1. Moral Distress Patricia (Paddy) Rodney, RN, MSN, PhD Associate Professor & Undergraduate Program Coordinator, UBC School of Nursing Faculty Associate, UBC Centre for Applied Ethics PHC Ethical Reflection Conference April 2, 2009 This presentation is based on research and writing done by P. Rodney, C. Varcoe, J. Storch, B. Pauly and G. Hartrick Doane

2. Ethical Musings… IS OUGHT

3. Moral Agency Personal enactment of ethical responsibilities Personal enactment of ethical responsibilities Action is intentional and directed towards “the good” Action is intentional and directed towards “the good” Action is experienced as embodied Action is experienced as embodied Action and reflection hold significant meaning for the moral agent Action and reflection hold significant meaning for the moral agent Effective moral agency requires authenticity, connectedness and trust Effective moral agency requires authenticity, connectedness and trust

4. Health Care Workplaces Over the Past Decade  Growing shortages of providers and resources  Increasing patient acuity, family stress  Growing workloads, casualization  Ongoing restructuring and reorganization, loss of practice leaders  Increasing stress, illness, injury, and attrition of nurses and other providers  Decreased patient satisfaction  Increased morbidity and mortality

5. Moral Climate Patient Safety Provider Safety

6. Safe Moral Climate The safety of patients is linked to the safety of nurses and other members of the health-care team. Both depend on a safe moral climate in which the required organizational, material and interpersonal resources are available and the values for safe, competent, ethical care are in place. (Rodney, Doane, Storch, & Varcoe, 2006)

7. The Moral Context of Practice Moral Choice Moral Action Moral Distress

8. 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)

9. Moral residue “is that which each of us carries with us from those times in our carries with us from those times in our lives when in the face of moral distress lives when in the face of moral distress we have seriously compromised we have seriously compromised ourselves or allowed ourselves to be ourselves or allowed ourselves to becompromised” (Webster and Baylis, 2000)

10. Environment: Structural and Interpersonal Challenges (unit, agency, region) Self: How People See Themselves and Their Own Action Self in Relation to Environment: How People Respond to Others and to the Challenges in Their Environment SITE FOR ACTION AND EVALUATION WHAT WE HAVE LEARNED…

11. Leadership for Ethical Policy and Practice: Using an Ethics Lens to Improve Healthcare Workplaces (2004-2007) Co-PIs: Jan Storch, Paddy Rodney Co-PIs: Jan Storch, Paddy Rodney CoIs: Colleen Varcoe, Rosalie Starzomski, Bernie Pauly, BC CNOs, National Nurse Leaders, BC Nurse Leaders & Direct Care Nurses, Other Health Care Professionals RAs: Kara Schick Makaroff, Lorelei Newton, Cherry Curry, Gladys McPherson, Laura Housden, Elaine Moody, Olecia Klotchkova

12. OUR THANKS TO FUNDERS…  Canadian Health Services Research Foundation (CHSRF)  Health Canada  Associated Medical Services, Inc  Each CNO & Region/Agency  Providence Health Care  First Nations and Inuit Health Branch

13. BC CNOs/Leaders Fiona BeesHeather Mass Lynnette BestAmy McCutcheon Anne CookeBarbara Mildon Kim DoughertyLynne Stevenson Tom FultonCathy Ulrich National Nurse Leaders Sandra MacDonald-Rencz Judith Shamian PLUS CONSULTANTS AND NUMEROUS PROJECT SITE LEADERS!

14. Sample Strategies…  Yearly conference with regions together  Site-based retreats/workshops  Unit-based councils  Interdisciplinary networking  Formal research proposals  Links to other initiatives (eg. patient safety)  Changes to related structures/processes (eg. rounds, staff meetings)  Involvement of other resource people (eg. ethicists)

15. Our Insights ………..  An ethical lens can enhance research on health care workplaces  The moral climate shapes patient and health care safety  Nurses and other health care providers need support to use the language of ethics  Including other disciplines in this proactive work is important  Nurses in advanced practice and other leadership positions are crucial

16. Our Insights continued ………..  Nurses and other health care providers in direct care roles MUST be able and enabled to be more actively involved  Health care providers from every facet of their profession need more time for self- reflection  There is a pressing need to move away from “us-them” stances  Collective action from all facets of health care professions is essential (Rodney, Doane, Storch, & Varcoe, 2006)

17. PROJECT ACTIONS to consider………..  Start with hope  Create an initial steering group  Negotiate leadership  Reflect on power dynamics  Seek support from others who can help  Convene an initial retreat/workshop  Work out short-term and long-term goals  Expect skepticism and be honest  Build in regular evaluation  Share with other providers and agencies  Consider research funding  Maintain hope! (Storch & Rodney, 2007)

18. Building Relational Capacity (Hartrick Doane & Varcoe, 2005) Individual, Organizational, Regional, National, International