Barriers to innovation: nurses' risk appraisal in using a new ethics screening and early intervention tool.

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Advances in Nursing Science Vol. 36, No. 4, pp. 304–319 c 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright

Barriers to Innovation Nurses’ Risk Appraisal in Using a New Ethics Screening and Early Intervention Tool Carol L. Pavlish, PhD, RN, FAAN; Joan Henriksen Hellyer, PhD, RN; Katherine Brown-Saltzman, MA, RN; Anne G. Miers, MSN, RN, ACNS, CNRN; Karina Squire, MPH, BS, RN We developed and assessed feasibility of an Ethics Screening and Early Intervention Tool that identifies at-risk clinical situations and prompts early actions to mitigate conflict and moral distress. Despite intensive care unit and oncology nurses’ reports of tool benefits, they noted some risk to themselves when initiating follow-up actions. The riskiest actions were discussing ethical concerns with physicians, calling for ethics consultation, and initiating patient conversations. When discussing why initiating action was risky, participants revealed themes such as “being the troublemaker” and “questioning myself.” To improve patient care and teamwork, all members of the health care team need to feel safe in raising ethics-related questions. Key words: ethical conflicts, feasibility study, moral distress

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ITHIN the context of advancing technologies, expanding treatment options, and proliferating consumer information, health care providers report increased pressure from patients, their families, and colleagues to provide intensive, life-preserving treatments.1,2 At the same time, moral distress among health care professionals appears to be on the rise.3,4 Nurses in particular experience moral distress when witnessing and providing what they perceive to be overly aggressive treatments.1,5-13 However, nurses

Author Affiliations: UCLA School of Nursing, Los Angeles, California (Dr Pavlish); Mayo Clinic, Rochester, Minnesota (Dr Henriksen Hellyer and Mss Miers and Squire); and Ethics Center, UCLA Health System, Los Angeles, California (Ms Brown-Saltzman). This study is funded by Sigma Theta Tau International. The authors declare there are no conflicts of interest. Correspondence: Carol L. Pavlish, PhD, RN, FAAN, UCLA School of Nursing, 700 Tiverton Ave, Factor 4-238, Los Angeles, CA 90095 ([email protected] .edu). DOI: 10.1097/ANS.0000000000000004

often hesitate to discuss their ethics-related concerns with others.14,15 In fact, Lachman and colleagues16 cited numerous ethical challenges for nurses and suggested that nursing science on moral courage is lagging behind the demand that currently exists in the health care system. They also indicated that moral distress could be mitigated when nurses choose to speak up about their ethical concerns. These researchers call for innovative solutions that ease moral distress by encouraging nurses to voice their concerns. Responding to that call, we created an innovative ethics screening tool for nurses who care for seriously ill patients and their families. The tool is designed to help nurses identify clinical situations with a high probability for ethical conflicts and initiate early action. This article describes one surprising finding in a feasibility study that aimed to assess the screening tool’s usefulness and acceptability in clinical practice. In particular, we detail nurses’ reluctance to speak up even while citing the benefits of using an evidence- and action-based screening tool. We discuss barriers to nurses’ voice

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Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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Barriers to Innovation and the importance of strengthening environments for innovative nursing initiatives.

BACKGROUND Recently, Teno and colleagues17 compared Medicare reimbursement patterns for 2000, 2005, and 2009 and found a steady rise in intensive care unit (ICU) stays during the last month of life. Researchers concluded that more older adults were likely receiving aggressive measures near the end of their lives. Other researchers found that Medicare recipients with cancer received high-intensity treatments relative to their poor prognosis in the last weeks of life.18 Bakitas and colleagues19 also reported that patients with heart failure are not often referred for palliative care services until the last month of life and suggested that advance care planning for patients with heart failure is frequently delayed. Providing aggressive therapies may be indicated in some cases; however, health care providers need to question whether this practice has become routine in our current health care system without adequate attention to the ethical dimensions of treatment decisions. For example, multi-site research with 603 patients with advanced cancer indicates that when patients have end-of-life discussions with clinicians and receive information that medical interventions are not likely to improve their condition, patients are likely to refuse aggressive measures.20 This suggests that health care providers need to have honest conversations with patients and their families about prognosis and treatment options including palliative care. And yet, more than 50% of 1891 physicians reported in a recent survey that they had provided a more positive prognosis to patients than the evidence supported.21 In a recent study about patient expectations, Chen and colleagues22 found that 64% of 384 patients with incurable lung cancer did not understand that their palliative radiation therapy was not at all likely to cure them, which corroborates the need for honest communication about prognosis. Nurses also miss opportuni-

