Author addresses moral distress in nursing in new book

One nurse devotes her career to understanding and tackling ethics issues in nursing that threaten to undermine not only the profession, but also healthcare quality.

[caption id="attachment_55227" align="alignleft" width="300"] moral distress in nursing Cynda Hylton Rushton, RN[/caption] Meet Cynda Hylton Rushton, PhD, RN, FAAN, the Anne and George L. Bunting professor of clinical ethics at Johns Hopkins University who co-chairs the Johns Hopkins Medicine's Ethics Consultation Service. She co-led the first National Nursing Ethics Summit, which resulted in "A Blueprint for 21st Century Nursing Ethics." In her new book, "Moral Resilience: Transforming Moral Suffering in Healthcare," Rushton takes a first-ever systematic look at moral resilience in nursing in the hope others use it as a catalyst to learn more.(Get a 30% discount on Rushton's book by using code AMPROMD9 at checkout.) We asked Rushton what fuels her work in ethics, how ethical issues might affect nurses professionally and personally and what nurses can do to help themselves and their profession.

You said the bedside experience has informed everything you have done professionally. What did you mean by that?

Rushton: I consider myself to be kind of a nurse's nurse. I have always been committed to my clinical practice. And it has always been in that context that I've learned the most about myself and about what it means to be a nurse and the moral adversity that comes with the role. I started out in the pediatric ICU and often was confronted with questions about how we ought to be using our technology to sustain the lives of children who had life-threatening diseases or injuries. I worked with families to try to figure out what was the right thing to do for their children.

It was really through those roles that I became more and more interested in the ambiguity and uncertainty that was part of our work -- especially as technology was expanding at a really rapid rate.

I do quite a bit of ethics consultation and, of course, that brings me right back to the bedside with patients, families and distressed staff. It's clearly what keeps things current and real for me.

Do you have an example of an ethical dilemma in nursing?

Rushton: There are so many. A lot of them have to do with end-of-life care. One example is a child with a very complex congenital heart defect and the need for sometimes innovative and risky surgery that could result in death or disability. Yet parents want to do everything possible to help their child. Of course, we want every child to live well, but sometimes there is a prolonged period of time in which children are tethered to technology. As a nurse, you witness how much the child is suffering, as well as people around the child -- the family and often the clinicians. We struggle trying to figure out how far we should go and what amount of suffering is reasonable to endure to give a child a chance for life.

I think there are issues around how do we demonstrate respect for people whose choices are contrary to our core values? For example, a parent who intentionally harms a child and that renders the child with a devastating injury. Yet our job is to care for both the child and the family regardless of how that child arrived in our care.

Those are the kinds of things that really call into question our core values about ourselves and our work.

What does it mean to practice ethically as a nurse?

Rushton: I think practicing ethically means that we first know who we are, what we stand for and what our core and professional values are. Then, it means having a way to recognize when ethical issues are arising that threaten those values and know how to think through and navigate them in a way that reflects the values that are most important. Values like respect, compassion and justice are part of many people's personal values and are very clearly part of our professional values as nurses and in our code of ethics.

It's an ongoing process of recognition and discernment. Nurses need to have the skills and tools. They need to practice in an environment that fosters their ability to do that.

That includes having mechanisms in which speaking up about concerns is an accepted response and those concerns are heard and responded to in a respectful way. That means there are resources that can be leveraged to support nurses to do the right thing, like ethics committees and consultation services. It also means organizations have proactive ways to recognize the patterns that create ethical challenges for people and take action to address them.

What forces in healthcare might impede ethical practice?

Rushton: I think there are many, many forces that impact nurses' ability to practice ethically, including external forces that involve financial arrangements and incentives. These include insurance and how we allocate resources and budget in terms of recognizing the pivotal role that nurses play in healthcare. There are laws and regulations that create pressures around things like documentation that influence the way nurses practice. I also think there are issues in society -- some of which I've already mentioned -- that show up related to social determinants of health. In many places, those include the erosion of community programs that support people's recovery from illness or injury and the breakdown of relationships in society. If you look at the Future of Nursing report, one of the things that was called for was for nurses to practice at the top of their license and training. I think that is still a barrier for some nurses -- that they are not in environments in which their authority and expertise is fully recognized and honored.

Why is it important to have a foundation of ethical practice? For example, do we know what happens when nurses feel unethical?

Rushton: Ethical practice is foundational to what it means to be a nurse. Without a moral compass, we are really rudderless in the sea of complexity that we practice in. We have to have some grounding that helps us when things are uncertain or ambiguous to sort of keep us connected to why we're doing the work we're doing. For example, our code of ethics is really clear about our obligations to the promise we've made to the public in terms of how we will serve them with respect and compassion and fairness.

Without those values, it's easy for us to get distracted with things that don't really matter but are sort of propelling us in a direction that doesn't really reflect why we're here.

What we know from research on moral distress in nursing is that having a gap between our values and what we actually do (if we are not able to do the right thing) causes moral distress. We know there's a relationship between moral distress and burnout, and that those situations are clearly a factor in the health and well-being of the workforce. That has huge implications both locally and nationally, because without a healthy nursing workforce this healthcare system is unsustainable. So, it's really a call to action to say we have got to pay attention to the signals and data about both moral distress and burnout and to take action at a systemic level to address the causes of moral distress and burnout.