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The use of clinical supervison, with employment of skilled external clinical psychologists, is widely used in the Maternal and Child Health field in Victoria to assist new (and experienced) practitioners to reflect and respond to situations that are personally challenging (or distressing) in their work roles. This type of session is not so focused to acute debriefing (although this is available separately), but to the reflection on common and recurring nursing situations that may cause a degree of moral distress.  The skilled psychologist guides the nurse, within a safe environment of trust/rapport,  to look inward and be aware of her own triggers to situations encountered. To process a change, this requires a deconstruction of feelings and responses rather than purely a recount of the situation that occured. This is a highly effective practice in managing moral distress, that can result in some changed outcomes. Clinical supervision continues to require employer funding support to remain effective and viable.

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The use of clinical supervison, with employment of skilled external clinical psychologists, is widely used in the Maternal and Child Health field in Victoria to assist new (and experienced) practitioners to reflect and respond to situations that are personally challenging (or distressing) in their work roles. This type of session is not so focused to acute debriefing (although this is available separately), but to the reflection on common and recurring nursing situations that may cause a degree of moral distress.  The skilled psychologist guides the nurse, within a safe environment of trust/rapport,  to look inward and be aware of her own triggers to situations encountered. To process a change, this requires a deconstruction of feelings and responses rather than purely a recount of the situation that occured. This is a highly effective practice in managing moral distress, that can result in some changed outcomes. Clinical supervision continues to require employer funding support to remain effective and viable.

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Bernie Cavanagh

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Like my peers, I found things topic to be very multi dimensional, I agree with Kerry that there are so many organisational aspects that at times hinder day to day client contact, I believe that also can put constraints on how we as leaders prepare new practitioners to recognise and respond and to challenge structural factors that foster moral distress.

I can see this from two perspectives, one being a new graduate 4 years ago, I commenced working in an adult mental health inpatient unit, mental health was my passion (and still is) and I wanted to do the best that I could for my patients and came into the position with values, hopes and aspirations. I was confronted at times with some practices I didn't feel ethical e.g. the overuse at times of seclusion and restraint and the over use at times of medications instead of encouraging alternative coping strategies. Thankfully I was teamed with a leader who also held the same values and beliefs as I did and who spent the time encouraging me to challenge these things, not to accept what I didn't see as right and how to do that in a manner that was professional.

Now I reflect upon my role as a CN, and in many ways I see that I am a leader for my fellow CN's, RN's, students and also new staff who are not only specifically nursing staff. Varcoe et al. (2012) acknowledges that nursing has a reputation for "eating our young", (yes I have experienced what this is like) being a new(er) practitioner I feel that I am fortunate to carry more awareness of this concept, and I feel that whilst nurses don't set out to "eat their young", a multitude of constraints that nurses face every day can lead to a build up of moral distress and de-sensitization leading to this concept of "eating our young". It is all too easy to "fall into" the negative culture.Varcoe et al. (2012) recognise that if new practitioners are not sensitised to "moral distress" by appropriately modelled behaviour, and the behaviour new practitioners run the risk of working to simply "fit in", in turn leading to compromised work ethics and culture.

Varcoe et al. (2012) argue that moral distress is a relational concept, experienced by individuals but also shaped by individual characteristics but also by the environment and context in which the person is working. Like Kerry, I believe strongly that a new practitioner cannot solely be responsible for navigating the system, I know that I am thankful for having leaders who guided me through the socio-political, interpersonal and cultural contexts during my grad year, as this helped me continue to practice ethically, and taught me how to manage and deal with moral distress. I agree with Varcoe et al. (2012)that it is responsibility of the organisation and the leaders within to have education around moral distress.