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ties for difficult conversations with patients about end-of-life choices.23 In an ethnographic study with nurses, physicians, and clinical ethicists, participants described a culture of avoidance characterized by delayed conversations about prognosis and treatment options in health care for seriously ill patients.10,24 Avoiding or delaying difficult conversations about prognosis and treatment increases the probability of aggressive and sometimes unwanted treatment for patients with serious and life-limiting conditions.18,19 Moreover, nonbeneficial and expensive treatments in complex, near endof-life care result in unnecessary suffering and unequal resource distribution—draining funds for basic health care, research, and innovation.25,26 Performing aggressive treatments near the end of life also raises the risk for ethical conflicts between health care providers and disruptive relationships in health care teams,11-13 which is important to patient safety. For example, in a national study of 10 184 nurses and 232 342 surgical patients, nurses reported more positive job experiences and fewer quality-of-care concerns. Patients also had significantly lower mortality risks in hospitals with better care environments as measured by the Practice Environments Scales of Nursing Work Index, which includes nurse-physician collaboration measures.27 Similarly, in a Canadian study of 18 142 patients, positive nurse-physician relationship was one of the hospital nursing characteristics that predicted 30-day mortality.28 These studies seem to indicate that compromised relationships, which often result from ethical conflicts, increase patient mortality and morbidity. Ethical conflicts and compromised teamwork can also lead to moral distress.1 Moral distress was initially defined by Jameton29 as a response when persons believe that they know the morally right course of action but constraints make it impossible to achieve. More recently, the focus of moral distress has widened beyond the individual toward a more relational and contextual perspective. For example, Varcoe and colleagues defined


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moral distress as “the experience of being seriously compromised as a moral agent in practicing [according to] accepted professional values and standards. It is a relational experience shaped by multiple contexts, including the socio-political and cultural context of the workplace environment.”30(p59) Most of the moral distress literature pertains to nurses’ experiences. However, moral distress has also been reported by other health care providers including physicians.1,2 The impact of moral distress is extensive. For example, health care providers can experience decreased job satisfaction31 ; disturbing physical effects such as insomnia, nightmares, and headaches; and disruptive psychological effects such as decreased self-worth and confidence.13 Nurses’ moral distress is also associated with burnout and intentions to quit.32 Other consequences of ethical conflicts and moral distress include threats to quality care and patient safety.3,26,33 For example, Cimiotti and colleagues34 used linear regression to measure the effect of nurse and hospital characteristics on health care– associated surgical site and urinary tract infections. Nurse burnout, which can result from moral distress,8,32 was significantly associated with both types of infection. Moral distress can also affect quality of care and health care economics when nurses and other providers decrease work engagement and productivity or even leave their positions or profession.7,9,32,35

THEORETICAL FOUNDATION: HEALTH CARE ORGANIZATIONS AS ECOSYSTEMS From its inception in the biological sciences, ecological models have proliferated in other disciplines including public health, social epidemiology, psychology, and health care. Social ecology focuses “attention on the social, institutional, and cultural contexts of people-environment relations.”36(p12) The result is a complex, multidimensional, multilevel, and circumstantial view of phenomena such as conflicting moral perspectives that

shape human behaviors and influence human experiences in health care organizations. From a socioecological perspective, health care organizations are composed of intersecting and interdependent relational networks that are set in processes of care that are constantly adapting and developing but have limited available resources. Moral distress and ethical conflicts flow from and are embedded in these relational contexts with their many values, social practices, and norms.37 Three principles of social ecology seem relevant to our understanding of moral behavior in health care organizations. First, health care systems are created out of particular values that exist within a larger context, and these often deeply entrenched values influence how relationships and networks of relationships develop, evolve, and normalize themselves within a system. Chambliss refers to this as “routinization” and claimed that moral issues are frequently buried in the “pile of repeated events.”37(p12) Power structures are part of the routinized, ingrained fabric of ecosystems and are strong determinants of relational behavior within health care organizations. Individuals’ position in the system’s power structure shapes not only interpretation of their own experience but also their view of obligations within the ecosystem.38 Positional and obligatory relationships, in turn, partially determine how people treat one another and who is accountable for what and to whom. Different viewpoints about these relational norms result in different expectations that can lead to interactional tension. A particular implication is cited by Jones,39 who asserted that certain social norms reinforce power differentials and promote a culture of silence that is a profound barrier to effective patient care in health care organizations. Second, all relationships in social ecosystems are interdependent, which naturally limits the autonomy (ie, power) of the system’s individual components. Therefore, interrelationships (not individuals) are key to the function of any system. McCullough25 argued that accountable care organizations need to


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Barriers to Innovation restrain the autonomy of any system entity in order to prevent harmful consequences to others. Amalberti and colleagues40 also asserted that ultrasafe health care organizations limit the autonomy of any particular group by encouraging effective teamwork and standardizing care. Placing a premium on the autonomy of any particular component in interdependent systems limits the effectiveness of the entire system. Third, tensions often arise at the interactive edges of system components. Therefore, rather than assessing each system component as separate and distinct entities, it is necessary to examine the borders between systems and how systems relate and interact to produce certain outcomes. For example, Rosenstein and O’Daniel41 explored nurses’ and physicians’ perceptions of disruptive behaviors in the clinical setting and their actual or potential impact on clinical outcomes. Defining disruptive behavior as “inappropriate behavior, confrontation, or conflict ranging from verbal abuse to physical and sexual harassment,” these researchers found that disruptive behaviors were very prevalent among nurses and physicians as they interacted during clinical care of patients.41(p55) Furthermore, research participants indicated that these negative interactions affected collaboration, increased adverse events and errors, and decreased patient satisfaction. Viewing ethical dilemmas and conflicts from a socioecological perspective requires widening the lens through which ethical issues are examined and developing “broad organizational awareness”37(p7) and “mindful interdependence.”38(p179) Ethics innovations from this perspective should attend to context and promote positive working relationships. Strengthening this call, Austin42 claimed that the essential work of moral communities such as health care organizations is to address the ethics of everyday clinical practice. The Ethics Screening and Early Intervention Tool was created and tested from this perspective.

