EXECUTIVE SUMMARY
Moral distress reported by ED nurses stems from the inability to provide good care to complex patients because of insufficient resources, according to a recent study. Bioethicists can do the following:
- Make ED nurses aware that it’s not a personal failure, but rather a systemic issue in need of fixing.
- Create mechanisms for ED clinicians to communicate their concerns to colleagues and leaders.
- Hold discussions of ethically challenging ED cases.
ED nurses participating in focus groups described a profound feeling of not being able to provide patient care as they wanted, a recent study reported.1
“ED nurses’ feelings of moral distress are the canary in the coal mine. They are a clear signal that there is something bad happening,” says Lisa Wolf, PhD, RN, CEN, FAEN, the study’s lead author. Wolf is director of the Institute for Emergency Nursing Research of the Des Plaines, IL-based Emergency Nurses Association.
Wolf and colleagues found that clinicians working in EDs experience moral distress as a result of threats to quality and safety of both patients and clinicians, inadequate or unsafe staffing, unnecessary pain and suffering, conflicting roles and expectations, triage and disposition of patients, and time pressures exacerbated by bureaucratic requirements that undermine nursing practice.
“Many of these issues reflect the burgeoning strain on the healthcare system to provide care to sicker, more complex patients without a sufficient infrastructure to do so in a safe, fair manner,” says Cynda Hylton Rushton, PhD, RN, FAAN, Anne and George L. Bunting Professor of Clinical Ethics at Johns Hopkins University’s Berman Institute of Bioethics in Baltimore.
Rushton says external factors are undermining the integrity of ED clinicians to uphold their ethical obligations to provide safe, respectful, and equitable care to those in need of healthcare. “Organizations and external regulatory agencies must begin to take seriously the unintended consequences of policy decisions that are undermining ethical practice,” she urges.
ED nurse practitioners experience moral distress due to inadequate staff communication and working with colleagues lacking the competence level needed for patient acuity, according to another study which suggested that moral distress influences ED nurse practitioners’ intent to leave their position.2
“Improving interprofessional communication, developing competencies of all medical staff members, and maintaining sufficient staffing are a few of the important aspects of ensuring moral distress does not reach levels that have personnel consider leaving their current position or their profession,” says Jennifer Trautmann, PhD, RN, FNP-BC, the study’s lead author. Trautmann is the Morton K. and Jane Blaustein Post-doctoral Fellow in Mental Health and Psychiatric Nursing at Johns Hopkins University School of Nursing in Baltimore.
The following are some underlying causes of moral distress in the ED setting:
• There is a lack of resources for behavioral health patients.
“There is a feeling like, ‘I should be able to help these people, but I can’t because their problems are so much bigger than I can address in the two hours that they are here,’” says Wolf.
Behavioral health patients are often boarded in EDs for days and weeks. “Nurses feel we are not doing anything for this person,” she says. There is a larger issue at play, says Wolf: that society doesn’t allocate resources for individuals who are homeless, addicted or mentally ill, and ED nurses feel unable to meet their needs.
“There is a pervasive sense, legislatively and socially, that some people deserve to be cared for and other people don’t,” says Wolf. “If we had an understanding that there is a social floor through which no one should fall, there would be more of a collective will to address this on a much larger scale.”
• When dying patients are brought to the ED, aggressive care is utilized when it may not be appropriate.
“The ED is just a bad time to have advance care planning discussions,” says Mark McClelland, DNP, RN, CPHQ, a nurse scientist in the Office of Research and Innovation at Cleveland Clinic’s Nursing Institute.
If nurses experience moral distress in this scenario, he says, “You need to support the nursing staff throughout, and after the fact.”
Bioethicists can help to identify possible solutions. “We are always going to have patients who probably shouldn’t be coded, who come in and are coded,” says McClelland. If the family wants aggressive care, says McClelland, “that’s the route we are going to go, generally,” he says. “We are not going to get away from that in the near future. But how we handle it overall could go a long way to decreasing moral distress.”