Thank you

Jessica Moussa

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How do leaders prepare new practitioners to recognise,respond and challenge structural factors that foster(moral distress) rather than simply ensuring that they navigate the system(Varcoe et al., 2012, pp. 55-56

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How do leaders prepare new practitioners to recognise,respond and challenge structural factors that foster(moral distress) rather than simply ensuring that they navigate the system(Varcoe et al., 2012, pp. 55-56

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I have been reading the articles by Varcoe for the last couple of weeks as part of the reading's for my Reflective Essay. I have found the term Moral Distress to be one that is quite challenging.
I like Kerry and Amanda am in a role that supports new practitioners to transition to my specialty.
These nurses and midwives are supported for 6 months on a graduate pathway that aims to transition them to primary health care. Some make and some find it difficult. I do like that Varcoe et al (2012) acknowledge that nursing has a reputation for "turning lambs into lions"and that we may eat our young!
I believe that has an experienced RN and CDN I am morally obligated to remain true to my values and guide these staff through this pathway.Staff that are supported by leaders who have a strong moral and ethical style of leadership will hopefully transition through the grad year to become well prepared RN's.
Kylie Rayner

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Moral distress is something as nurses we are expected to cope with as part of our role it appears. Having moral resilience was the answer to coping with ethical situations and not having a say in decision making and not being heard, just expected to follow directions.
Today things are changing in Nursing ad looking after staff needs to be taken seriously. Fast paced, high pressure environments place nurses under ethical tension(Wall, Austin ,Garros & Forum.2015).
Experiences of frustration and failure can result when meeting obligations to families and patients   are not met which in turn results in declining quality of patient care and poor job satisfaction.
Nothing is worse when you are run off your feet and leave a shift and because the work load was so high you don't know if you have done everything.
Empowering staff today to fight for safe working conditions such as reducing workload, improved staffing mix and increases in the shortage of resources.
Management need to encourage open communication with staff and listen to their concerns, to provide a supportive structure within the organization ( Wall et al. 2015)
Having a positive ethical environment reduces moral distress and supports ethical practice (Wall et al. 2015)
Leaders in nursing can prepare new staff by providing a strong moral environment, by acknowledging ethical dilemmas encouraging staff to discuss, by supporting staff and acting as role models to staff, and being staff advocates.
Staff need to know that they can have debriefing sessions when faced with ethically challenging problems and to be aware of protocols that may be in place in these situations.
Staff need to be made aware also that the hospital may have an ethics committee which can promote the organizational values and ensure management is incorporating these values into their decision making in ethic matters. ( Wall et al 2015)

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“How do
leaders prepare new practitioners to recognise, respond and challenge
structural factors that foster [moral distress] rather than simply ensuring
that they navigate the system” (Varcoe et al., 2012, pp. 55 - 56).

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“How do
leaders prepare new practitioners to recognise, respond and challenge
structural factors that foster [moral distress] rather than simply ensuring
that they navigate the system” (Varcoe et al., 2012, pp. 55 - 56).

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I found this a difficult question to answer as there are so many organizational aspects that get in the way of trying to manage day to day client contact, however I do believe it can start with one who speaks out and also supports new staff. An observation for me is being part of a program for transitioning newly graduated registered nurses. These nurses are supported and work-shopped in the specialty areas of mental health for one year. I have been involved with a number of new grads that have become morally distressed over this time.  A couple has left nursing and some have continued in nursing adapting to the very aspects that create the distress within them.Varcoe et al., (2012) makes reference to this as creating a “dissonance between stated professional values and actual behaviors” the result is we are ‘‘turning lambs into lions’’. The expression we are eating our young is not too far from the truth, however navigating the system as a new grad needs support from leaders who know how to work within a complex system and still remain true to their values as an RN.

Like Amanda, I have found the work on moral distress interesting. The descriptions of moral residue and the categories of deafness, silence and blindness have a subtlety to them that I see at different times in my own workplace. Varcoe et al., (2012) suggest moving beyond professional education and start “examining broader systemic organizational ethics in ways that may expose particular professional practices, management practices, and organizational processes/customs” so as to start making changes. I agree with this statement, though I still think day-to-day education can have a place, an example can be use of appropriate language to help staff understand distress and the interventions that contribute to lessening this. Also being able to present the literature to support the experience of moral distress is important which is always the benefit of study. Although Varcoe et al (2012) recognize the need to go beyond education, which I am in agreement with. I would also like to suggest we have not spoken about these concepts enough in the workplace. Leadership is also about the hard discussions that contribute to professional practice and encourage new staff in their practice.

