Moral Distress, Burnout and Compassion Fatigue in Ethics Work Rosalie Starzomski RN PhD Professor, University of Victoria October 23, 2013

To be discussed in the session 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

Ethics and the Law The law prescribes the boundaries of correct legal behavior Ethics describes wider boundaries for right and wrong 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 Also known as secondary traumatic stress (STS) Characterized by a gradual lessening of compassion over time

Refers to long-term exhaustion and diminished interest in work Burnout Refers to long-term exhaustion and diminished interest in work

Ethical Reflection & Decision Making Beginning with values, personal beliefs Response? Why do I feel this way? Collect information and identify the problem Specify a range of feasible alternatives Use ethics resources to evaluate alternatives 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 Person is not only offered the choice, but has the opportunity to develop the skills to make the choice Persons are respected for their decisions and encouraged to reflect on their values

Cultural Context Culture is more than ethnicity Understanding values and beliefs Valuing dialogue

Questions for Reflection in Relational Ethics 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 Hallmark of professional practice Knowledge and skill regarding professional boundaries put to the test when therapeutic relationships begin to change HCP’s become over-involved with patients or their family members

Questions What does providing patient/family focused care mean to us? How can we ensure that the relationships we develop are actually based on the needs of our patients and their families?

Power Imbalances Asymmetrical relationships can lead to abuse of power Can result in a detrimental situation for the patient or family member Asymmetrical power imbalances with HCP’s having more power due to: authority knowledge influence access to privileged information about the patient and/or the family

Healthy Boundaries 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 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

Strategies Combination of: caring and relational practice standards of practice policies codes of ethics professional judgment resource person/team consultation to provide direction to manage the complex issues

Strategies When in doubt: Discuss concerns with members of the health review existing guidelines. standards and codes of ethics Discuss concerns with members of the health care team and resource persons such as: ethicists or ethics committees practice consultants With HCP’s and patients and families 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 Include professional boundary literature in orientation material and conduct in-service presentations on the topic

RESOURCES Professional Practice Standards, Guidelines and Codes of Ethics such as: 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.