One goal is to make community caregivers aware of how they can avoid sending dying patients to the ED. “We can say, ‘Here’s how you can keep them from coming to the ED. Let’s talk about ways we can coordinate care,’” says Wolf.
• Admitted patients are held for hours or days waiting for an inpatient bed to become available.
Presumably, nurses chose the ED because it is a setting more conducive to their practice style. “ED nurses are forced to provide a level of care which is basically inpatient care, or sometimes ICU-level care, for which they are not accustomed or necessarily trained,” says McClelland.
Some hospitals have made changes to ensure ED patients are admitted expeditiously. “That removes a major source of moral distress. Boarding is just flat-out preventable,” says McClelland.
ED nurses need to see that unit leaders are responsive to their concerns. “It’s one thing to say, ‘Tell us your concerns,’ and then the nurse not see anything grow from that, versus seeing a very proactive approach,” McClelland says. “I guarantee if there’s one nurse experiencing moral distress, there’s many.”
EDs are viewed as unpredictable and chaotic. “We are coming to believe that’s not true. The ED is really quite predictable,” says McClelland. If an ED admits between 10 and 12 patients on the day shift every Monday, for instance, EDs should staff accordingly, and bed control should have 10 beds lined up
A formal ethics consult often isn’t feasible to address an individual patient’s needs in the ED setting. “An ethics consult takes at least a couple hours to get rolling, and sometimes a day,” says McClelland. “That doesn’t really help that patient and that family at that moment.”
However, McClelland says, “an ethics consult could be called — not for an individual ED patient, but for the ED itself.”
Wolf suggests ethicists can assist by making ED nurses aware that it’s not a personal failure, but rather a systemic issue in need of fixing. “It’s not that you are a terrible nurse. It’s that you are unable to do what you are supposed to do,” she says.
Rushton says bioethicists can help in the following ways:
- creating mechanisms for ED clinicians to communicate their concerns to colleagues and leaders,
- championing efforts for systemwide attention to the root causes of their distress,
- holding regular forums for discussion of challenging cases,
- engage organizational leaders in taking seriously the concerns of ED clinicians, and developing support systems to avoid burnout and moral distress,
- leading efforts that engage the broader community in devising solutions aimed at redressing the root causes of their moral distress, and
- leveraging provisions of the American Nurses Association’s Code of Ethics to support their concerns.
“Bioethicists can intentionally reach out to ED clinicians to explore their needs and to devise effective strategies to support their integrity,” says Rushton.
REFERENCES
- Wolf LA, Perhats C, Delao AM, et al. “It’s a burden you carry”: Describing moral distress in emergency nursing. Journ Emerg Nurs 2016; 42(1):37-46.
- Trautmann J, Epstein E, Rovnyak V, et al. Relationships among moral distress, level of practice independence, and intent to leave of nurse practitioners in emergency departments: results from a national survey. Adv Emerg Nurs J 2015; 37(2):134-145.
SOURCES
- Mark McClelland, DNP, RN, CPHQ, Nurse Scientist, Office of Research and Innovation, Nursing Institute, Cleveland (OH) Clinic. Phone: (216) 445-3355. Email: [email protected].
- Cynda Hylton Rushton, PhD, RN, FAAN, Anne and George L. Bunting Professor of Clinical Ethics, Berman Institute of Bioethics, Johns Hopkins University, Baltimore. Email: [email protected].
- Jennifer Trautmann, PhD, RN, FNP-BC, Morton K. and Jane Blaustein Post Doctoral Fellow in Mental Health and Psychiatric Nursing, Johns Hopkins University School of Nursing, Baltimore. Phone: (443) 287-8739. Email: [email protected].
- Lisa Wolf, PhD, RN, CEN, FAEN, Director, Institute for Emergency Nursing Research, Des Plaines, IL. Email: [email protected].
