An Ethics Early Action Protocol to Promote Teamwork and Ethics Efficacy.

BACKGROUND: Moral dilemmas and ethical conflicts occur in critical care. Negative consequences include misunderstandings, mistrust, patient and family suffering, clinician moral distress, and patient safety concerns. Providing an opportunity for team-based ethics assessments and planning could improve communication and reduce moral distress. OBJECTIVES: The aims of this study were to explore whether an early action ethics intervention affects intensive care unit (ICU) clinicians' moral distress, ethics self-efficacy, and perceptions of hospital climate and to compare nurses' and physicians' scores on moral distress, ethics self-efficacy, and ethical climate at 3 time points. METHODS: Intensive care unit nurses and physicians were asked to complete surveys on moral distress, ethics self-efficacy, and ethical climate before implementing the ethics protocol in 6 ICUs. We measured responses to the same 3 surveys at 3 and 6 months after the protocol was used. RESULTS: At baseline, nurses scored significantly higher than physicians in moral distress and significantly lower in ethics self-efficacy. Plot graphs revealed that nurses' and physicians' outcome scores trended toward one another. At 3 and 6 months post intervention, nurse and physician scores changed differently in moral distress and ethics self-efficacy. When examining nurse and physician scores separately over time, we found nurses' scores in moral distress and moral distress frequency decreased significantly over time and ethics self-efficacy and ethics climate increased significantly over time. Physicians' scores did not change significantly. DISCUSSION: This study indicates that routine, team-based ethics assessment and planning opens a space for sharing information, which could decrease nurses' moral distress and increase their ethics self-efficacy. This, in turn, can potentially promote teamwork and reduce burnout.

A Team-Based Early Action Protocol to Address Ethical Concerns in the Intensive Care Unit.

BACKGROUND: Ethical conflicts complicate clinical practice and often compromise communication and teamwork among patients, families, and clinicians. As ethical conflicts escalate, patient and family distress and dissatisfaction with care increase and trust in clinicians erodes, reducing care quality and patient safety. OBJECTIVE: To investigate the effectiveness of a proactive, team-based ethics protocol used routinely to discuss ethics-related concerns, goals of care, and additional supports for patients and families. METHODS: In a pre-post intervention study in 6 intensive care units (ICUs) at 3 academic medical centers, the electronic medical records of 1649 patients representing 1712 ICU admissions were studied. Number and timing of family conferences, code discussions with the patient or surrogate, and ethics consultations; palliative care, social work, and chaplain referrals; and ICU length of stay were measured. Preintervention outcomes were compared with outcomes 3 and 6 months after the intervention via multivariate logistic regression controlled for patient variables. RESULTS: The odds of receiving a family conference and a chaplain visit were significantly higher after the intervention than at baseline. The number of palliative care consultations and code discussions increased slightly at 3 and 6 months. Social work consultations increased only at 6 months. Ethics consultations increased at both postintervention time points. Length of ICU stay did not change. CONCLUSIONS: When health care teams were encouraged to communicate routinely about goals of care, more patients received needed support and communication barriers were reduced.

Ethics of organ procurement from the unrepresented patient population.

The shortage of organs for transplantation by its nature prompts ethical dilemmas. For example, although there is an imperative to save human life and reduce suffering by maximising the supply of vital organs, there is an equally important obligation to ensure that the process by which we increase the supply respects the rights of all stakeholders. In a relatively unexamined practice in the USA, organs are procured from unrepresented decedents without their express consent. Unrepresented decedents have no known healthcare wishes or advance care planning document; they also lack a surrogate. The Revised Uniform Anatomical Gift Act (RUAGA) of 2006 sends a mixed message about the procurement of organs from this patient population and there are hospitals that authorise donation. In addition, in adopting the RUAGA, some states included provisions that clearly allow organ procurement from unrepresented decedents. An important unanswered question is whether this practice meets the canons of ethical permissibility. The current Brief Report presents two principled approaches to the topic as a way of highlighting some of the complexities involved. Concluding remarks offer suggestions for future research and discussion.

A National Survey on Moral Obligations in Critical Care.