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METHODS This feasibility study was built on a critical incident study that examined risk factors and early indicators of ethical dilemmas and conflicts.43 Results of that study clearly demonstrated that nurses were sensitive to unfolding circumstances such as conflicting moral perspectives or family disagreements in ethically difficult situations but were often silent about their concerns. We concluded that a routine ethics screening process that encouraged nurses to identify high-risk clinical situations, present evidence of ethics concerns to the health care team, and initiate early collaborative action might mitigate ethical conflicts and prevent the moral distress that often accompanies such situations. This feasibility study aimed to assess the usefulness and acceptability of an Ethics Screening and Early Intervention Tool for clinical nursing practice in oncology and ICUs. Ethics Screening and Early Intervention Tool development Two members of the research team selected the most frequently cited risk factors, early indicators, and ethics interventions in the critical incident study43 and created the innovative Ethics Screening and Early Intervention Tool, which consisted of 5 sections. First, nurses assessed situations for the presence of risk factors that indicated an increased likelihood of an ethics conflict or dilemma occurring (Table 1). Second, the tool also listed pertinent earliest indicators such as specific signs of conflict, suffering, moral distress, ethics violation, unrealistic expectations, and poor communication (Table 2). Once nurses assessed for all relevant risk factors and early indicators, they were asked to analyze and score the probability of an ethics conflict developing (low, medium, or high probability). Next, nurses identified appropriate follow-up actions such as explore statements with patients and their families, discuss with medical team


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Table 1. Risk Factors for Ethical Dilemmas and Conflicts Risk Factors Patient risk factors Family risk factors Health care team risk factors Health care system risk factors

Sample Circumstances Diminished capacity, unnecessary suffering, failed treatments Disagreements, unrealistic expectations, or adamancy about aspects of care Lack of cohesive care plan, conflict within the team, or divergent viewpoints about prognosis Unclear or absent ethics policies, poor communication channels, lack of cultural resources

and/or nurse manager, refer to additional resources such as palliative care, or contact an ethics expert. As a final step, nurses rated perceived risk of negative consequences occurring to the nurse if they initiated these actions. The question about perceived risk was on a 5-point Likert scale that permitted ratings from low to high risk. The screening tool was available in a paper or an electronic format. Participation and training After gaining approval from institutional review boards at 2 sites, the research team, comprising a nurse clinical ethicist in each setting, an ICU clinical nurse specialist, and an academic nurse researcher, recruited oncology and ICU nurses via flyers posted

at 2 major, academic medical centers; each center had 2 affiliated urban community hospitals. Fourteen nurses from each medical center participated, for a total of 28 participants. Participants were required to attend a 4-hour training session. The research team developed a specific discussion outline that consisted of background information on ethics terms, review of the American Nurses Association Code of Ethics, an unfolding case vignette, and specific orientation to the screening tool and study responsibilities. Specific guidance on how to initiate discussion about ethical concerns was also included. The study team from both sites worked closely via phone conference to develop and prepare for the training sessions. To enhance consistency during the training sessions, we used the

Table 2. Early Indicators of Ethical Conflicts and Dilemmas Early Indicators Signs of conflict

Signs of patient suffering Signs of nurse distress Signs of ethics violation

Signs of unrealistic expectations Signs of poor communication

Sample Signs of Early Indicators Family members arguing among themselves, family expressing disagreement with or distrust in plan of care, health care providers objecting to family decisions Prolonged discomfort, unrelieved pain, anxiety, unmanageable symptoms from treatment complications Expressions of anxiety, uncertainty, beliefs that treatment is nonbeneficial, regrets Evidence of violating patient autonomy, patient’s right to information, disrespectful treatment, patient’s right to standard of care Expressions of an unwavering belief in recovery, insisting on everything possible be done in poor prognosis situations Deflecting questions, poor or lack of documentation about goals of care, insensitive statements, strained conversations


