Building moral communities for reflection and dialogue in pediatric and adult healthcare settings David Browning, MSW, LICSW Co-Founder, Institute for Professionalism and Ethical Practice Boston Children’s Hospital david.browning@childrens.harvard.edu Susan Gerbino, PhD, LCSW Clinical Professor Director, Zelda Foster Studies Program in Palliative and End-of-Life Care NYU Silver School of Social Work susan.gerbino@nyu.edu SWHPN Annual Conference March 12, 2018
Our focus this morning … n Introductory rationale n Defining terms n What is a moral community? n Examples from our practice n Discussion
Introductory rationale: n Clinicians practicing in healthcare settings, especially those who work with chronic and complex patients, or in intensive care or palliative care settings, are increasingly beset with heavy workloads, intra- and inter-professional tensions, and ethically challenging situations.
Introductory rationale (cont’d) n These occupational burdens contribute to well-documented instances and patterns of compassion fatigue, moral distress, and burnout across healthcare disciplines. n Insufficient attention and resources are devoted to creating spaces and places where professionals can reflect on the moral and ethical stresses embedded in their daily practice.
Defining terms … .. n Moral imagination : our capacity to envision various possibilities for acting in a given situation and the potential help or harm of these actions n Moral agency : our ability to make moral judgments based on our sense of right and wrong and to be held accountable for our actions n Moral identity : how we perceive ourselves in terms of moral agency and our capacity for moral imagination
Defining terms (cont’d) … n [Moral] integrity: our experience when there is a reasonable match between our moral agency/ moral identity and what we are asked or required to do professionally [in · teg · ri · ty] n Moral distress : our experience when there is a mismatch between our moral agency/imagination/ identity and what we are asked or required to do professionally n Affects what we see in mirror at end of the day …
What is a moral community?
What do we mean by “moral”? Morality is... n “a socially embodied medium of mutual understandings and negotiation between people over their responsibility for things open to human care and response” (Walker 1998) n relational and contextual n grounded in the roles and responsibilities of everyday social life. [As contrasted with ethics/ethical]
Keeping moral space(s) open … . Moral communities are … n places, both literally and figuratively, that “keep moral space open,” (Walker(1993) n Places/spaces where moral language can flourish in conversations about n our moral and professional identities, n our understandings of mutual responsibilities, n the values and beliefs we hold as members of a particular community. (Liaschenko 2016)
These spaces can be: n “structured” or informal n with individual or multiple disciplines n within or outside physical boundaries of healthcare organizations Our examples will include: Informal, single discipline, within org. 1. Structured, multiple disciplines, within org. 2. Structured, single discipline, outside org. 3.
Types of questions raised.. n What is your understanding of the situation/topic under discussion? n What knowledge do you have that is unique to your role and your context n What’s at stake for you? What’s at stake for others? n How do you think your perspective is valued by others inside or outside your own discipline? n Where and how do you voice your perspective? n How do you understand the perspective of others?
Essential ingredients for psychological safety that facilitates open dialogue … n Honoring multiple perspectives across lines of difference (including professional discipline, experience level) n Validating practice knowledge n Suspending hierarchy n Supporting reflection/self-awareness n Addressing “elephants in the room”
Ground rules (collective responsibilities) n Listen attentively—contribute to a learning atmosphere of equality, trust and respect. n Create a climate receptive to the sharing of thoughts, feelings, and experiences. n Support the expression of multiple perspectives, even if you may not agree.
Ground rules (cont’d) n Risk sharing your own perspective, even if you think others may not agree. n Create space in the conversation for less vocal participants to speak. n Maintain confidentiality in regard to any personal or patient/family information that is shared.
Where does social work fit in? n Moral concerns drove development of social work as a profession n Emphasis on knowledge base at the expense of social work values/mission (Bisman 2014) n Unique relationship to value of social justice n Obligation to bear witness to injustice, to speak up, and to act (moral outrage) (McAuliffe et al 2016)
Where does social work fit in? (cont’d) n Challenge of bridging gap between values/mission and practice (McAuliffe et al 2016) n Moral distress: social workers often in role of supporting other professions. n Importance of understanding and addressing … n how moral distress manifests itself for social workers n what role social workers play/should play in the creation and maintenance of moral communities
Examples from our practice
Discussion
References n Bisman C (2004). Social work values: The moral core of the profession. The British Journal of Social Work. 34(1). n Browning, D (2012). Sturdy for common things: Cultivating moral sensemaking on the front lines of practice. Journal of Medical Ethics. 38(4) . n Browning, D and Gerbino, S ](2011). Navigating in swampy lowlands: A relational approach to practice-based learning in palliative care. In T Altilio and S Otis-Green (Eds.), Oxford Textbook of Palliative Social Work. NY Oxford University Press .
References (cont’d) n Clark C (2006). Moral character in social work. The British Journal of Social Work 36(1). n Hermsen M and Embregts P (2015 ). An explorative study of the place of the ethics of care and reflective practice in social work education and practice. Social Work Education 34(7). n Liaschenko J and Peter E (2016). Fostering nurses’ moral agency and moral identity: The importance of moral community. Hastings Center Report 46 (Suppl 1). n McAuliffe D, Williams C, and Briskman L (2016). Moral outrage! Social work and social welfare. Ethics and Social Justice 10(2).
References (cont’d) n Traudt T, Liaschenko J, and Peden-McAlpine C (2016). Moral agency, moral imagination, and moral community: Antidotes to moral distress. The Journal of Clinical Ethics 27(3). n Walker M (1998). Moral Understandings: A Feminist Study in Ethics. NY: Routledge. n Walker M (1993). Keeping moral space open: New images of ethics consulting. Hastings Center Report 23(2).
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