BACKGROUND: Critical care clinicians routinely encounter ethically complex situations. Ethical conflicts sometimes arise from different perspectives regarding goals of care and moral obligations. These conflicts contribute to providers' moral distress and burnout and can erode trust between patients, families, and clinicians. OBJECTIVES: To explore the most disturbing and most frequent types of ethically complex situations; compare clinicians' perceptions of their own, each other's, and shared moral obligations for providing quality care in these situations; and examine perceptions of communication and teamwork. METHODS: A national, web-based survey was made available to members of the American Association of Critical-Care Nurses and the Society for Critical Care Medicine. The survey included rank order, rating, and open-ended questions. RESULTS: Nurses and physicians ranked similarly the most frequent and disturbing ethical situations encountered during critical care practice. Nurses and physicians rated similarly physicians' moral obligations, but their ratings of nurses' moral obligations differed, with physicians giving lower ratings. Physicians also were more likely than nurses to report higher levels of trust (90.6% vs 66.8%) and more satisfaction with team communication (81.3% vs 66.9%). Narrative comments revealed embedded, entwined, and sometimes divergent expectations about moral obligations, which interfered with effective teamwork during ethically complex situations. CONCLUSIONS: Teamwork in critical care would benefit from acknowledgment of and clear communication about role-specific, interdependent, and shared moral obligations. Opportunities for routine, team-based dialogue about ethical aspects of care and moral obligations could reduce role ambiguity and ethical conflicts.

SUPPORT: An Evidence-Based Model for Leaders Addressing Moral Distress.

OBJECTIVE: The aim of this study is to explore nurse leaders' experiences working in ethically difficult situations and helping nurses cope with moral distress. BACKGROUND: Moral distress is associated with ethically complex situations where nurses feel voiceless and powerless. Moral distress can lead to disengagement, burnout, and decreased quality of care. METHODS: The critical incident technique was used to collect descriptions of ethically complex situations from 100 nurse leaders in California. Responses were qualitatively coded, categorized, and subsequently counted. RESULTS: Participants noted affective, behavioral, cognitive, physical, and relational signs of moral distress. System-level factors along with team conflict and different perspectives were perceived to increase the probability of ethical conflicts. Key actions to address moral distress included acknowledging its presence, creating a culture of care, and increasing nurses' resilience to difficult circumstances through education, support, and collaboration. CONCLUSIONS: On the basis of study findings, we created the SUPPORT model as an action guide for addressing moral distress.

Predicting Levels of Policy Advocacy Engagement Among Acute-Care Health Professionals.

This study aims to describe the factors that predict health professionals' engagement in policy advocacy. The researchers used a cross-sectional research design with a sample of 97 nurses, 94 social workers, and 104 medical residents from eight hospitals in Los Angeles. Bivariate correlations explored whether seven predictor scales were associated with health professionals' policy advocacy engagement and revealed that five of the eight factors were significantly associated with it (p < .05). The factors include patient advocacy engagement, eagerness, skills, tangible support, and organizational receptivity. Regression analysis examined whether the seven scales, when controlling for sociodemographic variables and hospital site, predicted levels of policy advocacy engagement. Results revealed that patient advocacy engagement (p < .001), eagerness (p < .001), skills (p < .01), tangible support (p < .01), perceived effectiveness (p < .05), and organizational receptivity (p < .05) all predicted health professional's policy advocacy engagement. Ethical commitment did not predict policy advocacy engagement. The model explained 36% of the variance in policy advocacy engagement. Limitations of the study and its implications for future research, practice, and policy are discussed.

Avenues of action in ethically complex situations: a critical incident study.

OBJECTIVES: The aims of this study were to explore nurse leaders' experiences with ethically difficult situations, perceptions about risk factors, and specific actions for ethical conflicts. BACKGROUND: Research indicates that nurses are reluctant to bring ethical concerns to nurse leaders for fear of creating trouble, and yet, nurse leaders are key figures in supporting ethics-minded clinicians and cultures. METHODS: The critical incident technique was used to collect descriptions from 100 nurse leaders in California. Responses were qualitatively coded, categorized, and counted. RESULTS: End-of-life situations accounted for the majority of incidents. Most situations had 3 to 4 ethical issues. Healthcare provider and system-level factors were perceived to increase the likelihood of ethical conflicts more often than family and patient factors. Respondents were more likely to identify leader actions that address specific situations rather than specify system-level actions addressing root causes of conflicts. CONCLUSIONS: Findings can be used to help leaders create ethics competencies, policies, and education.

