Fundamentals of Nursing and Midwifery 2e

Chapter 11 Values, ethics and advocacy

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R E S E A R C H I N P R A C T I C E

Moral distress and clash of personal value

older person who is close to death; and a woman with cancer who has been vomiting all day and is in severe pain. You know you cannot meet everyone’s needs well. How do you ‘distribute’ your nursing care? (You really like the person who is going home in the morning.) Supporting consent A resident is attempting to perform a spinal tap on an ado- lescent whom you know dislikes the resident. After one failed attempt, the adolescent tells the resident to stop. The resident asks you to administer an anti-anxiety medication to the person so the resident can get the spinal tap done quickly. Should you administer the medication, knowing the patient no longer consents to the procedure? Conflicts between the person’s and clinician’s interests Community nurses are taking turns being assigned to care for new people who test positive for the human immuno- deficiency virus (HIV). One nurse, who is breastfeeding her 8-month-old infant, refuses to take her turn, fearing she will transmit the disease to her baby. The other nurses tell her she must accept the assignment of this HIV-positive patient because none of them is willing to take her turn. What erro- neous assumptions are the nurses making, and is a nurse ever justified in refusing to care for a person? Conflicts concerning the appropriate use of technology An infertile woman asks you what you think about in-vitro fertilisation. She tells you she is ‘desperate to produce a child for her husband and in-laws’, but also has grave reser- vations about the whole process: ‘I’ve read about couples who end up with seven frozen embryos, and I think that would kill me, thinking I’ve got seven potential kids on ice.’ Varcoe, C., Pauly B., Storch, J., Newton, L. & Makaroff, K. (2012). Nurses’ perceptions of and responses to morally distressing situations. Nursing Ethics , 19(4), 488–500. This paper reports on a study of 292 nurses and endeav- ours to understand the issue of moral distress in clinical practice. The authors feel that stress associated with the moral dimension of practice is now evident as nurses become more aware of their role as moral agents. Survey packages were distributed to nurses who consented to participate in the study. The nurses’ per- ceptions of the stress associated with moral distress and ethical climate were surveyed using three open-ended questions. Data were analysed drawing on interpretive description, a qualitative research approach. The analysis revealed that broad system factors of work overload and staff incompetence led to the

Nurses, midwives and doctors Nurse/midwife–doctor situations can also result in ethical distress for nurses. Common problems include disagree- ments about a proposed medical regimen, conflicts regarding the scope of the nurse’s role, and doctor incompetence. Disagreements about the proposed medical regime In the nursing home where you work, any client who loses a significant amount of weight (more than 10% of usual body weight) is automatically subjected to an exhaustive battery of tests (including a complete gastrointestinal [GI] series) to determine whether there are any physical causes for the weight loss (e.g. a tumour). You strongly object to one client being put through these tests because she has made it clear she wants to die and will starve herself to death if that is the only way she can do it. The medical director insists the person undergoes the diagnostic studies because there is a long history of family dissatisfaction with the facility’s medical care. The director wants to avoid causing further dissatisfaction. Are you responsible for preparing the client for these diagnostic studies and scheduling them? Are there grounds for refusing to participate? A nurse who works in the operating room notices that a pae- diatric surgeon who has been on the staff for several years and done excellent work suddenly seems to be not concen- trating during surgery and making more mistakes than usual. Rumours have been circulating about the surgeon having a problem with cocaine abuse after his recent divorce. The parents of one paediatric patient are dissatisfied with the Unprofessional, incompetent, unethical or illegal doctor practice inadequate care of patients. As well, specific situations such as witnessing unnecessary suffering, moral com- promises, and negative judgements about patients and/or their families were recorded as contributing to moral distress. The outcome suggested nurses require a collective approach, to be able to action structural changes instead of individual action. Relevance to practice This study revealed the concept of moral distress requires further education so that all healthcare workers can differentiate between moral distress and personal value clashes. As well, the authors suggest that, to facilitate collective action, education should include political theory and analysis of moral distress within power-laden contexts.