Hospitals should encourage clinicians to act on their values, expert says

December 15, 2011

When clinicians feel that they cannot act upon their convictions in providing patient care — and when this happens on a regular basis where they practice — they can experience distress and burnout.

To help prevent this from happening, health care facilities must be attuned to their clinicians' perception of their work and the workplace. They must ensure their frontline caregivers have the autonomy to express and act upon their values. That is according to Carol Taylor, the presenter of the late-October, CHA-sponsored webinar: "Between a Rock and a Hard Place: Facing the Challenges of Moral Distress." Taylor is a professor of medicine and nursing at Georgetown University Medical Center's Center for Clinical Bioethics in Washington, DC.

"When people can't translate their moral choices into action, their integrity is compromised," Taylor said. "People will think, 'I have to sell my soul to be effective at work.' But, it is not reasonable to expect workers to be untrue to themselves to do their work."

Taylor explained that clinical staff can feel moral distress when they believe their integrity is at stake. This can happen when they believe a certain course of patient care is appropriate, but internal or external factors prevent them from acting on their instincts. Taylor said studies have found that nearly 50 percent of nurses have experienced moral distress at work. She noted, though, that while moral distress commonly is associated with nurses, any clinician can experience the emotion.

To illustrate conditions that cause moral distress, Taylor spoke about a group of nurses at a small, rural hospital who believed that one of the surgeons was under-medicating pain in his patients. When the nurses complained, they were told, "You're not supposed to be an advocate for the patient." They felt their clinical observations of patients' distress were being dismissed.

Many different constraints can prevent clinicians from doing what they believe is right, said Taylor. On a personal level, they may feel powerless; they may doubt themselves or their knowledge; they may fear the consequences of standing up for their values.

On a facility level, hospitals must be alert for systemic issues that invite problems for the frontline caregivers. For instance, chronic staff shortages may force a hospital's caregivers into shortcuts they don't want to make. The hospital may be lax in securing advance directives from patients, and so conflicts can arise in deciding the course and intensity of treatment in late-stage illness. In the absence of advance directives, a hospital may engage in defensive medicine to ward off litigation, making some caregivers uncomfortable with the type and amount of care given, she said.

Commonly, moral distress arises because a hospital or clinical team has a dysfunctional culture, Taylor said. Facilities are at risk of dysfunction when they overemphasize titles and hierarchy, and discount the expertise and observations of lower-level employees. Leaders may overtly or covertly convey the message that hourly employees who offer unsolicited suggestions of how to improve patient care or work flow are acting beyond their station and are not team players. Employees in this situation may feel that to speak out is to risk a bad evaluation or be labeled as a malcontent.

Drawing on work by the American Association of Critical-Care Nurses, Taylor said health care facilities should regularly assess how well they're protecting clinicians' autonomy. For instance, they should have mechanisms in place to monitor nurses' comfort levels with how they are delivering care. The organizations should have a process in place to follow up on problem areas, and they should create policies that promote good communication. Taylor said, "We need to shine a light on these problems and address them."

She recommended that hospitals hold employee forums to give all clinicians a voice in important discussions. And there should be processes in place to ensure that employee input is taken into account in high-level decisions.

Taylor acknowledged that it is difficult for organizations to recognize and address systemic concerns that cause moral distress. But organizations that fail to do so can pay a price, she said.

Employees who continually feel they cannot do what is right may numb themselves to the situation, withdraw emotionally from their work and question their desire to stay at a facility, or even to remain in their field. "Then you see good people leaving the profession," Taylor said.

Over time, unaddressed problems at a hospital can create a culture of mistrust, defensiveness and divisiveness, which can fuel high turnover rates and contribute to chronic understaffing. Patient care can be compromised if communication problems among team members are persistent.

"To avoid this, we need to make a commitment to ensuring our clinicians feel valued," said Taylor. "We need to have a robust program in place to make sure they are willing to report problems and to stand up for their beliefs."


Copyright © 2011 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Copyright © 2011 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.