Screening situations for risk of ethical conflicts: a pilot study.

BACKGROUND: Ethical conflicts, often leading to poor teamwork and moral distress, are very challenging to patients, patients' families, and health care providers. A proactive approach to ethical conflicts may improve patient care outcomes. OBJECTIVES: To examine acceptability and feasibility of an ethics screening and early intervention tool for use by nurses caring for critically ill patients. METHODS: Twenty-eight nurses in 2 medical centers applied the ethics screening tool to 55 patient situations. Nurses assessed situations for risk factors and early indicators of ethical conflicts and analyzed level of risk. At study completion, nurses participated in focus group discussions about the tool's benefits and challenges. Frequency counts were performed on risk factors and early indicators of ethical conflicts. Content analysis was used on written explanations regarding high-, medium-, and low-risk situations and on focus group data. RESULTS: Older patients with multiple comorbid conditions and aggressive treatments were frequently assessed to be at risk for ethical conflicts. Nurses who witnessed patients' suffering and deterioration were likely to initiate the screening process. The most prominent family risk factors included unrealistic expectations and adamancy about treatment. The most prominent early indicators were signs of patients' suffering, unrealistic expectations, and providers' own moral distress. High-risk situations averaged a greater number of risk factors and early indicators than did medium- and low-risk situations. Certain risk factors featured prominently in high-risk situations. CONCLUSIONS: A phenomenon of shared suffering emerged from the study and signifies the importance of relational strategies such as routine family conferences and ethics consultation.

A culture of avoidance: voices from inside ethically difficult clinical situations.

BACKGROUND: Healthcare providers experience many ethical challenges while caring for and making treatment decisions with patients and their families. OBJECTIVES: The purpose of this ethnographic study was to examine the challenges and circumstances that surround ethically difficult situations in oncology practice. METHODS: The authors conducted six focus groups with 30 oncology nurses in the United States and interviewed 12 key informants, such as clinical ethicists, oncologists, and nurse administrators. FINDINGS: The authors found that many healthcare providers remain silent about ethical concerns until a precipitating crisis occurs and ethical questions can no longer be avoided. Patients, families, nurses, and physicians tended to delay or defer conversations about prognosis and end-of-life treatment options. Individual, interactional, and system-level factors perpetuated the culture of avoidance. These included the intellectual and emotional toll of addressing ethics, differences in moral perspectives, fear of harming relationships, lack of continuity in care, emphasis on efficiency, and lack of shared decision making. This information is critical for any proactive and system-level effort aimed at mitigating ethical conflicts and their frequent companions-moral distress and burnout.

The nature of ethical conflicts and the meaning of moral community in oncology practice.

PURPOSE/OBJECTIVES: To explore ethical conflicts in oncology practice and the nature of healthcare contexts in which ethical conflicts can be averted or mitigated. RESEARCH APPROACH: Ethnography. SETTING: Medical centers and community hospitals with inpatient and outpatient oncology units in southern California and Minnesota. PARTICIPANTS: 30 oncology nurses, 6 ethicists, 4 nurse administrators, and 2 oncologists. METHODOLOGIC APPROACH: 30 nurses participated in six focus groups that were conducted using a semistructured interview guide. Twelve key informants were individually interviewed. Coding, sorting, and constant comparison were used to reveal themes. FINDINGS: Most ethical conflicts pertained to complex end-of-life situations. Three factors were associated with ethical conflicts: delaying or avoiding difficult conversations, feeling torn between competing obligations, and the silencing of different moral perspectives. Moral communities were characterized by respectful team relationships, timely communication, ethics-minded leadership, readily available ethics resources, and provider awareness and willingness to use ethics resources. CONCLUSIONS: Moral disagreements are expected to occur in complex clinical practice. However, when they progress to ethical conflicts, care becomes more complicated and often places seriously ill patients at the epicenter. INTERPRETATION: Practice environments as moral communities could foster comfortable dialogue about moral differences and prevent or mitigate ethical conflicts and the moral distress that frequently follows.

