March 24, 2021

Episode 50: Building resilience in the face of moral suffering

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Description

In recent years, the issues of moral injury and moral suffering have become widely discussed within the field of nursing. These conversations have taken on particular urgency as the COVID-19 pandemic has exposed many nurses to death and patient suffering on an unprecedented scale. 

Our guest for this episode is Dr. Cynda Rushton, a Professor of Clinical Ethics at the Johns Hopkins Berman Institute of Bioethics and School of Nursing. After beginning her career in the pediatric ICU, Dr. Rushton became acutely aware of the moral suffering that clinicians face in the course of doing their jobs -- suffering that she says often goes unacknowledged. She eventually decided to pursue a career in bioethics, and has dedicated her professional life to helping nurses and nurse leaders find ways to build their resilience. 

In her conversation with Dan, Dr. Rushton talks about the interventions that she thinks can best help nurses meet the unique challenges that come from working at the bedside today and how to maintain their integrity in the face of moral suffering.  

Links to recommended reading: 

Podcast

Transcript

Dan:
Welcome to the show Dr. Rushton.

Cynda:
Thank you so much, Dan, for having me on your show.

Dan:
Yeah, this'll be fun. So this is a topic that's near and dear to my heart. I spent a long time working for Dr. Bern Melnick, and so mental health, and resilience, and coping with stress, has been a core of my entire nursing background and education, and has been something that I'm interested in professionally as well. Can you give us a little overview of what brought you into bioethics and then also the resiliency focus for your research?

Cynda:
I started my career in the pediatric ICU, and learned fairly quickly that there were a lot of ethical issues that come up with deciding about how to take care of critically ill and chronically ill children, and their families. And eventually I became a clinical nurse specialist and was involved in helping families make hard decisions. And I found myself drawn to that complexity, and it also coincided with what became known as a series of Baby Doe cases, where questions about what the role of parents ought to be in decision-making, and how we ought to think about decisions for imperiled newborns.

Cynda:
And that just caught my focus for a number of years clinically, and then I went back and got my doctoral preparation where I combined more training of bioethics with my doctorate in nursing. And I've been doing clinical ethics consultation for many decades. And in that work, it's one of the ways that really keeps me connected to patients, and clinicians, and the real reality of what healthcare is like. And I guess I would say I'm pretty comfortable with the ambiguity, and the uncertainty, and also just the messiness of it all.

Dan:
Comfortable with being uncomfortable, right?

Cynda:
Yeah.

Dan:
I was talking to a colleague earlier this morning, who's not in the healthcare space, he's on our IT team. And he was asking me what was going on today, I said, I'm having a conversation with Dr. Rushton, And he said, Bioethics, how do you even study that? What trajectory do you take to get into that space?" And I'd love to hear your thoughts on that.

Cynda:
Part of it is how you think about ethics and morality, and its relationship to us as people, but also to our professional work. I tend to take a pretty broad view of ethics and morality in terms of a lot of times it gets reduced to this thing we do when everything else is finished, or only when we have to look at it. Instead, I see it as part of everything that we do. It's a reflection of our choices. It's a reflection of our character. It's a reflection of who we really are. And so with that, I really see this dimension as central to our work in healthcare. And that's partly why, I know in my own work what really started my inquiry in addition to taking care of critically ill children was noticing in myself the kind of what I began to think about as moral suffering, that clinicians carry just as patients and families do.

Cynda:
And that often that's moral suffering was really not recognized. And so that launched me into trying to understand what were the sources of that moral suffering. Then really in the last five, or six years, my work has pivoted from focusing so much on the moral suffering aspect of our work, not denying it, of course, as really very much a part of the context where we work, but rather to ask the question of what else is possible? What else might be a way for us to be with that suffering so that it's not so detrimental to our wellbeing and our integrity? And that's what launched me into my own work around the concept of moral resilience, trying to think about how we might be able to preserve, or restore integrity, in response to the moral adversity that comes up in our work. And so for me, there's a distinction between the fact that moral adversity is part of everything, it's going to happen.

