A reader responds to our recent blog post on the Heavy Burden of Moral Distress. We hope you find this real-life example an encouragement that correctional nurses are speaking up when they have concerns about patient health issues in the criminal justice system.
The topic of moral distress among nurses is an elephant in the conference room of many healthcare organizations but at the core of conversations amongst nurses in the medication room. A few typical statements made during these informal, ethically charged and expressive gatherings include; “It doesn’t’ do any good to tell anyone, they won’t do anything.” “It’s all about the bottom line.” “They don’t care how much more work they give nurses.” “Nurses who complain too much get fired.” “I need a job to so I can take care of my family.” “This is just the way it is, get used to it.” Statements like these are made with such frequency today that moral distress could and should be viewed as an epidemic in nursing practice. The following is a glimpse into the challenges some correctional nurses faced and how their quest and obligation as nurses to do the right thing put them on a path leading directly into the dark, lonely void of moral distress.
While working at a correctional facility, three nurses expressed their ongoing concerns to supervisors and administration about the well-being of inmates who were:
- Not getting their prescribed medications for extended periods. This includes medications for chronic conditions, seizures and other serious illnesses,
- Providers prescribing incompatible medications and refusing to change the order(s),
- Providers documenting physicals on inmates they had not seen,
- Stat and other critical orders not getting noted for days,
- On-call providers not returning calls and,
- Inmates with serious, potentially life-threatening conditions, being transferred without regard to maintaining some continuity of care.
A few nurses called the allegedly anonymous organization “ Hot Line,” (nurses are encouraged to use these for reporting purposes) and voiced their concerns but to no avail. Having exhausted all efforts to report their concerns internally they reached out to their local nursing organizations. While these organizations provide invaluable services and support in many areas they were unable to provide immediate direction or tangible backing for these situations. They, like the nurses, were uncertain who they should and could turn to for support.
The onset of moral distress began when the first link in the organization’s chain of command broke because of failed communications and after dismissing the nurses concerns with indifference. The distress peaked when the nurses were terminated for doing the right thing. Terminated for doing what nurses are required to do, what we have vowed to do – complying with the Nursing Code of Ethics.
Nurses have taken an oath and are required to practice in accordance with the Nursing Code of Ethics which provides:
- A succinct statement of the ethical obligations and duties of every individual who enters the nursing profession.
- It is the profession’s nonnegotiable ethical standard.
- It is an expression of nursing’s own understanding of its commitment to society.
The sections applicable to the events being discussed are 3.4 and 3.5 as noted below:
Nursing Code of Ethics 3.4 “Standards and Review Mechanisms”
Nurses must bring forward difficult issues related to patient care and/or institutional constraints upon ethical practice for discussion and review.
Nursing Code of Ethics 3.5, “Acting on Questionable Practice”
When a nurse chooses to engage in the act of responsible reporting about situations that are perceived as unethical, incompetent, illegal, or impaired, the professional organization has a responsibility to provide the nurse with support and assistance and to protect the practice of those nurses who choose to voice their concerns.
Reporting unethical, illegal, incompetent, or impaired practices, even when done appropriately, may present substantial risks to the nurse; nevertheless, such risks do not eliminate the obligation to address serious threats to patient safety.
Obligated to Speak
Nurses are obligated to bring difficult issues forward for discussion and review. We are duty-bound to report unsafe practices and or circumstances and must do so regardless of personal risk. However, at the same time there is a responsibility to provide nurses with support and assistance when they do speak out. This is the crossroads where the path of moral distress becomes the loneliest and sometimes most frightening. It is alsothe time when a nurse needs support and encouragement the most. Unfortunately it is at this intersection that most nurses feel alone, abandoned, and with nowhere to turn. This often becomes a turning point for nurses believing they must choose between speaking out or getting terminated; consequently many nurses make a silent and painfully emotional promise to never speak out again. This forces nurses to overlook practices that not only put their patients at risk but their nursing license as well. At this juncture moral distress has become an emotional pathogen. Were it not for the support and encouragement of our patients and the public, many nurses would leave the profession.
The public’s long-standing esteem for nurses is well documented in public opinion polls. Nurses rate high with the public in trended national survey questions about trusted professions, prestigious occupations, and “honesty and ethical standards.” It is disheartening that organizations do not always see their nurses through the public’s eyes. It is regrettable that even nurses don’t see themselves through the public’s eyes. If nurses would stand together in our communities of practice perhaps we could begin a dialogue with our local nursing associations and employers to establish the support system illustrated in the Nursing Code of Ethics. Together we could address the circumstances and symptoms associated with moral distress at the onset and transform them into opportunities for change before nurses are forced to make that dreaded silent promise to keep quiet. Speaking out is included in the nonnegotiable ethical standards.
Would you be willing to speak out in a similar situation? Join the conversation with a comment.