Nurses face complex ethical decisions on a daily basis, making us susceptible to moral distress. The risks and uncertainty of the COVID-19 pandemic have intensified this distress. In this episode, nursing ethics leader Cynda Rushton talks about moral distress: what it is, why it occurs, and how it affects us physically and psychologically. She also explores shifts in thinking that can help alleviate distress, and offers her insights for building moral resilience during difficult times.
Welcome to the American Association of Critical-Care Nurses’ COVID-19 Support Podcast Series. I’m your host, nurse/journalist Jamie Davis. Our goal is to discuss important nursing practices during the COVID-19 pandemic and offer tips for nurses on the front lines or behind the scenes. We hear you, we’re with you and we support you.
Thank you for joining us. In this podcast series, we will do our best to provide you with the most current information from our incredible community of nurses. However, you should always check with the nursing practice standards for the state in which you’re licensed and working, as well as with the organization or healthcare facility where you work.
Today we’ll be talking to nursing ethics leader Cynda Rushton about how the traumatic stress and complex ethical decisions nurses face can lead to moral distress. Let’s listen to Cynda discuss some of the important resources that can help nurses build moral resilience.
Cynda, I’d like to welcome you to the podcast today. It’s great to have you on the program. Would you take a few moments and introduce yourself to our audience?
I’m Cynda Rushton. I am the Bunting Professor of Clinical Ethics at the Johns Hopkins University Berman Institute of Bioethics and School of Nursing. I’ve also been co-chair of the hospital ethics committee for many decades now and do a lot of work with front-line clinicians and patients and families about the ethical issues that come up every day in our work.
Let’s jump off that right away. As a clinical ethicist, tell us a little bit about the ethical problems you’re seeing right now as this pandemic unfolds.
Well, it’s a very interesting time because what this pandemic has done is really illuminate the kinds of ethical questions that people are struggling with every single day, and it ranges from the kinds of questions about resource allocation at all levels. Things like PPE, beds, ventilators, ECMO, medicines, blood, you name it. We’re having to look at that question differently now.
It’s, I think, a shift because, at least in the U.S., we actually are very privileged to have a lot of the resources that we need every day. Probably the most important limiting factor in the delivery of critical care is not the machines; it’s the people. I think this pandemic has really shined a light on how important our workforce is.
What I’m hearing from a lot of my colleagues is a lot of angst around how do I balance my obligations to my patients, to my family, to my friends and to myself. It has really raised questions about how we can think about weighing those competing obligations. All of us in healthcare, nurses in particular, have always known that there are risks associated with our work, but what’s different is that we’ve also had the assumption that the things that would keep us safe are available.
This pandemic has made really clear that we did not have the kinds of protective equipment needed for many, many front-line nurses and other clinicians. That has intensified this sense of distress that people feel. Should I come to work? What should I do in terms of my family? Should I live in a different living arrangement at a time when we really need a lot of support from the people we love and who love us?
There are those kinds of questions we’re asking as nurses. Another kind of question many front-line nurses are struggling with is, as we’ve moved from this preparation for the crisis (contingency planning) there have been a lot of changes in our practice standards and in our practice patterns. We’re in a situation where many clinicians are being redeployed, and it raises questions about providing safe, quality care in these kinds of situations where the way we’ve thought about providing care in the past may not even be possible right now. Questions about causing more harm than good to the people that I’m called to serve.
I had a conversation just yesterday with a group of cardiovascular surgical ICU nurses who were talking about how, as experienced nurses, they were experiencing a lot of distress because they were orienting so many new people, and the sense of responsibility that they felt for patient care led them to feel almost hyper-vigilant that they were constantly scanning for potential harms to their patients. I think you add all of those things together with the stress of a pandemic, and it has all the ingredients that really leave us feeling depleted, worried and often conflicted.
Let’s expand upon that a little bit, because we need a working definition of moral distress. Something that we can use moving forward in this interview. How would you define that?
