Transcript moral distress, burnout, compassion fatigue (ppt

Moral Distress, Burnout and
Compassion Fatigue in
Ethics Work
Rosalie Starzomski RN PhD
Professor, University of Victoria
October 23, 2013
Case Study
To be discussed in the session
Ethical Practice
Ethical practice is…
a way of being
 the process of enacting ethical decisions
 knowing what is right and doing it
 working the in-betweens
 picking the battles
 moving from moral intent to moral action
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Ethics and the Law
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The law prescribes the boundaries of
correct legal behavior
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Ethics describes wider boundaries for right
and wrong
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embraces law
extends further than the law
Consequences of Inability to
Practice Ethically
Moral distress “is when there is
incoherence between one’s beliefs and
values and one’s actions, and possibly
also outcome.”
(Webster and Baylis, 2000)
Consequences of Inability to
Practice Ethically
Moral residue “is 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
ourselves or allowed ourselves to be
compromised.”
(Webster and Baylis, 2000)
Compassion Fatigue
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Also known as secondary traumatic stress
(STS)
Characterized by a gradual lessening of
compassion over time
Burnout
Refers to long-term exhaustion and
diminished interest in work
Ethical Reflection & Decision Making
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Beginning with values, personal beliefs
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Response? Why do I feel this way?
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Collect information and identify the problem
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Specify a range of feasible alternatives
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Use ethics resources to evaluate alternatives
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Propose and test possible resolutions
Ethical Approaches
Contextualist
Relational/Narrative
Cross-Cultural
Principlism
Autonomy
Nonmaleficence/Beneficence
Justice
From
Moral Intent
To
Moral Action
Relational Autonomy

Best understood to be a capacity or skill that is
developed (and constrained) by social
circumstances
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Person is not only offered the choice, but has
the opportunity to develop the skills to make the
choice
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Persons are respected for their decisions and
encouraged to reflect on their values
Cultural Context
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Culture is more than ethnicity
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Understanding values and beliefs
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Valuing dialogue
Questions for Reflection in
Relational Ethics
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What brought you here?
What is the meaning of this situation for you?
What is your experience and how can I
understand it?
What might be good to do in this situation?
What is important in our relationships with
others?
Charting a New Course
Therapeutic Relationships
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Hallmark of professional practice
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Knowledge and skill regarding professional
boundaries put to the test when
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therapeutic relationships begin to change
HCP’s become over-involved with patients or their
family members
Questions
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What does providing patient/family
focused care mean to us?
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How can we ensure that the
relationships we develop are actually
based on the needs of our patients
and their families?
Power Imbalances
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Asymmetrical relationships can lead to abuse of
power
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Can result in a detrimental situation for the patient or
family member
Asymmetrical power imbalances with HCP’s
having more power due to:
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authority
knowledge
influence
access to privileged information about the patient
and/or the family
Healthy Boundaries
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Healthy boundaries keep the HCP-client
relationship a safe one where the client
and HCP are both respected
The client’s human dignity, autonomy and
privacy are safeguarded
Boundaries are unique to each person
Best policy - proceed carefully and, when
in doubt, ask questions
Establishing Healthy Relationships
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Key to remember that:
 interpersonal relationships between HCP’s
and patients and their family members are
meant to be professional in nature
 relationships are intended to meet the needs
of the patient and not the needs of the HCP’s
 must always act in the best interest of patients
Professional Boundaries

How can HCP judge whether something is inside
or outside of professional boundaries?
 no simple answer
 no set of “rules” that applies in all situations
 may be context dependent
 relational competence is key
Yellow Lights
 Frequently
thinking about patient or
family when away from work
 Frequently planning other patients’ care
around the patient’s needs
 Spending free time with the patient and/or
family
 Sharing personal information or work
concerns with the patient and/or family
 Feeling worried about the patient or family
view of you as a person if you don’t meet
their expectations
Yellow Lights
Feeling so strongly about the patient’s goals
 don’t hear other team members comments or
the patient’s/family’s wishes
 Feeling responsibility if the patient’s progress is
limited
 Feeling unusual irritation if someone or something
in the system creates a barrier or delay in the
patient’s progress
 Noticing more physical touch
 than is appropriate or required for the situation,
or…
 sexual content in interactions with the patient or
family member
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Strategies
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Combination of:
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caring and relational practice
standards of practice
policies
codes of ethics
professional judgment
resource person/team consultation
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to provide direction to manage the complex issues
Strategies
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When in doubt:
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Discuss concerns with members of the health
care team and resource persons such as:
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review existing guidelines. standards and codes of
ethics
ethicists or ethics committees
practice consultants
With HCP’s and patients and families
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develop unit/program guidelines that can be shared
take into account ethno-cultural diversity in terms of gift
giving and gift-receiving
Strategies
 During
selection/hiring interviews
acknowledge that due to the intensity
of the work environment staff are faced
with professional boundaries issues
 discuss in terms of program values
and professional responsibility
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 Include
professional boundary literature in
orientation material and conduct in-service
presentations on the topic
RESOURCES
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Professional Practice Standards, Guidelines and Codes of Ethics such as:
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Canadian Nurses Association. (2008). Code of ethics for registered nurses. Ottawa:
Author. Available online: www.cna-aiic.ca
College of Nurses of Ontario. (2006). Therapeutic nurse-client relationship. Toronto:
Author.
College of Registered Nurses of British Columbia (CRNBC). (2006). Nurse-client
relationships. (Pub. 406). Vancouver: Author. Available online: www.crnbc.ca
CRNBC. Boundaries in the nurse client relationship.
https://crnbc.ca/Standards/PracticeStandards/Pages/boundaries.aspx
College of Registered Nurses of Nova Scotia. Professional boundaries and expectations
for nurse-client relationships. http://www.crnns.ca/documents/professionalboundaries.pdf
Campbell, C., & Gordon, M. (2003). Acknowledging the inevitable:
Understanding multiple relationships in rural practice. Professional
Psychology: Research and Practice, 34, 430-434.
Farber, N., Novak, D., O’Brien, M. (1997). Love, boundaries, and the
physician-patient relationship. Arch Int Med, 157, 2291-2294.
Starzomski, R. (2002). Professional boundaries in nephrology programs.
CANNT Journal,12(2), 31-33.