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Barriers to Innovation same materials and worked consistently from the same discussion outline. However, we also encouraged participants to ask questions and provide their own clinical examples to demonstrate ethics concepts and concerns. The result was a structured, guided, interactive dialogue about nurses’ ethical responsibilities within the context of a specific case vignette, with some of their own clinical experiences included. After the sessions, the research team met via phone conference to debrief. Each site conducted 2 separate training sessions, for a total of 4 sessions. At least 2 researchers conducted each training session. At the conclusion of each training session, participants were asked to use the Ethics Screening and Early Intervention Tool in the course of their daily practice for 3 months. Data collection We developed and administered a 20-question ethics knowledge test before the orientation session and again after the 3-month testing period. We also collected evaluation data on the training sessions immediately after the session. During the 3-month data collection period, participants could select to complete the ethics screening tool online or on paper. Each time nurses applied the screening tool, they also responded to a brief questionnaire on the ethics situation (patient diagnosis and general condition and the estimated time required for assessment and follow-up) and on the tool’s usefulness for the particular situation. At the end of the 3-month testing period, participants completed a final online evaluation of the tool. We also conducted focus groups on their experience of using the tool in clinical practice. All focus groups were digitally recorded and transcribed. During the focus groups, we asked questions such as “What was it like for you to use the tool? Tell us about a time when it was particularly difficult to use the tool. How did the tool change your relationships or communication with other team members?” For this article, we are reporting quantitative data about

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nurses’ identification of appropriate followup actions and perceived risk of initiating those actions (screening tool questions) and qualitative data about how the tool affected their perceived risk when initiating follow-up actions (focus group questions). Data analysis Most of the quantitative data on tool use are still being analyzed with the intent to subsequently revise the tool. However, in the focus groups, researchers were struck by nurses’ high praise for the tool while also describing reluctance to initiate ethics-specific action. Therefore, we started with descriptive statistics to calculate the frequency of suggested follow-up actions and average level of perceived risk. We then qualitatively analyzed the transcribed focus group data to gain deeper understandings about participants’ perceived risks. All researchers first decided on a specific analytic process and then divided into site-specific research teams to read and code focus group transcripts from their own sites. Focus group transcripts were read and coded separately by each researcher. These detail codes were then clustered to form a categorical structure. Some of the categories such as benefits and limitations of the screening tool were heavily influenced by the focus group interview guide. Other categories, such as “barriers to speaking up,” emerged as topics that seemed to matter to participants. Site-specific research teams then met to compare codes and discuss categories. Differences in coding labels were slight and easily resolved. Once the categorical structure was finalized at each site, researchers sorted data according to the categories and detail coded the data within categories before using constant comparison to cluster the codes and find themes. We then met across sites to compare codes and categories and again found very similar topics with slight variation in labels. These differences were easily managed as we began to merge data from both sites and sought quotes that supported the major themes. This article reports on themes


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in 2 categories: perceived risks in taking action and barriers to nurses’ voice in ethically difficult situations. Researchers used the Lincoln and Guba44 criteria for creating trustworthiness in qualitative data. For example, we adhered to the principles of scientific research design, created detailed data collection and analysis plans, and consistently worked from the same research materials. We conferred throughout the process and drew from the work of MacQueen and colleagues45 on team-based data analysis. We sampled widely from ICU and oncology nurses who worked in 4 different hospitals in 2 different states and included both quantitative and qualitative data collection and analysis techniques. Triangulation not only verifies findings but also produces more expansive understandings of research phenomenon. Trustworthiness was also enhanced when researchers worked independently to code data, and the team met to compare and discuss detail codes and how codes clustered into broader concepts. The research team also set specific agendas for each phone meeting and maintained detailed notes to record discussion, decisions, and next steps. Themes that we report in this article were supported by multiple participants’ quotes across focus groups and across settings.

FINDINGS Thirty registered nurses enrolled in the study and participated in the training session. Twenty-eight actively participated throughout the 3-month data collection period. Twenty-four nurses participated in the focus group sessions. Participants were similar across geographic settings; however, site A nurses reported more years of experience whereas site B nurses showed greater variability in their educational preparation. Table 3 compares participant demographics at each site. Ethics-related actions The ethics screening tool listed potential nursing actions that participants could choose to implement. However, during the training sessions, we emphasized that nurses were not required to initiate any actions. Findings in our previous research studies showed that nurses have experienced repercussions, such as being severely reprimanded when intervening in ethically delicate situations,10 and therefore we asked participants in this study only to identify appropriate follow-up actions and score their perceived risk of negative consequences occurring if actions were taken. Participants elaborated on action decisions and

Table 3. Participant Demographics

Demographic Gender: female/male Average years in RN practice Practice in ICU setting (including transplant units) Practice in oncology setting Nursing education Diploma Associate degree Bachelor’s degree Master’s degree Formal ethics education Ethics conference attendance

Site A (n = 14 nurses)

Site B (n = 14 nurses)

11/3 11.5 14 0

12/2 7.8 11 3

1 0 13 0 7 2

0 4 8 2 7 3

Abbreviations: ICU, intensive care unit; RN, registered nurse.