Barriers to innovation: nurses' risk appraisal in using a new ethics screening and early intervention tool.

We developed and assessed feasibility of an Ethics Screening and Early Intervention Tool that identifies at-risk clinical situations and prompts early actions to mitigate conflict and moral distress. Despite intensive care unit and oncology nurses' reports of tool benefits, they noted some risk to themselves when initiating follow-up actions. The riskiest actions were discussing ethical concerns with physicians, calling for ethics consultation, and initiating patient conversations. When discussing why initiating action was risky, participants revealed themes such as "being the troublemaker" and "questioning myself." To improve patient care and teamwork, all members of the health care team need to feel safe in raising ethics-related questions.

Making the call: a proactive ethics framework.

This manuscript proposes a proactive framework for preventing or mitigating disruptive ethical conflicts that often result from delayed or avoided conversations about the ethics of care. Four components of the framework are explained and illustrated with evidenced-based actions. Clinical implications of adopting a prevention-based, system-wide ethics framework are discussed. While some aspects of ethically-difficult situations are unique, system patterns allow some issues to occur repeatedly--often with lingering effects such as healthcare providers' disengagement and moral distress (McAndrew et al. Journal of Trauma Nursing 18(4):221-230, 2011), compromised inter-professional relationships (Rosenstein and O'Daniel American Journal of Nursing, 105(1):54-64, 2005), weakened ethical climates (Pauly et al. HEC Forum 24:1-11, 2012), and patient safety concerns (Cimiotti et al. American Journal of Infection Control 40:486-490, 2012). This work offers healthcare providers and clinical ethicists a framework for developing a comprehensive set of proactive, ethics-specific, and evidence-based strategies for mitigating ethical conflicts. Furthermore, the framework aims to encourage innovative research and novel ways of collaborating to reduce such conflicts and the moral distress that often results.

The gift of voice.

Initial writings and moral distress research focused on nursing, however, it soon became clear that others in healthcare also experienced moral distress. The narratives discussed in this commentary show this variation not only in the authors' multiplicity of disciplines (psychologists, nurses, an ethicist, and physicians), but also in their workplace environments (prisons, hospitals, and homecare) and their roles, from students to well accomplished professionals. In other words no one is immune. By looking through the lens of time the author shows that the experience of moral distress is not isolated in time, but in fact continues to be lived over time. Other important themes drawn out here are: isolation, powerlessness, failure, regret, undermined potential and the way feelings are experienced. It is also noted that despite the pain and angst, there is a sense of gratitude in these stories. They touch our own woundedness, remind us of our own resiliency and give us hope for the redemptive power of the experience and reflection.

Nurses' responses to ethical challenges in oncology practice: an ethnographic study.

Oncology nurses encounter increasingly complex ethical challenges in clinical practice. This ethnographic study explored 30 oncology nurses' descriptions of ethical situations and 12 key informants' perspectives on factors that influence the development of ethically difficult situations. Nurses described the goals of preventing patient suffering and injury, being honest with patients, and contributing meaningfully to patient improvement and stated goals. Nurses experienced six primary challenges in meeting their goals: being the eyes and arms of patient suffering, experiencing the precariousness of competing obligations, navigating the intricacies of hope and honesty, managing the urgency caused by waiting, straining to find time, and weighing risks of speaking up in hierarchal structures. Nurse actions included addressing concerns, creating other avenues, murmuring to one another, staying silent, and looking away. Several factors influenced nurses' responses to ethical challenges. Results imply a contextual model of moral action that reveals a need for altering practice environments in addition to improving nurses' ethics skills. Nurses are very aware of their moral responsibilities in ethically difficult situations and need work environments conducive to interprofessional collaboration and open dialogue.

Nursing priorities, actions, and regrets for ethical situations in clinical practice.

