Challenges of Ethical Conflict and Moral Distress
The current ANS “Editor’s Pick” article presents a feasibility study to assess the usefulness of an innovative ethics screening tool for nurses who are dealing with critical ethical situations. The article, titled “Barriers to Innovation: Nurses’ Risk Appraisal in Using a New Ethics Screening and Early Intervention Tool” is by Carol L. Pavlish, PhD, RN, FAAN; Joan Henriksen Hellyer, PhD, RN; Katherine Brown-Saltzman, MA, RN; Anne G. Miers, MSN, RN, ACNS, CNRN; and Karina Squire, MPH, BS, RN. This team of authors has provided this message for ANS readers:
Have you ever stood at a patient’s side and wavered precariously between believing in the treatments you provide and
dreading the painful consequences? Have you ever hoped with all your heart that these treatments will work while the experienced voice inside worries they most likely will not? Have you ever turned away from yourself…your true self… just so you can come back to work the next day?
One of the most commonly-occurring ethical dilemmas that nurses encounter is silently weighing their moral obligations to patients while facing uncertainty, being surrounded by unwavering hope, and finding themselves squarely in the middle of a healthcare culture that dis-incentivizes difficult conversations. Silence is the powerful perpetrator of that culture – and we as nurses are too often its accomplice.
When researching the feasibility of applying an evidence-based ethics screening tool that encourages nurses to express concerns, we were surprised at the tenacity of their silence. We found that some nurses “let it slide” because systems see no profit in ethical deliberation and place certain demands on exactly how nurses should use their time. Hierarchical power structures can drive nurses to avoid “being the troublemaker”. Furthermore, some nurses “questioned themselves” instead of turning the question outward – outward to structures that concentrate power in the hands of a few making it all the more difficult to “query the gatekeepers.”
Speaking up is not a risk-free action in health care. As a result, concerns become “unspeakable.” Jane Georges warns us that compassion becomes more difficult and even impossible when concerns are “unspeakable.”
Without compassion, nursing care becomes mechanical at best – dangerous and alienating in its worst form. Our research seems to indicate that nurses who bring innovations to health care cannot just focus on preparing nurses for new roles. We must also challenge and change systems that find comfort in the status quo. As Peggy Chinn says in her editorial, “The time has come for nurses to come together as never before to revive some of the innovative models that existed in the past and to creatively forge ahead into uncharted territory.” We have a rich tradition of moral courage in nursing – from Florence Nightingale to Lillian Wald and many others – all of whom challenged the “unspeakable” and created conditions where health and human flourishing can actually happen.
Part of moral courage is reclaiming that heritage and finding our own voice to ask four key questions: a) What is wrong with this picture? b) Who benefits? c) What are the barriers to freedom from what is
wrong? and finally, d) What needs to change? Chinn and Kramer posed this four-question framework in Integrated Theory and Knowledge Development in Nursing (2011). The framework moves us beyond the “unspeakable” and strengthens our voices to participate actively in creating innovative systems of care – where clinicians appreciate value-laden contexts, challenge each other to dialogue about ethical concerns, and ultimately provide focused goals that honor what healthcare providers in good conscience can provide for patients.
While it is featured, this article is available to download at no cost. Then come back here and post your comments and questions here … the authors and I want to hear from you, and we will respond!
While I am not a nurse, I appreciate the attention being given to having difficult conversations. My husband and I are both moving into elder-care scenarios with our parents, and there are many conversations that need to take place, but aren’t always. I am glad that there are nurses who are willing to be courageous and facilitate such things, for healthcare in general, and elder-care in particular.
Thank you so much for sharing this comment! One of the fundamental principles on which nursing is based is that of advocacy, which means that nurses must be tuned in to what people want and need, and having courageous conversations flows from that. But yes, these conversations are not easy and are not always part of what happens, so hearing from you about this gives us an extra measure of determination to work toward this ideal! Thank you so much!
Excellent article and so happy Dr. Pavlish and her team has received the AACN Impact Grant for 2014 to continue this important research!