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Barriers to Innovation risk appraisal during focus groups. Table 4 lists actions as they appeared on the screening tool and the frequency with which nurses thought that particular actions were appropriate for the situation they were assessing. Risk appraisal on ethics-related actions The screening tool asked participants to use a Likert scale (1 as “low risk”; 5 as “high risk”) to rate the degree of risk they believed was involved for initiating action in each situation they screened. Table 4 compares risk scores from each setting. Overall, participants scored most actions as below-medium risk and many actions as low risk. Only the action of “exploring statements with patient, family” at site B was rated above-medium risk. Interestingly, both sites identified the same 4 actions with the highest risk scores, although each site ranked them differently. At the end of the 3-month data collection period, but before quantitative data were collated and calculated, researchers conducted focus groups. Participants’ comments about highest-risk actions verified the quantitative findings. For example, a participant at site B commented on approaching the medical team with ethical concerns and stated, “You bring up your [ethical] concern to the NP or the

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doctor and it is shooed away, like what you have to say is not necessarily important.” A nurse at site A explained, “If the physician says, ‘No, we aren’t going to do that right now’ I, frankly, am not going to. That is a wall, and I’m not going to try to climb it.” A nurse at site B described a situation when he was reading an ethics article on nurse-physician collaboration in ethically difficult situations. A physician walked by, stopped to examine the article, and commented rather forcefully, “It [collaboration] will never happen.” The participant stated that he tried not to allow the physician’s comment to shape his use of the screening tool, but he wondered whether subconsciously he was silenced by the physician’s comment. Participants also stated that exploring treatment options with patients and their families could be risky. A participant at site B stated, “What I see as being most risky is how much I should tell [the family], how should we talk about it [treatment options such as palliative care], what are your goals here? It felt risky.” Some nurses at both sites did not feel prepared to have difficult discussions with patients and their families. Others reported concern about breaching the trusting relationships they had with patients and their families. For example, a nurse stated,

Table 4. Follow-up Actions and Level of Perceived Risk in Taking Action

Follow-up Action

Site A (n = 30 Situationsa ) Site B (n = 25 Situationsa ) Frequency Level of Riskb Frequency Level of Riskb

Explore statements with patient, family Discuss with physician Discuss with colleagues Discuss with nurse manager Initiate ethics consultation Contact social worker Contact chaplain Contact palliative care team Other actiond

24 (80%) 22 (73.3%) 22 (73.3%) 2 (6.7%) 3 (10%) 11 (36.7%) 11 (36.7%) 11 (36.7%) 3 (10%)

2.63c 2.47c 1.10 1.38 2.92c 1.35 1.17 2.11c 1.57

19 (76%) 20 (80%) 20 (80%) 9 (36%) 5 (20%) 6 (24%) 6 (24%) 8 (32%) 0

3.05c 2.13c 1.23 1.33 1.77c 1.33 1.21 1.71c 0

a Situations:

The number of completed ethics screening tools on patient situations. of risk: The number indicates average with 1 = low risk and 5 = high risk. c Values indicate the actions with the highest reported level of risk in each setting. d Other actions included contacted discharge planner, contacted legal advocate, and contacted patient’s pastor. b Level


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Risky, is not the best word . . . maybe it’s comfort level. You don’t want to breach that relationship, especially, with the patient. Then you have a rift with the family, and it is difficult to take care of the patient . . . so that kind of risk.

Some nurses believed that physicians were responsible for discussing treatment options with patients and their families, and if the medical team was avoiding these conversations, then nurses were not obligated to initiate discussion regardless of how appropriate treatment information might be. Initiating an ethics consultation and contacting the palliative care team could also be risky. A nurse at site A explained, “I see it [contacting ethics] as a big deal and . . . if the primary team already kind of said no, I guess my perception is that it would be subversive.” At site B, a participant stated, “Ethics is sometimes taboo because . . . you don’t want anyone to feel like you’re a whistle blower or you always have a problem with something.” At site B, another participant described a situation when she approached a physician about palliative care for a patient who had received a transplant; the nurse asserted, “After this expletive tirade toward me . . . it just validated my concern that I can’t bring up my concerns to you because you’re not going to consider palliative care. That’s not how it works in [this unit].” Barriers to initiating ethics-related action During focus groups, participants at both sites described the ethics screening tool as easy to use and very beneficial to “thinking through [their] hunches that something is not quite right.” Nurses also indicated that the tool was a “great conversation starter,” although many nurses admitted that they hesitated to use the tool when approaching physicians or other colleagues. Nurses cited the need for an “objective score” and “more management support” before the tool could become mainstream practice. A few participants reported that the “perceived risk wasn’t really an issue whether talking to a physician or

the family. I was very comfortable bringing up things.” However, other nurses, often without prompting, described the barriers they encounter when initiating follow-up actions in ethically difficult situations. Perceived risk of negative consequences permeated each of the barriers that nurses identified. “Letting it slide” Some focus group participants described an attitude of “looking away” from ethical issues as they pertained to treatment choices in seriously ill patient situations. One nurse commented, “We’re not on the same page—the doctors, the nurses, the patient, family—and oftentimes I just kind of let it slide.” In some cases, nurses described limited time and energy to deal with ethical issues. A nurse discussed the emotional burden of raising ethical questions and stated, “You’re just trying to get through your day. It’s like do I really want to open up this hornet’s nest? I could just let it go. You think, ‘My day’s been bad enough. Let someone else deal with it.’” In other cases, nurses described a power hierarchy that is difficult to navigate. For example, a male nurse described a “very distinct hierarchy” that “trumps” nurses’ suggestions. He elaborated, You could bring something up, you could contact multiple resources and yet, there was a distinct glass ceiling that you couldn’t penetrate. So even if you had chaplains, social work, nursing, the charge nurse . . . whatever, you have a whole group. They may all have concerns. We bring them forward and yet you can’t penetrate the glass ceiling and say, “Hey, something needs to change.” It all depends— it is very, to be honest, consultant-driven. So the consultant always has the last word.

