Past Speaker Spotlights

Over the next few months, we will be interviewing a few of our key speakers for NNEC 2021 so that you can hear about their work, what they are contemplating about ethics these days, and reflections on moral agency.  Watch for upcoming Speaker Spotlights.

Our first 2021 interview is with Dorrie Fontaine, PhD, RN, FAAN
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Dorrie K. Fontaine, PhD, RN, FAAN, is a clinician, scholar, researcher, educator, and leader. During her tenure as the Dean of the University of Virginia (UVA) School of Nursing from 2008 to 2019, she was a strong proponent of mindfulness, compassion, and promoting healthy work environments. Among her many accomplishments, she founded the Compassionate Care Initiative at UVA. She served as president of the American Association of Critical-Care Nurses (AACN) from 2003 to 2004, the largest specialty nursing organization in the world. 

Interviewed on September 11, 2019 by Anna Dermenchyan, MSN, RN, CCRN-K

1. The theme of this year’s National Nursing Ethics Conference is Moral Agents in Action. In what ways does this theme resonate with you?

The theme is timely because being a moral agent is all about how we live, how we show up, how we take our values as a nurse and demonstrate them to patients and their families, as well as health care teams. Being moral agents is how our values are embodied to the public and how we can assist the institutions where we work to engage and behave compassionately.

2. In your 47-year career as a nurse, you have served in numerous roles as a clinician, educator, and leader. How has ethics been part of your journey? Do you have advice on how nurses practicing at the bedside can enhance their moral agency and be ethically grounded?

Ethics is doing the right thing, engaging in the right way, and having the courage to stand up for what you believe is right, not in a way that it demeans others, but in a way that excites others to go on a journey with you. For me, ethics has been about how I show up and how I make people feel when they are around me. When I look back, as a staff nurse, when things were not right, I didn’t always know how to label the situation. But I did know when people behaved in ways that didn’t serve the patient’s interest. For example, there were times when staffing levels were harmful in many ways for patients and nurses, and leaders were not acting in ethical ways. As an educator, I had to be a role model and demonstrate ethics and courage in action consistently. I was showcasing the values I believed in as the Dean of Academics in Georgetown and UCSF for almost 20 years as well as the Dean of the UVA School of Nursing and Chief Academic Officer. When I was being interviewed for the Dean position at UVA, I said we need to create a healthy work environment where faculty, staff, and students can thrive. A lot of people hadn’t heard of it like that. I borrowed the Healthy Work Environments concept from the American Association of Critical-Care Nurses (AACN) and brought them into the academic setting. In all of my roles, I tried to show up with empathy and compassion.

I believe it takes courage and a moral stance to notice what is going on around us by paying attention and not jumping in to fix the problem right away by creating workarounds. We need to stand back (pause) and think about the action, which I consider wise action and creating wisdom. I know people at the bedside want to be the very best they can be, but they can get frustrated easily when if they see things that are not right. The best approach is to look at your values and think about a solution-oriented framework. Then it would be best to work with colleagues and nurse managers to change policies and procedures, and how we treat each other at the bedside. In my leadership journey, I have distilled everything down into noticing and pausing and then proceeding with wise action, which includes kindness. We just published “No time to be nice in the Intensive Care Unit” – it’s really about how we treat each other. We need to go back to kindness.

3. You just retired as the Dean of the UVA School of Nursing with a strong legacy. What are some of the highlights that you are most proud of during this time in your career?

When I first went to UCSF, I had the goal to be a Dean someday, and Kathy Dracup, PhD, RN, FAAN, took me under her wing, and I watched her in action. She was a superb mentor. I was told that an important part of being a leader is to have a few key messages that I believe in, can enact, and raise money as a cause. I had chosen three when I first came to UVA, and I worked on them for 11 years. My first message was to create healthy work environments where everyone could thrive. To me, this was about nurturing and nourishing faculty and staff plus students, which morphed right into the compassionate care initiative for the next ten years. Second, it was to focus on interprofessional relationships and collaborations, such as working with physicians and other health care professionals. Third, was to promote diversity and inclusion. All three work well together. If we have healthy work environments, then we are going to be able to collaborate better and reach out to our partners across the whole university and focus on inclusivity and diversity. The staff brought those three initiatives together and helped me lead them. Initially, the staff defined the concept of a healthy work environment in an academic setting, and they started measuring it over 6-7 years. Then the faculty got on board. Since we had data, the Institute for Healthcare Improvement approached us to be part of their rapid cycle process in studying “Joy in Work.”

Over the last 11 years, I have raised 55 million dollars, and much of it was scholarships for students. The funds also enabled us to hire faculty, have a compassionate care program, and hire an Associate Dean for the inclusion and diversity role. Having resources is what you need to be a successful leader, so you have to know how to get them. People want to give to a worthy cause, especially if it is successful. There is no more worthy cause than a nurse caring for a patient and the patients’ family to feel supported. Isn’t it great that we have selected nursing as our profession? It’s a pretty wonderful way to have a meaningful life.

4. You founded a Compassionate Care Initiative for students, faculty, staff, and clinicians at UVA in 2009. The mission of the program is to alleviate human suffering by developing compassionate caregivers and systems. How did this impact the culture of the school?

