Don't Kill the Messenger
Article Outline
This month's Emergency Nursing Advocacy column entitled, Moral Distress: A Living Nightmare, brings up some important issues that are not only being reflected in the emergency department, but in our society as a whole.1 The authors describe moral distress “in a nursing context as the painful feelings and/or the psychological disequilibrium that occurs when nurses are conscious of the morally appropriate action a situation requires, but cannot carry out that action because of institutionalized obstacles, lack of time, lack of supervisory support, exercise of medical power, institutional policy, or legal limits.”1
It is true that we are currently experiencing a great deal of moral distress not only in our work lives, but in our professional and personal lives. The recent health care debate has set off a bout of name-calling, physical threats, and actual property damage to those legislators and individuals who supported health care coverage to all citizens. Such hostilities are not the proper way a good citizen responds to a democratic vote.
The recent recession has produced an increase in patients seeking care in the emergency department that they could no longer get from their private health care providers –as one patient said to me: “My doctor wants money for my care.” This has added to the many distresses already found in the ED: overcrowding, inappropriate use of the ED, and decrease in reimbursements. Tight budgets, staffing, and acuity continue to loom over the heads of many ED staff and managers, challenging the delicate balance between providing safe, competent care and appropriate use of resources. But a distress seldom discussed is the distress caused by fellow staff members due to insensitivity or misplaced hostilities.
What are some of the signs and symptoms of distress that may be seen in the ED? Felblinger2 notes that examples of disruptive behaviors include rude comments, verbal attacks, condescending language, lack of collaboration, attacking a person's professional reputation or integrity, blaming team members when something goes wrong, blaming others in front of a patient or patient's family member, withholding important information, and lacking empathy. The author also notes that these behaviors can contribute to high turnover and absenteeism.
Sheridan-Leos3 points out these disruptive behaviors can lead to lateral violence in nursing. Lateral violence occurs when there is an act of aggression by one nurse against another. I would expand that to include an act of aggression against any member of the ED team. Again, sources of this animosity include lack of autonomy, lack of control over one's work and work environment (sound familiar?), and low self-esteem related to one's work.
How do we manage these distresses? How do we work well with each other and with the patients we care for? One word being “heatedly” discussed is civility. Civility is described as training for the humanities, civilized conduct—especially courtesy and politeness.4 Other words connected with civility include commitment, forgiveness, respect, and feeling valued.
As this problem continues to be recognized in the ED environment and the nursing workplace in general, solutions are being proposed. Unruh begins by suggesting that we “pull the curtain back and visualize the moral distress monsters that are lurking in the corners of your emergency department.”1 Once the presence of the problem has been acknowledged, its influence in the work place can be changed.
There is substantial support to identify and initiate change, particularly by the Joint Commission. Hospital work environments should be safe and non-hostile for employees. The establishment of a code of conduct, methods to report disruptive behaviors or “bullying,” as well as a feedback mechanism should be in place in all accredited institutions.
It is important that nursing and medical leadership take an active role in identifying and preventing distress. Communication is one of the most effective methods. When communication is clear and consistent even when the information is not always good, a sense of trust and respect are cultivated.
Finally, one important aspect of civility is that it involves all who are a part of the emergency department environment—nurses, physicians, technicians, other support staff, leadership, patients, and family. As stated by Eldridge Cleaver, “You're either part of the solution or you're part of the problem.”5
References
- . Moral distress: A living nightmare. J Emerg Nurs. 2010;36:253–255
- . Bullying, incivility, and disruptive behaviors in the health care setting: Identification, impact and intervention. Frontiers Health Serv Manage. 2009;25(4):13–23
- . Understanding lateral violence in nursing. Clin J Oncol Nurs. 2008;12:399–403
- Merriam-Webster Web site. Civility. http://www.merriam-webster.com/dictionary/civilityAccessed March 26, 2010
- Quote World Web site. Eldridge Cleaver. http://quoteworld.org/authors/eldridge_cleaverAccessed March 31, 2010
Reneé Semonin-Holleran is Editor-in-Chief of Journal of Emergency Nursing.
PII: S0099-1767(10)00127-3
doi:10.1016/j.jen.2010.04.001
© 2010 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.
