that different situations have been experienced by staff and how disturbing the experience was for each individual. The survey had 20 questions and took approximately 15 minutes to complete.

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Participation in Initial MDS Survey

474 respondents = 44% response rate 81.5% were staff nurses 88% were female with 68.5% of White/Caucasian 62% were BSN Most frequently reported age group: 40 to 49 years Wide range of experience/tenure at the organization

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Counseling - Provide support and counsel to the affected staff via Employee Assistance Program (EAP) and Pastoral Care using The 4A’s. The purpose of this support was to allow time for staff in a private setting to recall distressful events; to have time to vent about their experience and the experience of the patient and family. Ethics Committee Consult – Provide ethical decision making and support. Cognitive Learning - Offer education by physician and nursing leadership related to assessment and treatment.

(Source: RIC, Chicago, IL 2011)

Breakthrough Intervention: 3 Pronged Approach Delineated Interventions

Intervention Control Group Experimental Group

Counseling/Support

X X

General Education presentation on Moral Distress

X X

Ethics Consultation

X X

Cognitive learning based on identified knowledge gaps

X X

Access to Moral Distress Hotline

X

Targeted rounding by Chaplain and/or EAP

X

Formal debriefing sessions for Moral Distress

X

Educational flyers on Moral Distress posted on unit

X

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Moral Distress Education

June 2012: Initial discussions regarding specific training for Moral Distress with Chaplain, EAP Coordinator and Associate Chief Nursing Officer July 2012: Moral Distress Steering Committee formed October 2012- November 2012: “Proactively Responding to Moral Distress” presented by Advanced Practice Chaplain and EAP Coordinator:

• Defined Moral Distress
• Identified signs and symptoms of Moral Distress and its impact
• Introduced the 4 A’s Method to Proactively Respond to Moral Distress
• Created awareness of organizational resources available when Moral Distress occurs
• Presented 12 sessions to 167 participants

November 2012: Schwartz Rounds Moral Distress Panel Presentation; 40 participants

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January 2013 – May 2013 Clinical Group Presentations Ethics Committee (16 participants) Operational Leadership (18 participants) Mother/Baby staff (50 participants) Case Management Team (2 presentations, 43 participants) April 2013 Moral Distress Algorithm developed and distributed Moral Distress Phone Hotline activated (monitored by Chaplain and EAP)

Moral Distress Education & Support

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Moral Distress Education Offerings

“So that’s what I’m feeling! Now what do I do???” Proactively Responding to Moral Distress OBJECTIVES

• Define Moral Distress
• Identify the signs and symptoms of Moral Distress

and its impact

• Utilize the 4 A’s method to proactively respond

to Moral Distress

(AACN toolkit: 4 A’s To Rise Above Moral Distress)

• Become more aware of the organizational resources

available when Moral Distress occurs

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The 4A’s to Rise Above Moral Distress

You may be unaware of the exact nature of the problem, but feeling distress. Ask: Am I feeling distressed or showing signs of suffering? Is the source of my distress work related? Am I observing symptoms of distress within my team? GOAL: You become aware that Moral Distress is present.

• 1. ASK

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The 4A’s to Rise Above Moral Distress

Affirm your distress and your commitment to take care of yourself. Validate your feelings and perceptions with others. Affirm your professional obligation to act. GOAL: You make a commitment to address Moral Distress

• 2. AFFIRM

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The 4A’s to Rise Above Moral Distress

Identify the sources of your distress.

• Personal
• Environment

Determine the severity of your distress. Contemplate your readiness to act.

• You recognize there is an issue but may be ambivalent

about taking action to change it.

• You analyze risks and benefits.

GOAL: You are ready to make an action plan.

• 3. ASSESS

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The 4A’s to Rise Above Moral Distress

Prepare to Act

• Prepare personally and professionally to take action.

Take Action

• Implement strategies to initiate the changes you desire.

Maintain Desired Change

• Anticipate and manage setbacks.
• Continue to implement the 4A’s to resolve Moral Distress.

GOAL: You preserve your integrity and authenticity.

• 4. ACT

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Clinical Interventions for Experimental Units

• Staff were encouraged by managers to contact either

Spiritual Care and/or EAP directly for confidential support.