Cynda:
And there are things that are modifiable, and things that are not, in our work. And so part of our challenge is to identify those things structurally, and interpersonally, and with patients, and with our team members, that we could modify. But importantly how do we strengthen our own inherent resilient potential to meet those challenges in ways that are both healthy and wholesome, but allow us to have a really sense of integrity at the end of the day? And that's really where my focus has been, and right now in the midst of COVID, the issues that are causing moral suffering are quite profound. And I think that this aspect of wellbeing, this aspect of resilience, has to be understood as a particular type of resilience, and that some of the interventions that are aimed at general resilience may actually not sufficiently address the moral aspects. And therefore we need some targeted interventions to address this part of our experience.

Dan:
I think that is an important distinction, and early on, even before the pandemic and as burnout has continued to be top of mind, and top of media, it seems like in healthcare, there are interventions that were, well, they just need to go do yoga, if we just had more yoga, if we just had more meditation with our physicians and nurses, that'll help you. And I think that's that generalized mindfulness piece of it, but it doesn't get down to the actual source of the stress, or the moral issues that might be causing the stress. And so what are some of those targeted interventions that actually dig into the underlying structures of this, that may be more effective than these general ones?

Cynda:
Well, I would say one thing in terms of your characterization of we don't need more mindfulness in yoga, and I have to push back on that a little bit [crosstalk 00:08:39].

Dan:
Sure.

Cynda:
... Because I think that these claims that those are ineffective in addressing these problems actually is not completely true. If that's the only thing that we do, it will not address the structural issues, but in terms of how do we help people meet these challenges? Those strategies are very important on the individual level to be able not to tolerate, or to overlook the challenges, but to allow people to not be in this system, and in this experience, without resources. And so that's an important point. It's not either, or. I think if we had organizations where everyone was really had the skills of mindfulness, I suspect we would make different decisions and we would prioritize different things, and we would relate to each other in different ways.

Cynda:
So on a large scale, I think that those interventions actually in our work have been shown to be important skills and tools to help us be able to restore moral efficacy and integrity because when our nervous system is completely dysregulated, we cannot think clearly, we cannot be creative, we cannot meet those challenges in a way that allows us to choose how we want to respond. So there is an important element of strategies that is focused on that. We've done work in our Mindful Ethical Practice and Resilience Academy focusing on just some of those skills. But in addition, I think individually we need to bolster our ability to recognize a name, and work with these ethical challenges in ways that allow us to speak up, that allow us to be able to advocate for change in our organizations, and also to be able to work together to find solutions. So, that's one piece of it. And related to that is the need to cultivate a really robust sense of self stewardship. And that self stewardship is counter to the culture in healthcare that we just soldier on, we don't need a lot of help.

Dan:
Yeah, we have the armor on, right? We put on our armor and no one can get through that, and that's like it's a badge of honor to not be impacted by the stressful things. Right?

Cynda:
Exactly. And I think that's part of our culture that we have to start really looking at, and my hopeful view of COVID, I think it has really clearly dismantled the assumption that we don't need help, and that we don't need each other, because we do. But self stewardship then is instead of saying, this is a selfish act for me to invest in my own wellbeing, it's actually an invitation for us to know ourselves well enough to know what we need, to be able to be whole, to be able to be healthy, to commit to investing in those kinds of resources, but also to turn toward our limitations with more compassion rather than judgment, and expecting ourselves to be these heroic figures in the midst of situations where it's just not possible, and then holding ourselves accountable for things that are largely beyond our control.

Cynda:
So that's the individual level, but on the system level, I think there are many things that we've learned in the midst of this pandemic. And one of those is that we need to really create the structures, the processes, the policies, and the infrastructure that support people to do the right thing consistently, confidently, and without punishment. So, that takes us to looking at what kind of culture do we have in our organizations. And that's a very, very, I think, important starting point of how do our values like respect, and equity, and compassion, and integrity, show up in our design of how we operate in our organizations. I think that's a really important part. I know Ben is really interested as I am in how we can, for example, remove the barriers to access to mental health services.

Dan:
Yeah.

Cynda:
The stigma, the worries of privacy that people have about getting access to those resources within their organization, I think those are some things at a very organizational level, need to be explored, and some of that involves looking at how we can normalize the experiences that people are having right now, rather than making them pathological.

Dan:
Yeah.

