In times of limited resources, nurses often face situations related to prioritizing care that can impact their values and clinical decision-making. These situations often lead to a sense of powerlessness and moral distress. With the possibility of surges in patient admissions over the winter period, how can nurses prepare practical strategies to empower themselves?
AACN Clinical Practice Specialist Sarah Delgado spoke with Sharon Hickin, MN, RN, BSc, CCNC(C), and Atussa Behnam-Shabahang, MSN, RN, who developed a front-line, informed, values-based decision-making tool to support prioritizing care.
Some units are preparing for possible patient surges in the next few months. How did you start using value-based decision-making specifically as a process for periods of surge that generate staffing deficits?
We started talking with staff, because we were seeing all this moral distress, and that's when we went in to talk to them about what was causing that and how they were feeling and how things were going. And it sort of evolved from there with Atussa bringing in this concept of let's take a look at what people are saying and how can we use what's important to them to turn this around to something that may help mitigate the moral distress? We can't solve the problem, but how do we make it so that people aren't feeling quite so helpless and distressed?
I think moral distress is a normal response that we have in a situation that is in conflict with our values. So it is almost one of those inevitable events that happens, but really trying to mitigate the impact of it and also minimize certain situations that can be prevented. But I think, in general, there are nurses that have lots of different values, and we prioritize our values differently. So there was always going to be some conflict. Learning how to work through it I think is key, and that's where the process comes in.
Could you talk about the process you designed?
When someone says, oh, we're distressed because we're short-staffed, well let's talk about why that's distressing. And then when we understand, it's like, well, yeah, I'm not able to do these X, Y, Z things for my patient, because I'm too busy doing all of these other things. We even got into the details about if nurses are not able to do specific care to provide a certain level of care, but also do certain things that they do that make them feel like good nurses. If they aren't able to do those specific things, then they are not feeling fulfilled, and it's really weighing on them. It was really interesting to see exactly where their values were and how they were able to describe it.
We had initially gone in thinking this is how we're going to do it, but after talking with the staff, it became very clear that you need to do this work ahead of time. If you're using this as a tool, as a unit, everybody is on the same page. Then everybody's approaching it from the same way. So, while we had initially thought, OK, great in the moment, a point of care tool, it actually became very apparent that the background work had to be done first to get everybody aligned with their values. Those values are unit values. They're not necessarily the individual's values. They all contribute to it, but there may be things that aren't really your own personal order of priority. But because you've agreed that this is what we are going to value as a unit and move forward on, that's sort of where you're going and you've now got the framework, the guidelines and the permission to follow those identified steps and priorities. But it is something that needs to happen before you get in the situation where it's “what do we do?”
If other nurses were thinking about preparation strategies, what advice would you offer?
The practice of personal and reflective communication is key. So even practicing it in your huddles, or practicing it to just use the terms that we've discussed in our [NTI] presentation, which it is important that we do this, this and this. Practicing that type of language to be able to reflect and say if this value is important to us, then we can do something in a way that prioritizes your values and your actions are in line.
There is also identifying the barriers to meeting those values. If you can identify what is actually stopping you from meeting that value, then that's where you've got something to work toward. Let's say we're in surge, and we haven't got enough staff to provide basic care. What's the barrier? The barrier is time. The barrier is human resources.
So, do we need a critical care nurse to come in, or is there someone else who can come in? That's then we should empower nurses to ask leadership for the resources to help support them during those situations. Your value identifies what is troubling you, the barrier is what blocks that value, and then your solution is what you’re doing to overcome that barrier.
I would also note the importance of taking time to work with your unit to sit down and do something of this nature, to make a preparedness plan for when, because it's not an if.
Then, if you can make meet with your leadership to work through a process of how are we going to manage a surge when it happens, and then everybody kind of being on the same page when it does happen, I think that will help people work their way through it a little bit more easily, because they will be back in that situation again.
In addition, those who are most impacted are our patients. Sometimes in this process, we have not talked about our patients' values. It was because it was about the surge and how we can best provide nursing care. But, in general, we would be speaking to everybody's values and prioritizing care that way.
I also want to emphasize that we are not ethics experts. There are people that study this and are ethics consultants. We're using some of the same processes, but I think that as nurses we're able to use it in a way that is beneficial for us. What I really like about the process is that it all comes from front-line nursing strategies, thoughts and values. The process is very nursing oriented, and I appreciated that a lot.