Well, there are a lot of definitions of moral distress. I think one of the easiest to understand is when a person recognizes what we think we ought to do, but because of either internal or external constraints, we’re not able to do the right thing. I think a lot of times distress comes up when there’s a gap between what we think we ought to be doing and what we’re actually doing. In the midst of a pandemic, I think there are so many situations where in our minds we’re thinking, ‘If this were a normal situation, I would be doing one thing. And now I’m being asked to do something that feels very different.’
How do nurses recognize moral distress compared with the other types of stresses they’re involved with facing day in and day out? We have a lot of people in the hospital setting who are facing the type of traumatic stresses that previously might only have been seen by first responders in the field. How do they recognize the differences and recognize moral distress for what it is?
When I think about moral distress compared with psychological, spiritual or other kinds of distress, I think some of the defining features are when we are starting to ask ourselves, ‘Is this the right thing to do?’ Where our conscience is often involved, and we feel that sense of conflict about the options that are in front of us, and the sense of questioning, ‘Am I a good person in the midst of this?’
For me, I find myself often going back to the question, ‘Can I see myself as a good nurse if I choose one path or the other?’ And I think embedded in that are questions about how can I really act with integrity in the midst of these constraints that are largely out of my control, and how do I confront those constraints in a way that reflects who I really am, what my values are, and what I stand for in my life and work.
You started a program called MEPRA to help nurses with moral distress by building moral resilience. I’d like you to ask you to define moral resilience and then talk a little bit about why you chose this particular approach.
The concept of moral resilience is an evolving one. It’s a concept that I’ve been particularly interested in during the last five or six years in response to the fact that there is a lot of moral distress, and the questions of what else is possible and where might we be able to create solutions and actually build the kind of responses that leave us feeling whole.
Moral resilience, from our point of view, is the ability of an individual to preserve or restore their integrity in response to some kind of moral adversity. Moral resilience is not about making an appraisal about whether you’re moral or whether you’re resilient or not. It’s actually an invitation to be able to see things as they are, which means not necessarily agreeing with or endorsing them, but actually having a realistic appraisal of what the situation is.
That doesn’t include being complacent or putting a positive spin on a really hard situation, but really acknowledging that I have to make a hard decision. The ability to recognize that there is a tension and there are options gives us a chance to choose: ‘How do I want to demonstrate my integrity in this moment?’
The way I like to think about moral resilience is a practice that is done in Japan called kintsugi. When a piece of pottery has broken, often our inclination is to take those pieces of pottery and to just throw them away. But in Japan, they use this process of kintsugi, which involves using cement and golden paint to take the pieces of the broken pottery and put them together in a new way, not to overlook or dust or discard the broken parts, but to actually honor those broken parts. To see that we can put ourselves into a new vessel, that we can honor that brokenness, incorporates those broken parts and allows us to move forward.
For me, it is a direction, a skill set that we can use to strengthen what’s already there. I think that’s an important part. Sometimes people hear the word resilience and they feel like, ‘Oh, I’m being judged as somehow deficient.’ That’s not the intention of this concept at all; it’s rather to honor what’s already there. And to say that there are things we can do that strengthen our integrity, that strengthen our ability to face whatever’s in front of us while minimizing any harm to ourselves or others.
With your work on this program, what do you think are the most effective ways to mitigate moral distress? We talked about resilience, but how do we mitigate the challenges ahead of time? How do we prepare for that?
When we think about responding to a morally distressing or ethically challenging situation, there are many ways we can respond. One possibility is that we use the awareness that we’re feeling something is not right. Usually it starts in our bodies, a kind of tension somewhere, to be able to use it as a signal to pause.
The first thing is to really pause to inquire, ‘Why is this a problem for me? What important values are at stake that I need to take account of? Where is the tension between my competing obligations coming from? Is it because I feel like I am balancing the benefits of harm and burden and benefit? Is it because I feel I have obligations to patients, to their families, to my colleagues and even to myself right now in the midst of this COVID crisis?’ Being able to actually pause and to touch into what seems to be at stake. ‘Where’s my integrity being challenged in one way or another?’