Another nurses stated, Nurse managers and clinical nurse specialists have pressure on them, especially in the transplant unit to . . . placate the attendings . . . it’s also the residents, it’s even the fellows. It really does feel like a top-down structure and we’re all playing our roles.

This statement seemed to indicate that the system has informal rules about who gets to


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Barriers to Innovation say what. In the midst of a discussion about the challenges of considering ethics, a nurse stated, “It [health care environment] has been this way for such a long time that we kind of fit into this mold and you just don’t question it. You just do what you are supposed to do.” Many nurses commented that raising ethics-related concerns is very challenging. One nurse stated, “Everybody goes to the team conference but nobody asks about the plan of care . . . it’s hard to ask, ‘How long are we going to keep doing this?’ It’s sensitive.” Another nurse commented on working in a hospital with a “lot of outside physicians who don’t like having the tough conversation with families.” Some nurses cited uncertainty as the primary challenge. For example, a nurse described a very sick patient who was improving slightly and stated, “You ask yourself, ‘Is it going to get better? Is it worth investing [time in ethics] if he’s going to continue to get better? Then it doesn’t and you think, ‘Oh shoot, we should have tackled this sooner.’” Finally, a consequence of all stakeholders “letting it slide” was captured by one participant who sadly commented, “I start to feel like I’m the only one who cares about this [ethics].” “Questioning myself” Another barrier to initiating action on ethical concerns appeared to be a lack of knowledge or confidence. A nurse stated, “I don’t know much about ethics, medical ethics or nursing ethics and it’s difficult for me to articulate my concerns in front of the team. All I have is this diffuse feeling of there’s something wrong.” Another nurse asked, “How do you talk about that [plan of care, treatment goals] when you don’t even know what the survival rate is for that patient population. Do you really have a right to share your concerns with the attending?” Many nurses agreed that they had very little guidance on how to communicate ethics concerns to nurse and physician colleagues during their nursing education or in work orientation. A nurse in a different focus group

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said, “I just don’t believe in my ability right now to take a more proactive role.” Some nurses discussed “questioning” their own judgments as part of the challenge of working with seriously ill patients with questionable prognoses. One nurse described a patient whom the nurse “had written off” but the patient recovered enough to be discharged. The nurse stated, “When you’re wrong about what’s going to happen to a patient and then they get better. It’s just interesting when you’re very, very wrong about the outcome of what’s going to happen.” Uncertainty seemed to fuel hesitance and lack of confidence for fear of losing credibility with colleagues. “Being the troublemaker” Several nurses at both sites discussed the burden of interpersonal conflicts that sometimes resulted from initiating discussion about ethics. One participant commented, “I find a lot of people don’t say anything because you don’t want to cause lack of harmony in the work environment by questioning a doctor and saying, ‘Do you really think this is the best plan of care?’” Another nurse described a physician using “abusive language” when the nurse questioned whether a debilitated patient who had been in the unit for 3 months should be a full code. The nurse stated, “It just validated for me that we are going to save people here at all cost.” Other nurses commented on their concerns that bringing the ethics screening tool to the medical team would cause a “nasty reaction” or opening discussion with the family might cause them to “fly off the handle.” A nurse stated, “I don’t want anybody to feel like I’m trying to get them in trouble . . . so you never know what repercussions or how people will receive that.” Another nurse shared that her greatest fear was to be labeled a “troublemaker” if she called ethics. Some nurses wanted to avoid a bad reputation because it influenced future work with team members. For example, a nurse commented, “I have seen physicians get upset [about an ethics call] and then they don’t


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want to talk to you next time they see you.” Other nurses were concerned about how raising ethical concerns may impact patients. One commented, “You can’t talk about treatments or options that the patient didn’t take. You don’t question it. Once a patient is on a path, then they’re on that path so you just support them.” Some nurses suggested that discussing ethics needed to become more routine: “We can be more comfortable to just say when you feel like something is wrong.” In a different site, a nurse commented, Somehow [we need to] take out the possibility of interpersonal conflict so getting back to the hierarchal structure, if you could create something that would automatically [trigger] a consult or something like that, it would take out the possibility of interpersonal conflict.

“Finding the gatekeepers” Noting a lack of accountability, some nurses described the challenge of considering who to approach with their ethics concerns. A nurse commented, “[There is] even a lack of administrative support. With nurse managers and CNSs, it’s not that they don’t support us, it [ethics discussion] is just not as open.” Another nurse worried that talking to the family without first talking with the physician felt like the nurse was “going behind their [family’s] back and asking the doctor or the charge nurse about palliative care.” In other cases, nurses noted that gatekeepers are not receptive to ethically relevant questions. A nurse stated, In my unit, people come because they want lifeextending treatment. It’s antithetical if we say, “Let’s think about hospice.” It seems like a forbidden word to the attending or fellows because they have set up the expectation from the get-go.

