Oncology nursing has always been a challenging career with many stressors, but the moral distress brought on by a global pandemic has increased rates of depression, anxiety, and professional burnout among nurses, Patricia Jakel, RN, MSN, AOCN®, and Devin Ballentine, RN, BSN, both of UCLA Santa Monica Medical Center, said during a session for the 46th Annual ONS Congress™ on April 22, 2021.

Morality Versus Ethics

“Moral disagreement is expected in complex care, but ethical conflicts are not,” Jakel said. Morality involves beliefs about what is right or wrong, whereas ethics deals with tools and methods of philosophy supported by evidence and framed into theories.

Moral distress occurs when a nurse knows the right thing to do but institutional constraints make it difficult to do those things. Jakel reported findings from a survey of nurses, which showed that the biggest contributors to moral distress were pressure from others, inadequate resources, and moral differences. Ultimately those factors can lead to professional burnout, medical errors, and substandard health care.

It Takes a Team

Standardized interprofessional communication tools can enhance care quality and patient safety, reducing moral distress and some of its negative outcomes. Jakel described the CO-Advocacy model, which was developed based on research studies with nurses, physicians, and clinical ethicists. “The model recognizes that nurses and physicians have shared responsibilities. We need to discuss this often and not just in times of crisis,” she explained.

CO-Advocacy stands for:

  • Community obligation to patients for safe, high-quality evidence and ethics-based care
  • Activate ethics assessment
  • Deliberate responsibilities
  • Voice concerns
  • Open opportunities for dialogue
  • Collaborate across disciplines/views
  • Analyze differences
  • Transform into agreeable components
  • Evaluate processes and early actions 

The intervention has four components:

  • An interactive, case-based online orientation
  • The Ethics Early Action Protocol, which includes an ethics assessment, analysis, and plan
  • The ability to incorporate into existing systems such as daily rounds and electronic medical records
  • Ongoing support through an app with communication models and resilience strategies

The early action protocol helps clinicians screen patients at high risk for ethical issues using patient risk, family risk, and situation risk domains. Based on their scores in the three domains, patients are identified as low, medium, or high risk.

Build Resilience for a Healthy Perspective

Although tools help clinicians manage moral and ethical struggles, many issues require additional strategies. One important technique is practicing resiliency, or the process of adapting well in the face of adversity. Resiliency allows a nurse to experience stress and but let their body and mind to recover from it. 

People who are resilient have self-control, self-sufficiency, creativity, optimism, persistence, and humor. Resilience is associated with close relationships with family and friends, a positive view of yourself and confidence in your strengths and abilities, the ability to manage strong feelings and impulses, and good problem-solving and communication skills.

Cultivating moral resilience helps when dealing with aspects of the clinical environment that are not easily modifiable, such as caring for patients with complex, often life-limiting conditions, and witnessing suffering, death, disability, and social injustices.

So, how do nurses build resilience?

  • Accept that change is a part of living.
  • Keep things in perspective.
  • Avoid seeing crises as insurmountable problems.
  • Look for opportunities for self-discovery.
  • Maintain a hopeful outlook.
  • Get needed social support.

“Self-care is every nurse’s responsibility. Make choices that are meaningful to you, but do not do nothing. Resilience is fluid, but you can build and grow your resilient self,” Jakel said. “Run toward educational opportunities in ethics and resilience strengthening.”