Cynda:
And that's part of the culture. Are we in a blame and shame environment, or are we really creating an environment that's focused on fostering the humanity of everyone?

Dan:
Yeah, I think that's really important. And I was just in a conversation recently, and it was with medical boards, and a couple of medical boards require that physicians disclose if they were under the care of a mental health practitioner. I hadn't heard about that on the nursing side at all, but that just struck me as what a way to stop someone in their tracks and even have themselves question themselves are they fit to practice? Even just the notion of having to disclose that I think has personal impact and also system impact, because I don't know, it just struck me as such a question that just the value of disclosing it wouldn't be as beneficial as the negative impact to the person.

Cynda:
Yeah. I think you're absolutely right. In our National Academy's report, that was one of our suggestions that licensing boards and accreditation bodies not include that as a question because it can have, in some cases, unintended consequences.

Dan:
Yeah.

Cynda:
So one of the things I really have learned in this process, we did a national Wikiwisdom Forum for frontline nurses, inviting them to share their experiences during this COVID time period. And we developed a report with recommendations from the frontlines, there were 14 recommendations, but what was really important in those recommendations is that people at the frontline said there are three things that would make a difference in our experience. The first one is to protect us, to not put us in a situation where we have to choose our own health over providing care for our patients. Giving us the resources that we need to be able to actually do our jobs, that's the most important thing.

Cynda:
The second thing was to listen to us. And I think that we have a real gap of wholehearted listening everywhere in our lives right now. And I think part of it is because under stress, it's very difficult for us to hear things we don't want to hear, or that we don't like. And so I think leaders can sometimes think they're listening, but they may not be able to hear, as we'd like to say, the commitment behind the complaint might be, and vice versa, people at the frontline also, I think, because of stress and distress, have a hard time hearing what their leaders are trying to communicate to them. So there's this gap of everybody's in an echo chamber and they're not actually hearing each other.

Cynda:
The third thing was to empower us. And this was about actually believing that people at the frontline had solutions to these big problems, and listening to their solutions, and involving them as the implementers of organizational plans in the design in a proactive way. So I just thought those were such important, but simple ways to think about how we might, from an organizational point of view, address some of the concerns that have come up during this pandemic.

Dan:
All those aspects you just spoke about are also in the literature around successful change and innovation in organizations. It's including the people who are experiencing the problem in the solution. It's listening to the user needs and taking them as important data points for the actual solution, and they're all parts of the culture change like you spoke about as well. Those initial interactions, those initial artifacts that eventually create the values and the deep assumptions of a culture. And I think they're just so right on, and those are some awesome tactics for nurse leaders. From my view, we've seen across 2000 health care facilities as we place nurses all over the country. And there's been some really interesting incidents and feedback about leadership and front lines. And I think COVID has definitely highlighted a lot of cracks in the system, but it's good that we have a framework now, and some tangible things that you can do tomorrow to help nurses like this.

Dan:
And I was in another conversation the other day, this is so timely, and I remember doing this as an ER nurse, you left work at the front door of your home and you would never bring it to your family. But I think in that you're also compartmentalizing things and not dealing with it. Do you have suggestions? Because we've talked with lots of nurses who are calling, crying, or at home and not able to cope, and we just have a lot of these communications. What are some tips for nurses who are coming home after seeing three, or four deaths in an ICU from the COVID surges? How do you process that and not maybe compartmentalize it completely and bring your family into it?

Cynda:
Yeah. It's a great question. It's one that I think really deserves more attention, and that is how do we make the transition from work to home, and how do we use that transition as a way to, first of all, acknowledge what we're carrying? And I've spent a lot of time with frontline nurses and leaders over these months. And I think part of the challenge is we haven't allowed ourselves to feel the feelings, and there's a fear that if I do I'll just fall apart, when in fact resisting feeling our feelings may actually make it worse. And so, for example, we created a video about how to, if you're working on a unit, how do you end your day together as a team? How do you acknowledge what's happened today, and how do you also begin to pivot toward what good happened? Because we tend to only see what was left undone.