Kerry

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Varcoe, Pauly, Webster, & Storch (2012), indicate that to address the phenomena of moral distress, a more vocal discussion is required. They further discuss the spectrum of experiences that can occur within the same organisation depending on the consumer group and the groups socioeconomic status. Varoce et al., (2012)discussed the concept of neo-liberalism with consumers and individuals taking responsibility for their own health and wellbeing and that of the family. This can lead to situation of stigmatisation and marginalising when the choices people make do not always espouse the moral belief systems of the rest of society. What can occur then is a sense of blaming the person for the situation they and their families are in as they have autonomous control over their choices. Varcoe, et al., (2012) make the point that social determinants such racism, stigma, poverty and mental health, can greatly impact on an individual’s ability to seek and access care. As an organisation, failure to actively reach out and advocating on behalf of these consumers is a failure to apply the principles of social justice and ethical practice. Does this mean that only when people have the right to equitable and fair access to health care if they are making good choices and decisions about their health care, and have the capability to access this care? It is often the people who, for whatever reason, find themselves in situations where it is difficult to make good choices who are the one’s reaching out to any service available for help. What can occur then is a situation as described by Varcoe, et al., (2012) is that of moral distress. For example, if a person presents with chronic drug abuse and is emotionally distressed by this, the likelihood of being referred from team to team becomes evident. This places considerable stress on the clinicians involved as it may not sit with their values and beliefs system. This may affect staffs work satisfaction as the principles of person centred care and recovery may be in conflict with organisational demands.
This article provides some interesting concepts that I would like to look at further. There are ideas within Varcoe, et als., (2012) article that also align with concepts of psychological safety that are discussed in Keyko’s (2014) article. Keyko (2014) describes a work place that supports the clinician’s ability to practice safely without impact on their moral decision making processes. Varcoe, et al., (2012) discuss Webster’s notion that holding onto experiences that have caused moral conflict place the clinician at higher risks of burn out and emotional distress. We have all experienced this and as such it is refreshing to read an article that perfectly articulates this situation and calls for further action and inquiry.

Varcoe, C., Pauly, B., Webster, G., & Storch, J. (2012). Moral distress: Tensions as springboards for action. HEC Forum, 24, 51-62. doi: 10.100/s10730-012.9180-2.
Keyko, K. (2014). Work engagement in nursing practice: A relational ethics perspective. Nursing Ethics. doi: 10.1177/0969733014523167.
Amanda

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"How do leaders prepare new practitioners to recognise, respond and challenge structural factors that foster (moral distress) rather than simply ensuring that they navigate the system" (Varcoe et al, 2012, pp 55-56

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"How do leaders prepare new practitioners to recognise, respond and challenge structural factors that foster (moral distress) rather than simply ensuring that they navigate the system" (Varcoe et al, 2012, pp 55-56

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Relying on individual resilience in todays work place to navigate systems is not an acceptable and leaders should take action to address organisational features and structural relationships to minimise the harmful consequences of moral distress (Wall et al, 2016). I found the statement poised by Wall et al, (2016) "to just deal with it" distressing and have had that said to me in the past.
I was working in a management team where the organizational issues that influence moral distress were not met. The relationship within the management team was not conducive to a healthy team environment. The management group were trying to change rostering practices, and were inflexible, which lead to a unhappy staff team. the leaders' did not agree on the changes, though had to present a joined force which started to crack fairly quickly.
The team structure and dynamics play an incredibly large part in moral distress or team harmony. Leaders will create a more conducive work force  involving staff in patient care and decision making in an emotionally driven environment, requires mutual respect and support. Leaders who have the ability to encapsulate this in to their orientation for new practitioners will earn greater respect and in turn avoid staff in crisis.
Catherine Maher

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There are several works by Varcoe (and others) in relation to moral distrss. Simply enter Varcoe AND 2012 AND "moral distress" in the library search field to yield many relevant articles. Sue 

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There are several works by Varcoe (and others) in relation to moral distrss. Simply enter Varcoe AND 2012 AND "moral distress" in the library search field to yield many relevant articles. Sue 