• Spiritual Care and/or EAP educated managers/leaders/CSC’s
• n how to support and provide periodic check-ins with staff.
• Educational flyers (“What is Moral Distress?” and “The 4A’s”)

were posted and distributed on experimental units to reinforce learning and support resources available to staff.

• Attendees at monthly Schwartz Rounds sessions were

reminded to contact either Spiritual Care and/or EAP for confidential support.

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Clinical Interventions for Experimental Units

Consultation with Unit Managers around distressful situations resulted in supportive interventions by Spiritual Care and EAP:

• Spiritual Care rounded on the units and informally

checked-in with individual staff.

• Spiritual Care provided 1:1 and small group support

for affected staff.

• Spiritual Care and/or EAP conducted formal debriefing

sessions during occurrences or shortly thereafter.

• Sessions were open to all staff and were voluntary.

Quantitative Findings

• Significant overall decrease in overall Total scores between Pre Intervention

and Post Intervention groups for both the control and experimental units.

• Significant difference in this decline between Control and Experimental

groups, with the Control group having lower overall change in Total scores when compared to the Experimental group.

• Average total scores for both the pre-intervention and post-intervention

respondents were significantly higher for those who indicated they were currently considering leaving their position.

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Total Score: Pre-Survey vs. Post Survey

Pre-Survey Post Survey

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Total Score: Pre-Survey vs. Post Survey

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Our Conclusion

The study findings suggested that distress levels in nurses can be reduced with a three-pronged intervention bundle over time.

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What Came Next

The decision was made to use focus groups to determine the nature and sources of “distress” experienced by nurses. Based on the results of the focus group data , we would propose strategies to assist in managing the distress.

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Can you tell me what was most helpful with the interventions? Is there anything that you recommend that we change about the interventions (think about the time, place or the type of interventions)? Is there anything that you would have preferred to have happen that was not

• ffered to you?

Can you comment on the overall effectiveness of the interventions? Can you describe how you think that you have resolved your feelings as a result of the interventions? Was there anything not resolved that you would like to share?

Focus Groups Script Qualitative Findings

“Being checked in on was wonderful, I was able to talk with colleagues…” “Had flashbacks and panic attack upon coming back to work the next day…everyone was supportive and great.” “Still having mini flashbacks to that day…still have a sense of dread coming into work, bad dreams still happen… Biggest struggle is trying to honor patient’s memory without torturing myself.” “It’s that kind of support (from hospital resources/colleagues) that make a staff member want to stay….” “Having the opportunity to discuss with someone in the group who has been though a similar situation was helpful.” “Interventions helped to normalize my reaction.”

Recurring Themes from Staff Nurses’ Focus Groups: January - September 2014

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Qualitative Findings

“Learning how to recognize it (Moral Distress) and give it a name. Hearing what others went through and learned; what they experienced.” “Having tools for early intervention. It’s almost like you need AA for Moral Distress. It takes some thinking and emotional inventory. I wish there was a ten question tool you could ask yourself.” “If you don’t reach closure, what’s the next step? It’s our job and we need to move on but you always wonder what happened in the time you were gone.” “Learning how to triage would be ideal. How do I deal with knowing if I should discuss it right away or let [staff] go home and bring it up again the next day? Knowing when to intervene and when not to is hard.” “Change the culture of thinking that ICU nurses should be tough and not need to talk and get away from certain

• situations. If I do that I don’t have the backup and it gives me an ethical dilemma.”

Recurring Themes from Nurse Leaders Focus Groups: April – August 2014

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Our Recommendations

Educate and support nurse leaders:

• To identify Moral Distress in staff and provide “in the moment” support
• To access additional resources (individual and/or staff debriefs)

via a process that respects staff self-determination in self-care Provide educational seminars:

• Emotional Intelligence
• Resilience Theory
• Somatic Regulation Interventions

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Our Learnings: The Paradoxical Nature of Empathy & Compassion

Neuroscience and Social Psychology Research are studying human responses to suffering related to empathy and compassion When arousal in response to another’s suffering is not regulated, it can give rise to personal distress (Eisenberg, et al., 1994), which undermines the possibility for expressing compassion Lack of self-regulation and hyper-arousal can result in self-focused behaviors such as avoidance or hyper activity aimed at relieving the distress Lack of self regulation leading to empathic “over-arousal” may shift the focus from relieving the distress of another to relieving one’s own distress

