The Culture of Healthcare and Ethical Dilemmas
Unrelieved pain and suffering, an aggressive, end-of-life treatment regime, and arguing family members —all indicators of an ethical dilemma. And while nurses are positioned to identify these dilemmas, they may feel compromised in their ability to take action.
With advances in technology, complexity of healthcare financing, and proliferation and accessibility of healthcare information for patients and their families, moral pressure is more complex than ever, yet the current healthcare culture doesn’t incorporate shared ethical decision making for healthcare providers.
“The electronic medical record doesn’t provide any prompt to document ethical concerns, as it does for clinical or psychosocial issues,” said Katherine Brown-Saltzman, Co-Director of the UCLA Health System Ethics Center. “It takes a person to actually elevate the discussions, in a sense its having to go against the grain.”
Carol I. Pavlish, Associate Professor, UCLA School of Nursing, has been dedicated to pursuing cutting-edge clinical ethics research with Brown- Saltzman. They began studying what ethically difficult situations are and completed an ethnographic study to better understand what beliefs practices or other factors surround these scenarios, most of which pertained to treatment decisions toward the end-of-life.
“Clinical ethics is a really new field; it doesn’t have much research behind it yet,” said Pavlish “We have a lot to learn in how to effectively and proactively address ethical issues.”
Based on their findings, they developed a tool to help nurses identify ethically difficult situations and take early action to prevent or mitigate them. It was tested in oncology and intensive care units at UCLA Health System and the Mayo Clinic in Rochester, MN with results published in Advances in Nursing Science in September 2013.
“We thought the research was really valuable,” said Joan Henriksen Hellyer, Ethics Consultation Program Coordinator, Mayo Clinic, Rochester. “That project went really well having parallel projects in two different major medical centers, and we had very similar results, so that was encouraging.”
But despite use of the evidence- based tool, raising ethical concerns with physicians or bringing an ethical consult was still difficult for the nurses to do. The tool helped validate the ethical concerns they perceived, but did not provide the courage or comfort level to speak up. The nurses thought they would be ostracized by the physicians, scolded by their nurse managers or feared being the troublemaker.
“They saw those things or perceive those things as risky—say riskier than talking to a colleague or calling in a chaplain or social worker,” Henriksen Hellyer said. “So we were trying to design systems that make it easier for people to do the right thing.”
Moral Distress
Pavlish was surprised how much and for how long moral distress really affected nurses. There was prolonged regret, where healthcare providers looked back and wished they did more.
“Moral regret does accumulate in certain instances, and moves toward moral distress which obviously has negative consequences such as disengaging from the work that you are doing,” Pavlish said. “One of the dangers or morally difficult situations is not having a venue or an opportunity to process them.”
If moral concerns are addressed earlier, they can be dealt with before they become conflicts that are really difficult to resolve and before they lead to damaged work relationships or even deteriorate quality of care.
“So often an ethical conflict can be seen as I’m right, you’re wrong,” Brown-Saltzman said. “Once you enter into that realm, then people are placed into their corners.”
Conflicts can also occur among many different levels and relationships.
“We found conflicts not only between healthcare providers, which did occur, but also between providers and families, and families and patients,” Pavlish explained.
Systems Focus
Expanding the research focus to include other direct care providers, such as physicians, Pavlish found the systems were not operating well. For example, physicians are seeing more patients, are pressured for time, and didn’t always view ethical communication as a shared moral obligation for the healthcare team.
“Nurses are called patient advocates, and it’s interesting that physicians also say they are patient advocates, so what we need to do now is talk about how we can advocate together,” explained Pavlish. “We were trying to understand how these systems really could work with nurses and physicians collaborating on this.”
Ironically, “advocating” for a patient can be an aggressive, single-minded action, if not approached in the right way.
“This idea of advocacy can actually be harmful, acting simply as the lone advocate versus being a co-advocate,” Brown-Saltzman said. “In a sense, it is an essential responsibility to enter into a collaborative relationship with others where we share responsibility and enhance relationships, even as we raise difficult issues.”
Pavlish and Brown-Saltzman have developed a collaborative model called CO-ADVOCATE (as an acronym for the essential steps), which incorporates the voice of the patient, family, nurse and physician to work through moral challenges. Together with nurse ethicists from Mayo Clinic and Massachusetts General, they received a grant from the American Association of Critical- Care Nurses to test it.
Culture Shift
Improving nurses’ ethics skills is not enough; a cultural shift is needed to address all the factors surrounding ethical decisions. Ethics should be integrated to the point it is an expectation and a shared responsibility among healthcare providers—a value of the organization.
“If you have a safe environment, a safe place, people can really speak out freely about their concerns and the distress which is placed on their own personal value systems,” Henriksen Hellyer said. “Only if it’s safe, can they keep their patients interest as the highest priority.”
Pavlish, Brown-Saltzman, and Henriksen Hellyer are redesigning the ethics screening tool incorporating the results of their 2013 study. Pavlish and Brown-Saltzman are also researching how ethically difficult situations are handled by nurse managers and leaders.
“What we’ve done is create, for all healthcare professionals and administrators, a sense of comfort in cultivating an environment where ethics is integral—just a part of the fabric,” Brown-Saltzman said. “I think we are getting there.”