So it's the unit or the team coming together to identify values they can all get behind to direct the care. Can you give us a few examples of how a value might translate to specific actions?
The two top themes that occurred over and over were either patient safety and well-being or staff safety and well-being. So, it was not only how do we provide that compassionate care to families and our patients, but how do we make sure we provide that compassionate care to ourselves as well, to support each other?
We had a whole bunch of people say, “It's important to me that my patient's safe, so I'm not going to take my break.” And there were other people who said, “It's important to me that I get away for five minutes and take my break so I could just get my head back on straight.”
The practical strategy was the understanding of each other's needs for a break and knowing who needs to get away for that break and who needs to stay for their own mental well-being to make sure their patient is cared for.
That being said, we don't advocate for people missing breaks. Everybody needs their breaks and should go take them. But having those huddles at the start of a shift where you see who is on your team, understand who has what needs, and know who their go-to people are, was one of those practical strategies to help staff manage their own well-being.
It’s not being able to do those little extra things with patients - the basic care that we do every day that falls down because everyone's crashing. And it was looking at things like how do we bring in extra care aides to come and help with basic care so that patients are getting their face washed, maybe getting their hair combed, so that staff didn't feel like they weren't providing good care.
And all of the practical strategies were things that came from the staff themselves. These were all things that they identified as, if I could do this, it would help, so how do we make it possible? And if something doesn't get done, what's OK to leave? What has to be done?
What kind of challenges did you run into in working with nurses to develop the value-based decision-making approach?
Nurses want to do it all; it's just part of our identity. It's so closely tied to our actions and the way we show kindness and compassion. Everyone I think has a little different style or flair to their practice that helps us feel fulfilled.
It was very hard for some of the nurses to let go of certain things. A lot of people identify as nurses by those little extra things they do. So, asking them to let go of those things or to allow someone else to take care of them really went against the grain, and it was their identity that was being robbed. That in itself was kind of distressing for people.
In the ethics decision-making process, once you've identified and articulated values, you discuss them to see which ones should be the priority for the group. In a situation where there's differing approaches or ideas, there's obvious conflict. So, how are you going to prioritize your values in order to come up with solutions that can address the conflict or help you get through the situation?
If we were in a group, we'd say, “OK, this is a strong consensus here,” so that would be more prioritized, whether it was patient safety or care and compassion. We organized the values in a way that were general values and then specific values. That's another way that we can look at it. Your general values are things like patient safety and then more specific values, such as it's important that my patients' infusions are correct and weight-based for them, for instance. So that's one way you can articulate values in general and specific ways. And the more specific you are with your values, I think the better because then you're going to get a specific action out of them. It's like, OK, then I know this is what we're going to do.
Were there specific questions or strategies you used to help nurses move from general to specific values? Or was it more like a conversation, and then you were taking notes or keeping track and noting those differences?
I would try to make it specific. I would say, “Can you help clarify, or do you mean to say that this specific thing is important to you?” For example, there'd be an end-of-life situation and the nurse would be upset because they were too busy; they were short-staffed. So the conversation was, “We're too short-staffed and I can't help with a patient who is near death.” Obviously, it's important to that nurse that you're providing a certain level of care at the end of life. What specifically is the care that you can't get to that's important? Then you just keep digging a little bit and can reveal the core problem in their general statements.
You ask for clarification, and it can give you a specific value that is causing the distress when you get into specifics. I think that's where the jewels are - those pearls of wisdom and where the values are lying and you can try to pull them out.
Is there a way for nurses to work through this kind of value clarification as individuals, or do you think this happens more effectively in conversation with someone with ethics expertise or another confidant they might rely on?
Having someone who's been through a framework approach is helpful, because they can help guide the conversation. When you’re trying to work through it on your own, you don't always recognize what you're thinking. Having that sounding board does help bring up those other facets that you may not necessarily have thought of yourself.
A lot of times you go around in circles in your own head, and you need someone to put the brakes on and help you break out of it. That's where that group conversation comes in, because then it's finding out as a group how you’re going to address it. It's almost like doing a code. You do simulations for codes; you run practice codes. So do a run-through of how you want your unit to look when you have less staff, what are your ABCs, and work through from there. I think the conversation is probably the biggest piece of it.
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