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Our Learnings from Neuroscience Research

Somatic therapies broaden traditional (cognitive) approaches to trauma treatment

Trauma can result in:

• Failure of the body, psyche and nervous system to process adverse events
• Fragmented memories stored in parts of the brain with no access to speech or reasoning
• Repetitious recounting of distressful experiences has limited impact on healing
• Emotional support and connection with others can normalize distressful experiences,

but also lead to Re-traumatization

• Long-term emotional residue remains, even after initial “emotional distance” is achieved
• Cognitive thinking as a singleresource can result in:

Powerlessness Helplessness/hopelessness Physiological overwhelm in nervous system, particularly amygdala Inability to achieve deeper embodiment of the experience

• Dr. Bessel VanderKolk– The Body Keeps the Score (2014)

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November 2013 – May 2014: Practicing with Kindness, Compassion & Firmness: Setting Appropriate Boundaries with Patients and Families

Panel Presentations: Chaplain, EAP, Patient Relations, and Patient Satisfaction

July 2014 - October 2014: Managing Challenging and Disruptive Patients and Families

Panel Presentations: Chaplain, EAP, Patient Relations, and Patient Satisfaction

November 2015 – Present: Practicing with Kindness, Compassion & Firmness: Managing Challenging and Disruptive Patients and Families

Panel Presentations: Chaplain, EAP, Patient Relations, and Patient Satisfaction

Additional Moral Distress Education

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Learning Objectives

Recognize behaviors that can lead to discontentment among patients, families, and/or employees. Explain how limit setting maintains a culture of safety and ultimately supports patient engagement. Create a structure that empowers the use of limit setting in conjunction with a culture of teamwork and communication.

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Practicing with Kindness, Compassion & Firmness

• Self-Awareness
• Empathy & Compassion
• Communication & De-Escalation
• Limit Setting

Summary of Concepts

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Levels of Disruptive Behaviors

Level 1: Inappropriate/Disrespectful Persistent Behaviors Level 2: Dangerous/Safety-Compromising Behaviors Level 3: Physically Dangerous or Criminal Behaviors

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Principles of Effective Limit Setting

Provide Reasonable Choices Language is Clear/Calm Non- threatening Limits are Enforceable Directions likely need to be repeated Give Person time to process information Consistency

• Use huddles/email to

communicate expectations that have been set

• Use buddy system for

staff safety concerns

• Set limits early
• Uphold limits

consistently

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What the Data Shows

Pre Assessment Immediately Post 6 Months Post 12 Months Post In the moment, I notice when my own emotions impact a conversation with patients/families. 14% 21% 39% I recognize when my interactions with a difficult patient/family member impact the care I provide to them as well as

• ther patients.

15% 25% 43% I am using skills/strategies that help me to emotionally self-regulate when I get triggered by patient/family behaviors. 16% 33% 41% 0% 10% 20% 30% 40% 50% 60% Percentage Indicating Very Often

Practicing with Kindness, Compassion and Firmness Skills Self Assessment- Rolling Month Data

Intervention

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What the Data Shows

Pre Assessment Immediately Post 6 Months Post 12 Months Post Limits set with patients/families are clearly communicated with the team. 12% 26% 33% My colleagues consistently follow the limits that are to be set with patients and/or families. 11% 14% 26% I am comfortable asking for help if I am faced with a challenging patient/family behavior. 41% 52% 69% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Percentage Indicating Very Often

Practicing with Kindness, Complassion and Firness Skills Self Assessment- Rolling Month Data

Intervention

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Front Line Participant Feedback…

“Our office doesn’t have specific boundaries on acceptable patient

• behavior. The number one goal is

patient engagement without regard to patient behavior.” “In our office, providers and staff do give into patient’s demands and it’s hard to set limits with patients until it gets out of hand.” “I don’t feel supported by my leader when setting limits!” “Staff is afraid that limit setting may impact patient engagement scores.” “I don’t feel all staff are agreeable to limit setting. I feel some staff take the path of least resistance, which sometimes sets the next staff up for failure.” “Mixed signals as to where the limits are within our

• rganization.”

