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

2. To be discussed in the session
Case Study
To be discussed in the session

3. 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

4. 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

5. 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)

6. 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)

7. Compassion Fatigue Also known as secondary traumatic stress (STS)
Characterized by a gradual lessening of compassion over time

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

9. 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

10. Ethical Approaches Contextualist Relational/Narrative Cross-Cultural
Principlism
Autonomy Nonmaleficence/Beneficence Justice

11. From
Moral Intent To
Moral Action

12. 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

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

14. 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?

15. Charting a New Course

16. 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

17. 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?

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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:
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:
CRNBC. Boundaries in the nurse client relationship.
College of Registered Nurses of Nova Scotia. Professional boundaries and expectations for nurse-client relationships.
Campbell, C., & Gordon, M. (2003). Acknowledging the inevitable: Understanding multiple relationships in rural practice. Professional Psychology: Research and Practice, 34,
Farber, N., Novak, D., O’Brien, M. (1997). Love, boundaries, and the physician-patient relationship. Arch Int Med, 157,
Starzomski, R. (2002). Professional boundaries in nephrology programs. CANNT Journal,12(2),