Cynda:
And so being able to have some of those rituals and practices together as a team, and then to have a ritual as we, for example, as you take off your PPE, and have a ritual of saying, here's what's left from today, and I'm taking off my PPE now, and I am acknowledging that I did the best I could with what was available today. And now I'm going to put down whatever's left, forgive myself for mistakes made and things left undone, and to really be generous toward ourselves. And then to have some rituals/ you get into your car to pause and to take a few breaths, and to really acknowledge how am I feeling right now, and to give yourself permission to feel whatever it is. And then to turn the key on. And then to use the process of the commute, whatever that is, to really just take stock and to try to get our nervous system a little bit back into balance instead of it being all in hyper rouser, or sympathetic systems gone wild for 12 hours, and that's where the breath comes in. This is where mindfulness actually does help people.

Dan:
Well, and I think the key that you're talking about as well is you have to embed it into the work. And I think there's a culture of nursing of show up to your shift, go home, and whatever happens in that 12 hours, you leave in that 12 hours, and it doesn't go outside of that. And even the systems are set up to say, well, we know you're here, but we're not going to deal with this stuff either. And so to really be intentional about addressing it from the start of your huddle, and your shift report, to the end of taking off your PPE, or even just taking off your scrubs and things when you get home. Putting in those intentional practices is the key to normalize these feelings, and eventually get them out there and not lock them away in that shift mentality.

Cynda:
Exactly. And I think we do have this tendency to think that we just put it in a box and then it's gone. The truth is that doesn't really work very well. It's going to start leaking out in some other way, anger, resentment, depression, whatever it is. So having some of these rituals, maybe it's in the shower, maybe it is some other way that you allow yourself to really take stock, and then to release what no longer serves. It's also, I think really important that we notice when we turn in a destructive way against ourselves. When we start criticizing ourselves of you're not good enough, you didn't do a good enough job, you're failing. Those tapes are actually very harmful to our ability to see ourselves as capable and whole. And so when those start coming up, to really ask ourselves, is that true?

Cynda:
We have had to make really hard decisions, and there will always be a moral residue as a result of that. But I think integrity isn't about perfection, it's actually being committed to living our values as best we can in this unpredictable and chaotic world. And expecting ourselves to be able to meet the needs of everyone in the way we think we should is not possible right now. And so we've got to find also some spaces where we can together as groups of nurses to create a community, a space, a shared space where we can reflect and support each other. I've been doing renewal circles with both nurse leaders and frontline nurses. And it's really about just creating a space where people can acknowledge what they're carrying, and what maybe they might be able to put down given their interactions with each other and with themselves. This is not about fixing people, it's just about honoring what is true, and honoring their experience, and giving them permission to be human beings.

Dan:
I remember one ritual we did a long time ago when I was at Arizona state, we had a really stressful set of circumstances that happened. And we did a burning circle where we wrote down our stresses and threw them into the fire. And even that was just cathartic. Everyone just looked around, you could see the energy change. And I think simple things like that are great to be able to practice. You recently launched the Resilient Nurse Initiative. Can you tell us a little bit more about that and how we might find some more information about it?

Cynda:
It's interesting how things evolve. The proposal that was funded started in July. We had no idea what was happening in terms of this pandemic when we submitted it. It turned out to be very timely. This is a statewide initiative that's focusing on building resilience and ethical practice in nursing school faculty, in students, and in nurses who are in nurse residency programs in our state. And so this is a four year grant, we'll be developing lots of resources, and have already started developing a network of organizations and individuals who are interested in this kind of work and focus, but we'll be doing a series of workshops for nursing school faculty to start first with their own wellbeing, and integrity, and how do we help them to get in touch with those aspects of themselves in service of being able to offer these kinds of resources to their students in an authentic way.

Cynda:
And then we will also be giving them some specific tools to integrate into their existing courses because we know what the real estate is like in curricula, there's not going to be extra space. And so instead of adding more, we are going to be offering things that can be integrated into whatever you're doing in your course. And then we'll also be looking at some of the cultural and structural issues within schools of nursing that are either contributing to well-being of students and faculty, or not. And beginning a process of trying to understand those, and develop some targeted interventions to address some of those factors and issues. And then we're working with our NRP colleagues, and we'll be offering some resources that will facilitate continuity of content that students will learn in their programs into the nurse residence team program curriculum. So it's very exciting and just a lot of really incredible dedicated people involved.