“I feel that if limits had been set earlier by other staff members or units, difficult situations could have been stopped or more easily de-escalated.”

Perceptions

Staff Felt Leaders… Leaders Felt…

Unaware of daily challenges Offended by difficult behaviors “Excellence care” – no excuses Unsure of available resources Unsure of available resources Less confident and professional Fears…

• Perception of others
• Being critiqued
• Inability to handle behavior
• Initiating difficult conversations
• Unsure of available resources

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Strange Bed Fellows: Patient Engagement & Patient Safety

Belief that only “really nice people” work in healthcare. Inordinate focus on preventing patient dissatisfaction. Belief that patient engagement and zero tolerance cannot coexist. Focus on patient rights with little attention to patient responsibility.

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Leader Development/Support: Bridging the Gap

Resources for the Care and Maintenance of Successful Leaders

• Human Resources
• Employee Health
• Employee Assistance Programs
• Spiritual Care
• Department of Professional Practice
• Relationship Based Care

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Closing the Gap Through Leader Action

• Create a cultural commitment to balance compassion and firmness
• Create a Zero Tolerance Workgroup
• Give permission and support to frontline staff to identify, address

and potentially de-escalate disruptive behavior in real time

• Give permission for staff to suspend conversations

with patient/families who engage in unacceptable behaviors

• Include disruptive scenarios in onboarding simulations

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Structuring for Success

Leaders set the tone for Clinical Units/Departments

• Consistent use of huddles to assure reliable communication
• Regular “check ins” for patients/families that pose a concern
• Communicate challenging situations using SBAR
• Safety First!

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Structuring for Success

Leadership By Example

• Timely escalation of concerns
• Role modeling, mentoring and shadowing to address concerns
• Debriefing
• Stop, start, continue

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It’s in the headlines… Nurse sexually assaulted during hostage ordeal at Geneva hospital By ByWill Jones and Rob Elgas May 13, 2017

Geneva, IL — A patient inmate at Delnor Hospital held one Delnor Hospital nurse against her will for three and a half hours, allegedly beating and raping the nurse. The prisoner was hospitalized May 8 after ingesting cleaning fluid and trying to eat his jail-issued sandal. "For the entire time that she was held captive, he held her hair with one hand, he had the gun to her head with the

• ther hand," said the nurse’s attorney.

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RESOURCES - Code Lavender

• The Code Lavender System is an integrative healing equivalent of a Code Blue.

It provides holistic rapid response to emotionally stressful events.

• Services consist of a rapid response team of specialists who are called upon

when an individual – patient or family or employee – has reached his/her emotional limit.

• In a 2008 survey of patients receiving Code Lavender therapies at Cleveland

Clinic, 93% said they were helpful and 90% said they would recommend these services to others.

• Employees accounted for 40% of the requests. 99% said they met or

exceeded expectations and 98% said they would recommend.

• Team includes nurses, touch therapists and chaplains and responds to all

requests within 30 minutes, then partner with EAP and the Wellness Center for long term assistance.

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RESOURCES - RISE: Resilience in Stressful Events Program

RISE: Resilience in Stressful Events, an emotional peer support structure, supports second victims who were emotionally impacted by a stressful patient- related event or unanticipated adverse event. This RISE team is composed of a multidisciplinary peer responder team who has volunteered to support second victims when an unanticipated patient-related event occurs. Support from RISE is available to “second victims” or health care providers having difficulty coping with their emotions after patients’ adverse events and who subsequently have difficulty coping with their emotions.

• Standardized program from John Hopkins Armstrong Institute for Patient Safety and Quality
• Includes internal , organizational assessment, multidisciplinary peer responder team, skill

training and development, ongoing internal marketing and evaluation

• Includes Cost-Benefit analysis

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RESOURCES – From the Literature

• A Philosophical Taxonomy of Ethically Significant Moral Distress

Journal of Medicine and Philosophy, 40: 102 – 129, 2015

• Compassion Fatigue, Moral Distress, and Work Engagement

in Surgical Intensive Care Unit Trauma Nurses: A Pilot Study

Wolters Kluwer Health / Lippincot Williams & Wilkins. 2014

• The relationship between moral distress, professional stress,

and intent to stay in the nursing profession

J Med Ethics Hist Med. 2014, 7:4

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Questions?