PURPOSE: Nurses in all clinical settings encounter ethical issues that frequently lead to moral distress. This critical incident study explored nurses' descriptions of ethically difficult situations to identify priorities, action responses, and regrets. METHODS: Employing the critical incident technique, researchers developed a questionnaire that collected information on ethically difficult situations, nurse actions, and situational outcomes. Data on nursing priorities and actions were analyzed and categorized using a constant comparison technique. FINDINGS: Addressing patient autonomy and quality of life were ethical priorities in the majority of cases. In many cases, nurses analyzed ethics from a diffuse perspective and only considered one dimension of the ethics conflict. However, some nurses were specific in their ethical analysis and proactive in their action choices. Nurses also identified 12 ethics-specific nurse activities, five ways of being, three ways of knowing, and two ways of deliberating. In 21 cases, nurses chose not to pursue their concerns beyond providing standard care. Several nurses expressed significant regret in their narration; most regretted unnecessary pain and suffering, and some claimed they did not do enough for the patient. CONCLUSIONS: Not enough specific, evidence-based ethics actions have been developed. Stronger and more proactive nursing voices with early ethics interventions would make valuable contributions to quality of care for patients, especially at the end of life. CLINICAL RELEVANCE: Ever-expanding treatment options raise ethical issues and challenge nurses to be effective patient advocates. Evidence-based nursing interventions that promptly identify and address moral conflict will benefit patients, their families, and the entire healthcare team by mitigating potential moral distress and disengagement.

Early indicators and risk factors for ethical issues in clinical practice.

PURPOSE: Nurses in all clinical settings encounter ethical issues that frequently lead to moral distress. This critical incident study explored nurses' descriptions of ethically difficult situations to identify risk factors and early indicators of ethical conflicts. METHODS: Employing the critical incident technique, researchers developed a questionnaire that collected information on ethically difficult situations, their risk factors and early indicators, nurse actions, and situational outcomes. Two nurse researchers independently analyzed and categorized data using a constant comparison technique. FINDINGS: Most of the ethically difficult situations pertained to end-of-life care for children and adults. Conflicts in interpersonal relationships were prevalent. Nurses were especially moved by patient and family suffering and concerned about patient vulnerability, harm-benefit ratio, and patient autonomy. Researchers discovered risk factor categories for patients, families, healthcare providers, and health systems. Additionally, researchers found subcategories in six major categories of early indicators: signs of conflict, patient suffering, nurse distress, ethics violation, unrealistic expectations, and poor communication. CONCLUSIONS: Nurses are keenly aware of pertinent risk factors and early indicators of unfolding ethical conflicts. Many nurses reported feeling powerless in the face of ethical conflict. Research that develops interventions to strengthen nurses' voices in ethically difficult situation is warranted. CLINICAL RELEVANCE: Nurses are in a key position to identify patient situations with a high risk for ethical conflict. Initiating early ethics consultation and interventions can alter the course of pending conflicts and diminish the potential for patient and family suffering and nurses' moral distress.

An intervention to improve respiratory therapists' comfort with end-of-life care.

BACKGROUND: Respiratory therapists (RTs) are often involved in treating seriously ill and dying patients, but receive little instruction in end-of-life care. Prompted by several difficult cases, we developed an interdisciplinary program to introduce practicing RTs to ethical and end-of-life issues, and evaluated the program with a dedicated survey instrument. METHODS: A convenience sample of RTs from a university hospital and nearby community hospitals participated in a one-day interactive program, in 2005 (n = 49) and in 2008 (n = 36), that included role-play and didactic components. The questionnaire completed before and after the program included scales on comfort with end-of-life care and role in end-of-life care, and knowledge indices. RESULTS: Nearly all the RTs had recently encountered end-of-life situations, yet most had not received dedicated training and felt ill-prepared to deal with these situations; one third reported distress related to withdrawal of treatment. The 78 participants who completed both the before and after surveys had increased comfort with end-of-life care (P < .001) and their perception of their role in end-of-life care (P < .001). Knowledge about end-of-life care also increased (P < .001). CONCLUSIONS: A one-day interactive educational intervention can improve short-term RT comfort and role perception concerning end-of-life care. Evaluation of longer-term clinical outcomes and implementation in other venues is needed.