In that pausing, it’s also an opportunity to connect to why we’re doing this work in the first place. To connect to our sense of purpose and meaning, and to use that as fuel for what we intend to bring about, what it is that we’re hoping will happen as a result of our action, and to use that as a resource and a guide as we proceed to the second step, which is reflecting.
Reflecting gives us a space, as well, to calm our nervous system so that we can actually see things clearly where we’re not so dysregulated or distracted that we’re missing important points that are present in the current situation. With that reflection arises a potential for various options that we might consider as we think about what’s the right thing to do in this important space we’re in.
Reorienting ourselves in the midst of that reflection on our primary obligations, thinking about what our ANA Code of Ethics for Nurses says about what priorities we ought to have in providing patient care or in resolving ethical conflicts, can be another place to reflect and to reconnect, and to really explore where the distress is affecting us. It may be in our bodies. It may be that we are feeling anxious or fearful or helpless or angry or sad. All of those are normal feelings.
Being able to pause to actually name what the source is, to reflect on our ethical obligations, allows us to respond rather than react. Responding means we need to pause, as well, to answer the question, ‘What will really serve now in this circumstance? Given the constraints, given the resources that are available, how can I respond in a way that reflects my values as a person, as a professional, and reflect the nurse I really am.’
That gives us a starting point and a place for us to then discern, ‘Is action needed, or is inaction the appropriate response? Who else might be able to help me?’ And to determine what the right path is, and what resources I have within myself, my team, my organization and beyond that can help me make sure I’m using good facts, that I am using a process of ethical analysis that really illuminates all the various dimensions of these very complex questions.
Once we’ve had a chance to respond, then the last piece is to review and to step back and ask ourselves, ‘What happened? How did it turn out? What part of that am I responsible for? And what part of that am I not responsible for? Can I also, at the same time, acknowledge my effort, regardless of the outcome, to exercise my integrity and my moral agency in the midst of really challenging situations?’
It’s often the case in these really challenging situations that we can feel a sense of inadequacy. ‘Did I really fulfill my ethical obligations? Did I do all I could?’ On the one hand, that’s a normal kind of question, but on the other hand, it can tap into a pattern that is very common among us: We are constantly expecting ourselves to be able to perform, to be able to produce outcomes that are largely beyond our control.
Because that’s particularly highlighted in the midst of a pandemic – much of what’s happening is actually beyond our control – it’s important to be able to also acknowledge when I have taken action and I have discerned the right path, I have evaluated the various options, and I have done that from a place of integrity. I have fulfilled my obligations, even though the outcome may not be the one I would choose or would hope what happened. It doesn’t erase the very real contribution that has been made.
So, we also have to have space to reflect on how we can leverage our moral agency, our courage, our compassion, in a way that helps others do the same for themselves. What that might mean is, at the end of these challenging situations, and as we are going through them, intentionally creating times to pause and to notice, in a very intentional way, all the efforts that people are putting forth. Physically, emotionally, mentally and ethically.
You recently created an amazing video with the Berman Institute in which you walk the viewer through a day in the life of an ICU nurse during COVID-19. It’s a super-powerful video. Do you think this is giving an accurate view of what nurses are facing? How does a nurse who walks through that day in real life deal with the stress they’re facing on a regular basis?
I think it’s not an understatement to say that what critical care nurses are experiencing on a day-to-day basis is intense. It is challenging on different levels. Personally, relationally, professionally. I think there’s no question that there’s an incredible burden many nurses are carrying. And I think many nurses are experiencing a sense of moral residue, that sort of leftover sense of distress or angst at the end of their shift that can accumulate day after day after day.
I think part of our challenge right now is to acknowledge this and ask, ‘And what else might be true?’ Because it’s very easy, I think, in the midst of a pandemic where fear is the primary emotion people are feeling, as well as uncertainty and confusion, that we tend to focus in on the things that were left undone. It’s really easy for us to forget that in the midst of all of this complexity and chaos, a lot of good was done.
