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4 Rs Strategy Offers a Fresh Perspective to Confront Ethical Challenges


Kathleen Turner, RN, CHPN, CCRN-CMC, Clinical Nurse III in the Medical-Surgical Intensive Care Unit at the University of California San Francisco Medical Center, knows all too well how repetitive ethical challenges can become entrenched in nurses' minds, affecting the way they think, feel, and practice.

Turner and co-author Cynda Hylton Rushton, PhD, RN, Professor of Clinical Ethics at the School of Nursing and Berman Institute of Bioethics at Johns Hopkins University, Baltimore, Md., studied and discussed the issue that's becoming more acute in the age of COVID-19 ICU care and came up with a four-step process to help nurses combat how ethical challenges affect them. Their paper "Suspending Our Agenda: Considering What Will Serve When Confronting Ethical Challenges" was recently published in the American Association of Critical-Care Nurses' Advanced Critical Care.

Can You Relate?

The authors referred to a patient, Tom Franklin, and his wife as an example of how the cascade of events in an ICU might unfold. Franklin had been in the ICU for several weeks and had a lot of ups and downs. The healthcare team and patient's wife developed an adversarial relationship and were not seeing eye to eye regarding the patient's care. [caption id="attachment_76857" align="alignleft" width="200"] Kathleen Turner, RN[/caption] "Doctors and nurses have a very definite idea of how we expect things to play out and what the right answer is going into the family meetings," Turner said. "The situation that we described with Mrs. Franklin is that the team doesn't expect that he will survive his hospital stay and the team is concerned that their care is providing harm rather than benefit. What they're hoping for from his wife is that, at the very least, she'll agree to the do-not-resuscitate order and ideally that she would agree to transition to comfort care." Turner said in her 17 years as an ICU nurse, at any given time, there has been at least one patient and family on her unit in a similar situation.

Hitting the Ethical Challenges Roadblock

Turner admits that when she was a new ICU nurse she was distressed and surprised when these situations would come up. "I would think that what is happening to my patient must be an anomaly," Turner said. "Then it sort of shifted to well it must be a problem with the physicians. Maybe if they said the right words or if they met with this family one more time. Then, as I gained more experience and sat in on more family meetings myself, even on night shifts, I could see that the doctors were doing their very best to lay out really complicated and catastrophic situations. I started to shift to wondering how is this family member not seeing what I'm seeing? Why are they continuing to expect that this plan of care that seems for of stuck will continue indefinitely?" Those questions, according to Turner, developed into a chronic form of moral distress.

The Ramifications

There is a relationship between futile and potentially inappropriate care and burnout, according to a 2019 article in the Journal of Palliative Medicine. The authors discovered for all members of the care team, both witnessing and providing this kind of care was associated with all dimensions of burnout.

"It seemed to be mediated by feelings of guilt and shame, where nurses and doctors were avoiding their own patients or avoiding patients' families or avoiding other members of the care team in a way to sort of hide from their own painful feelings," Turner said.

Taking an Alternative Road With the 4Rs

While many of the ethical challenges that critical care clinicians confront will have a moral remainder, it is possible not only to shift their perspectives but to shift their relationship to the realities they're in, Rushton said in an AACN news release on the paper. "A process that cultivates self-awareness, self-regulation and compassion is vital for creating a foundation that fosters mindfulness and insight," Rushton said. Turner and Rushton created a potential solution built on 4Rs: recognize, release, reconsider, and restart. Recognize. The first thing nurses should do is recognize the situation for what it is; not what it represents. A nurse's first thought when walking into a patient's room is that the situation reminds the nurse of so many others have experienced. There may be that temptation to short-change the complexities of the patient, the patient's family, the care team, what they're hoping for, what they're afraid of, and what they're worried about, according to Turner.

"Past experiences with other families and other physicians might bleed into my assessment of the current situation," Turner said.

