Interview Transcript - Katherine Brown-Saltzman, RN, MA

Co-Director, The UCLA Health Ethics Center
Assistant Clinical Professor, UCLA School of Nursing, Los Angeles, CA

Interviewed March 2013

Tell us your name, organization you’re with and what's happening today in this hotel.

That will be awesome. My name is Katherine Brown-Saltzman. I'm with the UCLA Health System Ethics Center. I'm here today as Chair of the Ethics of Care and National Nursing Ethics Conference. It is our Second National Conference after 20 years of doing a Local Ethics Conference.

Why did you decide to get involved in this subject area? What are you trying to accomplish in terms of education?

I've been a nurse for 38 years. In those years, especially early on before we even had true ethics committees, what I witnessed amongst my colleagues, nurses, physicians, social workers and myself was in the midst of these ethical conflicts that evolved into often true conflicts because they were the toughest of the cases that people walked away harmed essentially. In 1984, we had Jameton define moral distress for us. It was an ah-hah moment for most nurses saying, "This is what I'm experiencing, this idea of being constrained, of believing that you know the morally right thing to do but literally being constrained from carrying out that action." Those constraints can be anything from a legal-bind situation. It can be policy. It can be resources. There are many reasons why we are constrained. Time, time can constrain us. The effect of that... Of course, most of us are in the profession a long time. It's not just one incident of moral distress, of going home at night and putting your head on the pillow and thinking about what I failed to do, what I was not able to do in the moment that I believed I was morally obligated to do.

Living with that, not just that one time but over and over and over again, how that impacted myself and my colleagues, living with that and watching it escalate over time.

The people who care the most about ethical issues are in harm’s way. They, in their core, have a sense of ethics that drives them in their profession and their obligations to their peers, their obligations to the families, to the patients. To hit someone in the place of their core values, why am I a nurse? Why have I come over and over to that bedside? Because I believe in serving the other, caring for the other. If I believe that I'm harming the other, how do I live with that? For me, it has been a passion to really begin to think about how do we... I mean, we clearly defined it now. The question becomes now, what do we do with it? Because given the fact that you have ethical conflict, you will always have moral distress. People will come to the table with different values. Now, the question is, what do we do about it? We're just beginning to really think about the interventions now. I had the opportunity several years ago to do a retreat on moral distress. We combined writing and the use of movement in order to bring health care professionals together to begin, to be able to express what they carried. It was actually an amazing time.

What are you seeing in the faces of people downstairs in terms of people's awareness and being able to identify and deal with moral distress?

Sure. Having a conference like this, people say it's networking. It's not networking. It's the building of relationships and the telling of stories. You see it all over the place from the newest of nurses, students even, to the eldest sitting down and sharing stories and expressing what they are dealing with in their clinical roles. It is very clear that not only do they have opportunity then to do that sharing, but also to learn from each other.

Again, those moments of saying that is a different approach that might help me. I might be able to take this back to my institution and inspire a change or inspire a way of us being able to share our stories. I think it's these kinds of moments. We try to build in time for people to actually connect as part of the conference. We also try to put together a conference of caring, a place of rest for people who are doing the hard work at the bedside, who are experiencing moral distress and need the opportunity to step back and be able to reflect about what is this experience. How am I living it out? How might I just through a tiny shift in how I'm viewing this might I be able to show up in a different way?

Give us your definition of moral distress and what weight it carries in this career?

Moral distress, I think the easiest way to define it is the sense of knowing, believing that you know the morally correct thing, action to take and being constrained from being able to do that. Their constraint, again, could come from anything, from a law, a legal matter, from policy, from a sense of a lack of resources, time. Once you are constrained and you're not able to carry out that action, you then experience a sense of moral distress. In terms of the outcome of that, over time, it certainly impacts people. They experience everything from the most subtle of disengagement with the patient or even their colleagues. It can go to the extreme of beginning to numb oneself, certainly, by the use of drugs, alcohol. You can have depression, somatic things like stomachaches, headaches, work avoidance, calling in sick. You end up potentially having depression, withdrawing from your profession itself and literally leaving your profession.

The implications are very, very powerful. Particularly, I think, in the people who do not deal with the moral distress, those professionals who stay because they feel they must stay, they feel trapped and they enter into that disengagement peace. When you disengage, you are not taking in the whole picture. You're more likely then to have error. You're more likely to not have trusting relationships with patients and families. You're more likely to not be relating to your colleagues. All of those things actually break down the best that we have to offer in health care.

What message would you like to share with students or practitioners who come into such a situation and do not know how to address it?

Sure. Not only from the research that is out there, but I've had the opportunity to do research with Dr. Carol Pavlish at the UCLA School of Nursing. In that research, we've asked nurses to explain their experience of ethical conflict, to describe things that are early indicators, to describe risk factors. One of the things that is happening is that nurses recognize moral conflict beginning to unfold, yet, are not in fact speaking up.

They're often silent about it. They're living for long periods of time until they finally do speak up or maybe they never speak up. We know when that happens that moral distress doesn't go away. In fact, it worsens.

From the work that's been done, the one anecdote from moral distress that seems to impact it and lessen it a bit is speaking up. Clearly, when you speak up if you don't have the outcome that you wish for, even if it doesn't change the course of events, the fact that you spoke, the fact that you paid attention and said to someone else, "We have an issue here. We need help with this," seems to change the course. It's a critical piece. If you think, "How easy is that to speak up?" It's not easy. Essentially, not only do we have to change helping that individual speak up. We have to change the organizations to create workplace environments where speaking up becomes the norm, the standard, it becomes the expected.