pediatric and adult healthcare settings David Browning, MSW, LICSW - - PowerPoint PPT Presentation

Building moral communities for reflection and dialogue in pediatric and adult healthcare settings

David Browning, MSW, LICSW

Co-Founder, Institute for Professionalism and Ethical Practice Boston Children’s Hospital david.browning@childrens.harvard.edu

Susan Gerbino, PhD, LCSW

Clinical Professor Director, Zelda Foster Studies Program in Palliative and End-of-Life Care NYU Silver School of Social Work susan.gerbino@nyu.edu SWHPN Annual Conference March 12, 2018

Our focus this morning…

n Introductory rationale n Defining terms n What is a moral community? n Examples from our practice n Discussion

Introductory rationale:

n Clinicians practicing in healthcare

settings, especially those who work with chronic and complex patients, or in intensive care or palliative care settings, are increasingly beset with heavy workloads, intra- and inter-professional tensions, and ethically challenging situations.

Introductory rationale (cont’d)

n These occupational burdens contribute to

well-documented instances and patterns

• f compassion fatigue, moral distress,

and burnout across healthcare disciplines.

n Insufficient attention and resources are

devoted to creating spaces and places where professionals can reflect on the moral and ethical stresses embedded in their daily practice.

Defining terms…..

n Moral imagination: our capacity to envision various

possibilities for acting in a given situation and the potential help or harm of these actions

n Moral agency: our ability to make moral judgments

based on our sense of right and wrong and to be held accountable for our actions

n Moral identity: how we perceive ourselves in terms

• f moral agency and our capacity for moral

imagination

Defining terms (cont’d)…

n [Moral] integrity: our experience when there is a

reasonable match between our moral agency/ moral identity and what we are asked or required to do professionally [in·teg·ri·ty]

n Moral distress: our experience when there is a

mismatch between our moral agency/imagination/ identity and what we are asked or required to do professionally

n Affects what we see in mirror at end of the day…

What is a moral community?

What do we mean by “moral”?

Morality is...

n “a socially embodied medium of mutual

understandings and negotiation between people over their responsibility for things open to human care and response” (Walker 1998)

n relational and contextual n grounded in the roles and responsibilities of

everyday social life. [As contrasted with ethics/ethical]

Keeping moral space(s) open….

Moral communities are…

n places, both literally and figuratively,

that “keep moral space open,” (Walker(1993)

n Places/spaces where moral language can

flourish in conversations about

n our moral and professional identities, n our understandings of mutual responsibilities, n the values and beliefs we hold as members

• f a particular community. (Liaschenko 2016)

These spaces can be:

n “structured” or informal n with individual or multiple disciplines n within or outside physical boundaries of

healthcare organizations

Our examples will include:

1.

Informal, single discipline, within org.

2.

Structured, multiple disciplines, within org.

3.

Structured, single discipline, outside org.

Types of questions raised..

n What is your understanding of the situation/topic

under discussion?

n What knowledge do you have that is unique to your

role and your context

n What’s at stake for you? What’s at stake for others? n How do you think your perspective is valued by

• thers inside or outside your own discipline?

n Where and how do you voice your perspective? n How do you understand the perspective of others?

Essential ingredients for psychological safety that facilitates open dialogue…

n Honoring multiple perspectives across

lines of difference (including professional discipline, experience level)

n Validating practice knowledge n Suspending hierarchy n Supporting reflection/self-awareness n Addressing “elephants in the room”

Ground rules (collective responsibilities)

n Listen attentively—contribute to a

learning atmosphere of equality, trust and respect.

n Create a climate receptive to the sharing

• f thoughts, feelings, and experiences.

n Support the expression of multiple

perspectives, even if you may not agree.

Ground rules (cont’d)

n Risk sharing your own perspective, even

if you think others may not agree.

n Create space in the conversation for less

vocal participants to speak.

n Maintain confidentiality in regard to any

personal or patient/family information that is shared.

Where does social work fit in?

n Moral concerns drove development of social

work as a profession

n Emphasis on knowledge base at the expense

• f social work values/mission (Bisman 2014)

n Unique relationship to value of social justice n Obligation to bear witness to injustice, to

speak up, and to act (moral outrage)

(McAuliffe et al 2016)

Where does social work fit in? (cont’d)

n Challenge of bridging gap between values/mission

and practice (McAuliffe et al 2016)

n Moral distress: social workers often in role of

supporting other professions.

n Importance of understanding and addressing…

n how moral distress manifests itself for social workers n what role social workers play/should play in the

creation and maintenance of moral communities

Examples from our practice

Discussion

References

n Bisman C (2004). Social work values: The moral core of

the profession. The British Journal of Social Work. 34(1).

n Browning, D (2012). Sturdy for common things:

Cultivating moral sensemaking on the front lines of

• practice. Journal of Medical Ethics. 38(4).

n Browning, D and Gerbino, S ](2011). Navigating in

swampy lowlands: A relational approach to practice-based learning in palliative care. In T Altilio and S Otis-Green (Eds.), Oxford Textbook of Palliative Social Work. NY Oxford University Press.

References (cont’d)

n Clark C (2006). Moral character in social work. The British

Journal of Social Work 36(1).

n Hermsen M and Embregts P (2015). An explorative study of

the place of the ethics of care and reflective practice in social work education and practice. Social Work Education 34(7).

n Liaschenko J and Peter E (2016). Fostering nurses’ moral

agency and moral identity: The importance of moral

• community. Hastings Center Report 46 (Suppl 1).

n McAuliffe D, Williams C, and Briskman L (2016). Moral

• utrage! Social work and social welfare. Ethics and Social

Justice 10(2).

References (cont’d)

n Traudt T, Liaschenko J, and Peden-McAlpine C

(2016). Moral agency, moral imagination, and moral community: Antidotes to moral distress. The Journal

• f Clinical Ethics 27(3).

n Walker M (1998). Moral Understandings: A Feminist

Study in Ethics. NY: Routledge.

n Walker M (1993). Keeping moral space open: New

images of ethics consulting. Hastings Center Report 23(2).