I spend time trying to help my colleagues remember at the end of their day, yes, there were things that were left undone, but can we pause and notice what good was done. To know the fact that they showed up is huge. The fact that they listened, they brought their competence to the moment, makes a difference in how that patient experienced their day, their life, and they accompanied people as they always have, through the hard parts, recovering and also at the end of life.
We’ve developed a couple of very simple practices to help nurses make the transition from their workplace to home. One of those involves what we call a personal protective strategy, which is a team huddle at the end of the shift. This process allows us to track our own physical experience, because a lot of times we’re thinking about things, but our bodies are a wealth of information about how we really are.
The process is to have everybody come together in a huddle and for each person to have a chance to talk about what was hard and also what went well. The point of this is to acknowledge both, but to intentionally spend more time in the space of ‘how does it feel when we talk about the good thing? What does that look like in our bodies? How can we connect to that?’ To have a way of acknowledging this in each other, and also noticing what it’s like for me to say that I listen to my colleagues, to say what went well for them. To use that as part of the transition to home, so we’re not leaving our work with all the weight of the responsibility and the crisis with us.
There are other practices. How do we begin to titrate the amount of time we spend with the hard things? During the day when things are feeling really overwhelming, can we bring our attention to something that’s pleasurable? Maybe it’s a person, maybe it’s a pet, maybe it’s a place, but the point is that we can’t stay in the hard place all the time. We have to find ways to give ourselves even momentary relief, so that we can preserve our energy and our effort in ways that will really make a difference.
One of the things that have lifted me up so much throughout this pandemic has been seeing the ways nurses have innovated and found ways to demonstrate their caring in the midst of a challenging environment. The ways they’ve connected families with dying family members and found ways to do things that we never would have thought of trying before. When it comes to the facilities, you mentioned how the teams work together, and I’m curious what other ways hospitals and organizations can help support moral resilience in their staff.
That’s a great question, because the truth of the matter is that this is not a responsibility of just the individual. Yes, it’s true we are responsible for our own well-being, but our organizations are also responsible for creating the conditions for our well-being to thrive.
I think there are a number of ways organizations can support front-line nurses to be morally resilient. One of those is to actually invest in support systems. And that can be peer-to-peer support. It can be having forums. We are currently implementing moral resilience rounds and a virtual format where we’re offering a space for people to come together to talk about these issues as a community.
In some ways it’s easier for us to come together on a Zoom call than it is for us to actually meet in person. We’re finding those calls to be an opportunity to acknowledge that it is hard, that there is a lot people are carrying, that we need to create a sense of community and solidarity among our staff, that we’re investing in a space and a time dedicated to hear from them. It’s not a session about giving information. It’s a session for everyone to come together and to bear witness to each other’s experiences, to offer support and caring and resources that might help us manage with a little more ease.
Also, I think that organizations have an opportunity right now to take seriously the recommendations of the National Academy of Medicine’s report about burnout and to look specifically at the systemic contributions to burnout. A lot of those contributions have to do with job demands and job resources. The job demands category right now is very intensified in the midst of the pandemic.
What are some of the ways we can begin to step back from the crisis and really look at what needs to happen to be able to support front-line staff in doing their jobs well? Hopefully, one of those lessons is having the kinds of resources that allow them to feel safe in their jobs. That’s not an option going forward. In addition, we need to be able to look carefully at the patterns in our organizations that are causing this distress.
You mentioned the ingenuity of nurses. One of the places where nurses are really struggling right now is the changes in relationships with patients and families. That has often been a source of great meaning for nurses. I think that’s an area where we’ve got to pay some attention – how we restore a sense of meaning and connection with our patients – so that we’re not asking nurses to just do tasks, but actually honoring what it means to be a good nurse. Those are the kinds of things I think are really important.
Also having a whole menu or array of support mechanisms, because it’s never a one-size-fits-all. People need different things at different times, and we need to think about what the menu of options ought to look like. Some people will benefit from one-on-one interventions, others with groups and others may need something else.
To me, this is a really important time to put the priority on the well-being of our healthcare workforce, because I really don’t believe our healthcare system can function safely and effectively without a healthy front-line workforce.
