Question

Natalie Rodriguez is a clinical nurse on a 65-bed oncology unit in a large teaching hospital in Phoenix, Arizona. She is a new graduate from a baccalaureate nursing program and strives to provide the best possible care to each of her clients. Nurse Rodriguez checks in on a 90-year-old patient, Mrs. Marting, who has pancreatic cancer. She has only one granddaughter, Allie, to come visit and stay with her for long hours each day, and the two are very close. Mrs. Marting has said she does not want any resuscitation measures, but when Nurse Rodriguez offers her DNR forms to sign, she waves them away. “I’m too sick right now, dear,” she says. “Let me deal with paperwork some other time.” In the meantime, Nurse Rodriguez has other patients she must attend to, but even as she tries to perform other tasks, Mrs. Marting’s wishes are on her mind. However, before she can return to Mrs. Marting and Allie, Dr. Daly arrives on the unit with a list of demands. Dr. Daly has a reputation for wanting “what I want when I want it,” and he asks Nurse Rodriguez to complete a laundry list of tasks that are not particularly patient-centered. She is restocking a supply cabinet, at his request, when Allie calls for help. Dr. Daly gets to Mrs. Marting’s room first and by the time Nurse Rodriguez arrives, Allie is begging the doctor to “do whatever it takes to save my grandma!” Mrs. Marting has undergone cardiac arrest. Nurse Rodriguez explains Mrs. Marting’s wishes, but Allie says, “I know, but I don’t care now! Just save her!” and Dr. Daly starts resuscitation.

1. Nurse Rodriguez is devastated by Dr. Daly’s choice and wonders what she could have done to stop resuscitation, which has broken one of Mrs. Marting’s ribs. “I don’t ever want to see that happen to one of my patients if I have anything to say about it,” she says. What kind of stress is Nurse Rodriguez experiencing, and which category of obstacle created it? Please Include citations/references.
2. Nurse Rodriguez has said that she does not want that to happen to any of her patients again, if she can do anything to prevent it. What stage or phase of the “change process” outlined by the AACN is she most strongly associating with, and what, if anything, should she do first before acting on it? Please Include citations/references.

Answer 1

Nurse is in psychological stress and she was facing psychological obstacle.

As a systematic process for change, this article offers the AACN's Model to Rise Above Moral Distress, describing four A's: ask, affirm, assess, and act.

ASK:
In this stage, you become more aware of your distress and its effects. It is a
stage of self-awareness and self-reflection. Moral distress may cause suffering
that can manifest in a variety of ways. Suffering occurs when a person’s integrity
and sense of self are threatened; it affects a person’s physical, emotional, behav-
ioral, and spiritual well-being. The sources of suffering are many and varied.

AFFIRM
➲ Affirm your distress and your commitment to take care of yourself:
Prolonged or unrecognized suffering due to moral distress can be detrimental to your per-
sonal and professional life. • You have an opportunity to be free from moral distress.
• You have a professional responsibility to contribute to the creation of a healthy
work environment.
- Validate your feelings and perceptions with others:
Talk to coworkers, nurses in other settings, or friends and family to seek validation for
what you are feeling. • AACN’s national office and local chapters are additional sources of
validation.
- Affirm your professional responsibility to act:
ANA Code of Ethics: The nurse owes the same duties to self as to others, including
preservation of personal integrity and wholeness of character.

ASSESS
-Identify sources of your distress. Under what circumstances do the signs
and symptoms occur? Do other people experience distress/suffering related to
these sources? Sources may be personal, interpersonal, and/or environmental.

ACT : SELF-ASSESSMENT—Determine your readiness to act
On a scale of 0 to 5 (0= not to 5=very) rate your response

If you are uncertain about taking action, consider 4 R’s: Relevance, Risk,
Rewards, and Roadblocks
Relevance—Imagine the impact your action could have:
• Improved patient care
• Enhanced relationships
• Enhanced personal well-being
• Professional satisfaction
Risk—Consider the risks of not acting and the possible outcomes for the patient
and for yourself:
• Personal suffering (refer back to the signs/symptoms of suffering)
• Dissatisfaction with practice environment
• Decreased quality of patient care
Rewards—Imagine how you will feel after you take action:
• Recall situations in which you have succeeded in effecting positive change in
the past.
• Imagine how you would feel coming in to work after changes were in place.
Roadblocks—Make a written list of the specific roadblocks you foresee to help
you identify strategies to avoid them. Some of these roadblocks may include con-
cerns about:
• Resistance to change
• Criticism
• Retaliation
• Alienation
After contemplating the four R’s, go back and answer the SELF-ASSESSMENT question again.