Another nurse commented, I feel like our physicians are kind of hesitant to get ethics involved. We have one patient . . . it’s a very clear ethics case. It’s more about the family but it took awhile for physicians to call an ethics consult.

And finally a nurse commented on the paradox of ethics concerns and noted, “I feel like people are concerned about some of these things [code status] but it [doesn’t] translate to the bedside very well.”

DISCUSSION AND CLINICAL IMPLICATIONS Addressing ethical issues about the care of patients with serious illness carries some level of personal risk for most nurses who participated in this study. Although participants worked in high ethics consult rate institutions and affirmed several benefits to the Ethics Screening and Early Intervention Tool, most nurses still claimed that it felt risky to bring their screening tool results to some health care providers and initiate conversation about goals of care. The risks appear to arise because of the need for challenging discussions or dialogue with key stakeholders in a patient’s care. Although we noted that nurses perceived a below-medium risk level in almost all cases, we question all health care environments that pose any level of risk to nurses who initiate collaborative action in ethically difficult situations. Some participants in our study claimed to be the most vocal nurses on their units. While some said they were not afraid to raise ethical issues, they also seemed to indicate reaching a point when they believed that they hit a wall where dialogue about ethics held some level of perceived risk. This appears to corroborate other studies that have found that nurses’ moral action is partially influenced by the ethics environment. For example, Attree14 studied factors that influenced nurses’ decisions to question practices that threatened care quality. Generally, nurses in that study perceived raising concerns as a high-risk, low-benefit activity. Feeling considerable dissonance between moral obligation and fear of repercussions, nurses experienced uncertainty about initiating action. Among the disincentives to raising concerns was nurses’ perception of risky organizational


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Barriers to Innovation cultures characterized by closed communication and disruptive, blaming behaviors. Factors that facilitated raising concerns about care included having trust and confidence in colleagues and management. Interestingly, nurses in our study did not choose to discuss their ethical concerns with nurse managers (Table 4). Some participants in the focus groups expressed confidence in raising concerns, whereas others described negative past experiences that seemed to influence their decision on whether to raise ethical concerns with nurse managers. Austin42 described the “geography” of health care environments and claimed that the sociopolitical landscapes of organizational cultures strongly influence care quality. These landscapes determined power dynamics and also harbored moral questions pertinent to everyday nursing practice. Furthermore, Austin asserted that ethical action needs to be understood within the context of relationships and requires “perpetual responsiveness to others.”42(p86) Focus group participants in our study described heightened vulnerability when they perceived barriers to communication and tension in relationships. Some nurses in this study described a tendency to allow ethical concerns to “slide” because of the challenging circumstances that often resulted when questions were raised. Other researchers also note that interpersonal and intrateam conflicts are energy- and timeintensive.24-26 This finding emphasizes the importance of prevention, early intervention, and mitigation strategies for ethical conflicts. However, participants noted a persistent culture of “letting it slide” and avoiding difficult conversations in health care that reinforces silence and potentially allows ethical concerns to build into conflicts and moral distress. At least 2 concerns surface with this finding. First, Jones39 described the culture of silence that surrounds medical errors and claimed that team relationships and deconstructing power hierarchies were keys to error prevention and quality care. Participants in our study also claimed that power hierarchies stifled conversations about ethical concerns. Furthermore, they suggested that it was

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sometimes difficult to “find the gatekeeper,” which appeared to discourage nurses from raising questions. Garon46 studied nurses’ “speaking-up” behaviors and found that management structures influenced nurses’ willingness to raise concerns. Organizations that had policies supporting open communication also encouraged nurses to voice their concerns. Second, a health care structure that fails to reimburse or hold people accountable for having difficult conversations, such as careful advance care planning with patients and their families and regularly collaborating and documenting on plan of care, tends to favor aggressive treatment among seriously ill patients.23 When organizations fail to hold health care providers accountable for these difficult conversations and decisions, and nurses remain silent, the potential for providing unnecessary and unwanted treatments to patients increases.25 Some participants in our study indicated that they wanted to avoid the reputation of being a “troublemaker.” Furthermore, some described lack of confidence in their ethicsrelated abilities. Sayre and colleagues47 also noted nurses’ reluctance to express concerns and conducted a “speaking-up” intervention study that featured a videotaped message from nurse leaders and administrators. The purpose was to support nurses’ speakingup behaviors. The quasi-experimental design studied outcome differences in speaking-up and collaboration measures and found statistically significant changes in both. Researchers suggested that nurses develop a personal plan to develop speaking-up and collaboration skills. Furthermore, nurse managers were urged to transmit the message that speaking up was important and would be supported. Participants in our study seemed to indicate that they could benefit from developing a personal plan for speaking up.