I’ve heard this pandemic called more of a marathon than a sprint. A lot of the people in the public want this to be over, want to see the light at the end of the tunnel. But those of us in healthcare see it differently. We are seemingly in a trough right now between some different waves. What can we do moving forward to prepare for another wave? We’ve learned some lessons from what’s happened in recent months. What are we going to do that can help prepare us and be more resilient come the fall?
I do think it is a marathon. I want to answer that question in two ways.
One is, I think one of the things we have to acknowledge is that we’re in a process of change. We’re not going back to how things were. Now we’re in the phase of trying to figure out how things are, so that we can make the transition to how we want them to be in the future.
I think it’s a really good time for us to pause and to take stock of what we learned. Preparation is necessary. We made choices about things like redeployment and training and staffing in the midst of the crisis. Now we need to stop and ask, ‘Did it work? What else is possible? How do we actually design differently to accommodate for the possibility of another surge?’ Instead of waiting until there’s a crisis, now is the time for us to really plan. What will our staffing look like? What will our resources, of all types, look like?
One of the things I’ve been working on with a group of about 20 interprofessional colleagues is our resource allocation plan. We have been working now almost daily for eight weeks, thinking about how we can put in place protocols for the allocation of scarce resources when we reach that crisis point of view. Over the summer, we’re going to try operationalizing those plans and to see how they work in the midst of a lull, before we might have to use them in real life.
I think the more we can do that kind of planning, the better off we’ll be. It will also be reassuring to people that we have a plan, rather than this idea of just making this up as we go along. We do have the opportunity now to stop and pause.
In terms of these ethical issues, I think one opportunity is to actually acknowledge what people have experienced so far and to give them an opportunity to voice their concerns, to explore them and what consequences have resulted from them. To think about how we can intensify the skills and tools they may need to be able to confront those issues going forward. Learning at every level is really important right now, so that we can be better prepared for the kinds of issues we will inevitably face.
Someday this marathon will be over. Someday there will be a finish line. What is that silver lining? What is that thing we’re going to find at the other end of the tunnel that’s going to say we’ve made a change for the better, we’ve made a brighter future for nursing and for healthcare and for our patients? What have we learned from this process? What can we do to be better prepared for moral resilience and to deal with moral distress?
I am hopeful, actually. Hopeful meaning recognizing the truth of the situation we’re in, but also being aware of what else might emerge. I think what I’ve seen is the dissolution of some of the old structures that have kept us stuck in old patterns and old narratives that we’ve told repeatedly, for decades, about ourselves as nurses, about our teams and about our work. I think that gives us a foundation to be able to say, ‘We need to stand proud and we need to stand firm on our foundation, an ethical foundation of nursing practice.’
The silver lining is that this pandemic has made very clear the fissures in our healthcare system. It has made very evident the places in our healthcare systems that are not serving the welfare of our front-line clinicians.
I think it is a huge opportunity to step forward with solutions and to say, ‘This is what is needed now.’ In the midst of chaos, I’m a fan of ‘let's just do it.’ Waiting for everyone to be ready for the changes that are needed is a missed opportunity. I think we want to charge forward with our ingenuity, with our incredible knowledge and wisdom, and say, ‘Here are the solutions that we need to adopt, and we’re not apologizing.’
Cynda, it’s been great chatting with you. I think there’s a lot of great information in what we’ve discussed that is going to help a lot of nurses in our community. I want to thank you again for taking time out of your busy schedule to come on the program and share your thoughts with us.
Thank you. It’s been a pleasure. I feel like we’re in a really important shift in our profession. If we can stand together in solidarity, in our commitment to our patients as the grounding of everything we do, the solutions that we’ll develop will create a more compassionate, just and caring healthcare environment. I’m looking forward to what we will create together. I am so proud to be part of this community.
That will conclude today’s episode of the American Association of Critical-Care Nurses’ COVID-19 Support Podcast. Thank you for taking the time to join us. You can stay up-to-date with us on our website, www.aacn.org and connect with us on Instagram at @exceptionalnurses. We hear you, we’re with you and we support you.