Rushton has written papers about "moral residue," the baggage that nurses and others carry with them. This moral residue can color a nurse's perception of an individual patient's situation, narrowing the nurse's view about what's really going on at that time. It's human to have assumptions and biases. The key is to recognize them, according to Turner. The reality is there's so much more than one's past experience. Turner, who works the night shift, said most senior members of the medical team are not readily accessible. "The person who may be called to have really difficult discussions with the family members is someone who is only a few years out of medical school and has been up all day, hasn't had anything to eat, has a pager going off and all these other patients to worry about," she said. "To recognize that I, myself, may be tired. To recognize the very human limitations of myself, my colleagues in other disciplines, of the family member."

Families, for example, might be frustrated because they can't get access to their loved ones, or if they have access, they might have been stuck in the hospital for weeks at the bedside.

It helps everyone involved to have that moment of shared humanity, recognizing someone else's unique situation, according to Turner. Release. The next step is to release. A nurse who recognizes what's going on in a particular situation can then look at what is and isn't his or hers to "hold," according to Turner. What can and can't the nurse change or make better? "Exhale and let go of what needs to be put down," Turner said. "That might be all of the memories of past patients in similar situations. It is sad that all these people that I'm remembering went through what they went through, but this patient has his own situation and he deserves my full attention. So, release, but not in the sense of dismiss. Bracket feelings, thoughts and behaviors that are not helpful in the present moment." Reconsider. Reconsidering the situation might be as straightforward as reframing an issue or looking at it in an entirely new way. It involves being open to new approaches and invites clinicians to understand the perspectives of others to rebuild trust and rapport with the patient, family, and team. An example of a troublesome issue occurring during the pandemic is hospital visiting policies, Turner said. "We've done the immediate crisis step of locking down our hospitals," Turner said. The "reconsider" step involved looking at how to connect patients with their families and caregivers despite visitation rules. "How can we inside the hospital reach out to them to help build and maintain trust and rapport," Turner said. Restart. At this point, nurses might find that they're asking new questions, feeling empathy and have a fresh focus on how they can help the team and the family move to a place of greater understanding and engagement. One solution that nurses are using to connect patients, families, and care providers, for example, is virtual platforms, like Skype. Some of what nurses try in these situations might or might not work. But that shouldn't stop the nurse from trying new things or the same things on other patients and families, according to Turner. "It's a very empowering way to practice nursing because it really focuses on what can I do?" Turner said. "It taps into the creative problem solving that's a strength of the nursing approach to care," Applying the 4Rs has made it possible for Turner to continue practicing in the ICU, she said. "In the ICU where I work, it's a 32-bed unit and we're full almost all of the time," she said. "The in-between process from arrival to either discharge or death has a lot of bumps, even under the very best circumstances. That can wear me down or make me hard or detached or in some ways decrease my empathy and compassion for my patients, families, and colleagues." Instead, when she takes this approach of looking at situations through the eyes of others' and understanding what's at stake for them, she feels the sadness without feeling depleted or harmed.

"It doesn't stop being hard but it becomes sustainable and even rewarding," she said.

While Turner has applied the concept only in the ICU setting, she believes it could help nurses in many other hospital units, including oncology and transplant. "The kinds of situations that are difficult for me in the ICU differ in details but not in substance from issues that nurses have in other parts of the hospital," she said.

Take These Courses to Learn More About Ethical Challenges:

Nursing Ethics, Part 1: The History of Bioethics in the United States (2 contact hrs) This course provides an overview of the history of bioethics as it applies to healthcare and nursing in the U.S. Describing the historical events and forces that brought the bioethics movement into being, this module helps nurses understand the concepts, theories, and principles that are its underpinnings. Nursing Ethics, Part 3: Ethics in Nursing (1.5 contact hrs) Nursing is a moral profession. But technological advances in healthcare require that nurses expand their instinctive understanding of ethics into one of reasoned and deliberate knowledge. This course informs nurses about the Code of Ethics for Nurses, nursing ethics committees and nursing advocacy, all of which help maintain the integrity of nursing. Nursing Ethics, Part 5: The Process of Ethical Decision Making (1 contact hr) The principle of well-being, or beneficence, doing good and preventing harm, obliges the nurse to promote the health and safety of patients in decisions made by and for them. The principle of equity, or justice, requires that patients be treated fairly and equally in the decision-making process. This module will further explore these principles and discuss methods of determining decision-making ability in borderline cases.