POTENTIAL LIMITATIONS Conclusions drawn from this study are preliminary and tentative since this was an exploratory project. Participants were chosen


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from nurses who volunteered to participate in the study and may have had a higher interest in ethical issues and higher sensitivity to the moral distress that occurs when issues are not resolved. Other limitations include our small sample size, which is not necessarily representative of oncology and ICU nurses in other settings. The short time frame also limits conclusions about sustainability of tool benefits over longer periods. Future studies need to further validate constructs in the ethics screening tool, and researchers should eventually use an experimental design to assess effectiveness in achieving measurable outcomes such as speaking-up behaviors, physician-nurse collaboration, length of stay, timing of ethics consultations, and patient satisfaction.

A CALL FOR EMANCIPATORY KNOWLEDGE DEVELOPMENT Nurses in our study uncovered 4 common barriers for initiating ethics-related actions. These barriers often left nurses silent about their ethical concerns in the care of patients with life-threatening conditions. Much more research is needed on these barriers and how institutional processes such as interprofessional power dynamics influence nurses’ moral actions. Chinn and Kramer48 developed the idea of emancipatory knowledge as social and political information about inequities and other injustices accompanied by the realization that circumstances could be different. Researchers seeking emancipatory knowledge resolve to improve people’s lives by exploring interactions between human experiences and the context in which these experiences occur. Developing emancipatory knowledge requires investigators to raise 4 questions: (a) What is wrong with this picture? (b) Who benefits? (c) What are the barriers to freedom, and, finally, (d) What needs to change? These authors described methods that pursue emancipatory knowledge and suggested that an essential aspect is praxis—a

continual process of reflecting on and within action. In nursing, this reflection is best accomplished by those who are “in the trenches” at the point of care—often where action occurs but deep reflection on actions is not necessarily recognized or valued. The next patient, the next responsibility, the next task await—creating crowded environments that are not conducive to reflection. The result of action without reflection is often a deepening silence. Kagan and colleagues indicate, “More work is needed in the discipline to uncover the emancipatory voices of nurses and bring their ideas to light for a broader audience to analyze and use.”49(p83) Our research findings highlight the importance of this statement. We uncovered evidence that nurses often knew their ethical responsibilities but were sometimes caught in powerful, resourceconstrained systems that failed to recognize or value the required skills or time that nurses need to spend on ethical concerns. Our findings also indicate that “speaking up” to initiate collaborative, ethics-specific action is not yet risk free. Georges50 described the “unspeakable” in health care and warned that compassion becomes more difficult and even impossible when concerns are unspeakable. Research that seeks emancipatory knowledge on moral experience and the “moral habitability” of health care structures is sorely needed.42(p81) For example, administering an organizationwide ethics environment survey; setting organizational and unit-based benchmarks; creating collaborative, ethics-related competencies for job performance evaluations; and tracking progress could open conversation about the ethical landscape in health care settings. Alongside that effort, health care providers, administrators, and consumers need opportunities to collaboratively reflect on the meaning and processes of ethical practices for seriously ill patients. These efforts could lead to evidence-based strategies that encourage routine, ethics-based conversations from the start of care and throughout the course of serious illness. Removing the “unspeakable” would start when we begin to have


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Barriers to Innovation comfortable, risk-free conversations with each other and with patients and their families.

CONCLUSION From this study, we developed deeper understandings about moral behavior, which seems to be much more than a product of individual beliefs and experiences or even relational interactions. Moral action also seems to be influenced by powerful, often unstated sets of social assumptions about “who gets to say what” and “who has responsibility for what” in ethically difficult situations. These subtle messages are frequently reinforced by financial, political, and social forces far beyond the individual—be it patient, family, or provider. Nurses evidently experience pressure to conform to these social assumptions and get caught in “questioning myself” instead of questioning the system, “letting it slide” instead of determining accountability, and feeling like the “troublemaker” when pursuing moral obligations. As a result of this study, our research trajectory has shifted to extend beyond developing individual and interactional capacities for moral action to include research that probes the “unspeakable” and pursues the meaning of health care organizations as moral communities. We also learned that innovation in health care requires careful attention to stakehold-

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ers, sociocultural context, and the powerful structures that surround the delivery of care to patients and their families. The Ethics Screening and Early Intervention Tool successfully prompted nurses to step back, consider, and often affirm what they already believed about the ethical issues in difficult patient circumstances. Furthermore, the tool facilitated nurses’ understanding of situational dynamics and why they were uncomfortable. From this, we conclude that the screening tool has the potential for strengthening nurses’ internal voices. However, the tool did not always strengthen nurses’ external voices. Participants clearly identified actions that would be helpful, but they also described powerful barriers including perceived personal risk in taking early action. We contend that quality of care suffers whenever nurses perceive risk in initiating collaborative dialogue on ethical concerns. Nurses are uniquely positioned to assess ethics-related dynamics and make positive changes in patient situations. However, the continued presence of hierarchical constraints and cultural sanctions on difficult discussions is potentially hindering nurses’ willingness to engage in necessary ethical conversations with patients and their families, physicians, and ethics consultants. Understanding and reducing these barriers can empower all health care providers as they collaboratively seek to provide safe, high-quality, and ethics-based care for seriously ill patients and their families.

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