Dan:
Yeah, that's so wonderful. And I was recently speaking at an AACN conference, and my pitch to the audience was the change in nursing culture begins in the classroom, in the first day they step into nursing school, and through every single level of education you can do in nursing. And so I think it's so great that you're training the faculty and then embedding this into the curriculum because then that sets the tone as they move through their program and into work life, hopefully with the skillset to change this whole thing, because even in recent history, it just hasn't been part of the program. So you don't necessarily spend a lot of time on how to cope with all the stressors you have other than maybe debriefing from a simulation, or from your clinicals. And so being much more intentional about that, I think is the right way to get the culture change to happen. I'm excited to see how that goes.

Cynda:
Yeah. So one of the things we're working on right now, again, using our Wikiwisdom Forum platform, which is a crowdsourcing platform, we've already started gathering wisdom of frontline nurses about how they keep themselves resilient and whole. Our second phase of that process is we are going to be targeting students as well as nurses who are doing precepting and clinical practice, to try to understand what the students need, but where are the gaps between what happens in academia and what students need when they get into practice. And our goal is to try to articulate what that gap is, and then to be very intentional about what are some of the strategies that would dismantle that gap. And that's going to be a report that'll probably come out later this spring. So we'll be looking forward to sharing that.

Dan:
Yeah, I can't wait for that publication. I think it's, like I said, it's so needed. And those insights from the frontline will just take the theoretical and make it tangible and vice versa. So that's a great way to connect and get it out quickly to the frontlines as well. This has been awesome. We could go down so many rabbit holes. As you're talking I'm just like, Oh, man, let's go talk about this story, and this story, but we're coming up on the other time mark here. I would love to hear, we talked about a lot of things here. I would love to hear what you would like to handoff. What's that one nugget that a frontline nurse, or a nurse leader can take to their practice tomorrow and make a meaningful difference in how they stay resilient, or they empower their teams to be resilient?

Cynda:
I think the bottom line here is that moral suffering is real. It is pervasive, and it impacts our integrity, and our wellbeing as nurses, that moral resilience is a protective resource that can be used to address the impact of moral adversity in and health care. And that it really is an invitation to harness our innate goodness and resilience to meet those inevitable ethical challenges so that we can be involved in creating solutions to the system factors that really degrade our sense of wholeness as people. And I think my message would be that we are all resilient. If we weren't resilient we wouldn't be nurses. So it's not that there's anything deficient in any of us, it's a question of how do we actually strengthen what's already there so that we can do the important work that we have been called to do. And how do we do that in a way that preserves our sense of integrity, but also protects our health and wellbeing?

Dan:
I think that's so great and it is normalizing it, and having the conversation, and like we said earlier, listening as well. And sometimes that's all you need to do, is just listen and let things flow.

Cynda:
Well, I think listen to ourselves too, there's great wisdom in nurses. In one of our renewal circles one of the nurses reflected that survival right now actually is an indicator of resilience. And there was something really important about reframing that, that we don't all have to be heroic, and we all can't necessarily practice, or be at the top of our game all the time, but surviving actually is an active resilience in these circumstances.

Dan:
Yeah, that's so true. I know there's going to be a lot of listeners who are interested in these topics. Where's good places for them to find you and find more information about what we talked about today?

Cynda:
You can find me at Johns Hopkins Berman Institute of Bioethics, I have a website there and at the School of Nursing. I would encourage people who are interested in learning more about our work in moral resilience to take a look at our book, Moral Resilience: Transforming Moral Suffering in Healthcare. It really is the accumulation of what we've learned so far and has both individual and system strategies included in it. And I think that's probably the most comprehensive place to learn more about our work.

Dan:
Awesome, and we'll put links to that in the show notes as well so people can easily get to that. Thank you, Dr. Rushton so much for the conversation today, this was awesome and near and dear to my heart. And I know that our listeners out there will get a lot from it. So just really appreciate your time.

Cynda:
Thank you so much.

Dan:
Thank you so much for tuning in to The Handoff. If you liked what you heard today, please consider leaving us a review and subscribing on Apple podcasts, or wherever you listen to podcasts. And for more information about Trusted, please visit trustedhealth.com. This is Dr. Nurse Dan. See you next time.

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