Moral Compromise: Burnout Revisited

(Figure 1) In the November edition of AJN, Judith Shindul-Roths child will expand and update her interpretation of the qualitative data that she and colleagues collected for AJN's Patient Care Survey last year. In revisiting the reports of 7,500 RNs on what was happening to them and their patients, Dr. Shindul-Rothschild finds a theme of "moral compromise." She proposes that "moral compromise occurs when nurses are in situations where they feel obliged to commit acts that can be justified, but they know are morally wrong." Today this commonly means a conflict between the economics of your employing institution and the need of your patients. More directly, you are expected to make choices between keeping your job and doing what you need to for your patients, and the forces that put you in that position are frequently economic.The words "moral compromise" evoke vivid memories in most of us. Nurses have a strong and well-developed sense of right and wrong. Contrary to the opinion of some, we have adjusted well to changing times again and again and have remained resolute in our advocacy for the public. That advocacy mission has often cast nursing as the conscience of the health care delivery system in the form of its organizations. A striking example has been nursing's tireless effort on behalf of universal health care. In the 1960s the ANA was the first and often the only health care organization to speak out loudly on behalf of Medicare and Medicaid. Nurses are at risk to suffer feelings of moral compromise. They are privy to the inner workings of the delivery system, they possess a conscience that refuses to rationalize injustices, and their patients confide in them. They may wield power through their organizations, but have little capacity to change things in their personal practice. "Whistle-blowers" are often at risk of losing their jobs. Appeals to reason are infrequently successful in stopping the displacement of nurses from the workplace. Questioning the clinical management of a patient is, if not grounds for dismissal, at least labeled disloyalty. The scene has changed little over the past generations, but the challenges have become more sophisticated and more frequent. And nurses are more sophisticated today-in their education and their practice. That increased understanding causes more frustration, especially since nurses are those most certain to witness the outcomes of poor clinical decision-making and impersonal systems. What was the burnout from frustration in another era now becomes a personal assault on our integrity, a matter of conscience, a moral imperative, and ultimately, for most, a moral compromise. The situation will only become more difficult as education rises to the occasion of preparing a cadre of nurses suited to the chaos and complexity of the future. Knowledge will create more questions about the morality of our day-to-day practice. In this case there was more bliss in relative ignorance. The moral dilemmas will grow as systems are better understood and insight is gained into the economics of health care, the documented value of nursing, the use and misuse of unlicensed assistive personnel, and the management and human resource principles that favor the presence of highly competent caregivers. The solutions are not simple, easily put in place or even complete, but they do exist. Some years ago, costing out case-specific nursing services and inserting this information on the bill for the hospital stay was proposed as an approach to establishing economic leverage. With the subsequent appearance of all-inclusive rates and managed care, that strategy became less attractive. In our current outcome-driven health system, information linking nursing to safety, morbidity, mortality, and the patient's self-reliance is much more potent. And bringing this information to those who purchase and pay for health care creates an effective partnership. This is the intent of the ANA in Nursing's Safety and Quality Initiative. But what are the solutions for the practicing nurse? It would serve us all well to develop a heightened sensitivity to situations that cause us moral concern, and decide whether our response is objective. Given repeated encounters with such events, and a valid basis for our discomfort, what are the options? It is naive to believe that the merits of our concerns will protect us from retribution. When burdened with a sense of moral compromise, we need the counsel of an external advocate who can help us think through our options and perhaps identify additional choices. Many nurses have obtained this kind of support from a district or state nurses association. Others find it by networking, either formally or informally, with their colleagues.