As a new Dean for only six weeks, a wonderful benefactor invited me to go to Upaya Zen Center for the Being with Dying program. It was an 8-day retreat in the Santa Fe Mountains in New Mexico. The program had a big focus on ethics as well and Cynda Rushton, PhD, RN, FAAN, was one of the teachers. It was about how to better care for the dying. But what I learned is that caring for the dying is about caring for the living and caring for the self. That’s where I was exposed to concepts like mindfulness, meditation, paying attention, giving attention from the right place, and how you want to be as a leader. When I came back, we started the Compassionate Care Initiative with Cynda’s help and a physician named Monica Sharma, MD, who had previously worked with the United Nations in developing leadership capacity for 20 years. We started hosting workshops for faculty and staff at UVA. I also began sending physicians, nurses, social workers, and pharmacists to the Being with Dying program. We had over 70 people attend the program throughout the years. When attendees came back, they felt different, and they acknowledge the fact that you have to take care of yourself before you could take care of others. You also have to reach out and demonstrate compassionate action.

Having been successful in this program with staff and faculty, we then started the process of teaching our students. We decided to create a curriculum that would focus on these concepts for students. We created four courses that we still offer: Leading with Presence, Foundations in Medical Yoga, Practicing Wisdom and Resilience, and Foundations of Mindfulness Practice. I build a mindfulness classroom with 40 yoga mats and movable furniture. Susan Bauer Wu, PhD, RN, FAAN, who now works for His Holiness the Dalai Lama as President of Mind & Life, was then the endowed professor who helped me conceptualize the plan and move it to action. We now have a curriculum for students from second to their fourth year, where they take courses and go on retreats. The students get a sense of how they can be their best selves. We talk about mindfulness as the ability to pay attention and notice things around us. The school offers free yoga, tai chi, and meditation, five days a week. I raised a lot of money for these programs, and I spent it. We also have Compassionate Care Ambassadors throughout the UVA Health System on all the inpatient units. The new Dean of UVA, Pam Cipriano, PhD, RN, NEA-BC, FAAN, is continuing the work that I started.

5. As a leader and champion for healthy work environments, what are some recommendations on how academia and practice can improve the health of their work environment?

As a leader, you have to show that compassion makes a difference. There are many examples where people feel that they are not treated well in healthcare, and nurses can be mean/unkind to each other with bullying types of behavior. We have to define what it means to be a compassionate caregiver in all settings. Mainly, how do we take care of ourselves so that we can be better in taking care of others? As a Dean, I taught students, faculty, and staff about creating healthy work environments and compassionate care. We all need to find places that value healthy work environments. We also have to showcase the great work being done in nursing schools and hospitals because most of the time, we have a negative bias for the things that are going wrong.

The values of healthy work environments include respect for all, integrity, working with others, standing up for people, and not gossiping. It’s a moral stance to say that healthy work environment standards of skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership, are not negotiable.

Right now, there is another nursing shortage on the east coast, and I see that new graduates have many choices. I tell them to take the Healthy Work Environment standards with them during job interviews and ask the managers if those standards are in place. For clinical practice, we have to talk about the difficult issues and have the courage to say if something is not right. People have to speak up.

Reference

Fontaine, D. K., Haizlip, J., Lavandero, R. (2018). No Time to Be Nice in the Intensive Care Unit. American Journal of Critical Care, 27(2), 153-156.

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Past Speaker Spotlights

Speaker Spotlight with Elizabeth Peter, RN, PhD “Direct care is at the heart and soul of nursing and without it we lose nursing as a profession and as a discipline.”   Elizabeth Peter joins our conference this year bringing to us her perspective on Nurse’s Moral Agency.  Her academic studies of nursing, philosophy, and bioethics afford a unique lens in which to view the development of ethical competence, cultivate ethical cultures, and appreciate the complexity of being moral agents and acting in more well-informed and virtuous ways. Over the years Dr. Peter has looked at nurse’s moral agency within the framework of the hospitals and institutions in which they work.  Looking at not only what constrains the development of the moral agency, but also on actions nurses can take that builds that agency.  Dr. Peters identifies her research as “focusing on examining the political dimensions of nurses’ ethical concerns and understandings.”      Katherine DuBois, a longtime member of the NNEC planning committee recently had the opportunity to ask Dr. Peter her thoughts. 1. You have been looking at nursing relationships and how professional trust is developed for many years.What shifts have you seen in nursing that you feel have helped and changes you have seen that have hindered nurses ability to establish and maintain trust in healthcare relationships? Over the years, the complexity of relationships of professional trust has become more apparent to me as healthcare systems grow and change. One thing that has helped maintain the trust in nurse-patients relationships is the enduring commitment that nurses have to patients and their families. I am struck by the students that I encounter that they remain deeply concerned with not only their patients’ diseases, but also their illness experiences. In fact, I notice a growing interest in issues of social justice as nurses work with patients in hospitals and communities and make great efforts to support people in their efforts to access the social determinants of health. On the other hand, cut-backs and pressures to make health systems more efficient have led to the distrust nurses have in healthcare systems. It also sometimes has led to nurses having little time to develop the kind of relationships they would like to have with patients/clients leading to an erosion of trust. I have also noticed that families sometimes place a great deal of pressure on nurses to support aggressive treatment at end-of-life as expectations in the power of medicine to sustain life have increased.  At times, this kind of pressure also has eroded the trust among nurses and families. 2. What do you see happening that gives you hope that the professional nurse will be successful in maintaining their caring practice, especially those taking direct care of patients? The fundamentals of care movement gives me hope in that it makes visible and valuable the importance of care practices that sometimes are unjustifiably considered menial. Direct care is at the heart and soul of nursing and without it we lose nursing as a profession and as a discipline. Over the past two years I have had a number of close family members in need of care as a result of illness and disability. The aging of many societies may drive the significance of nursing to the awareness of the public. Humans do not survive without care whether it be at the hands of family and friends or professionals. 3. In the current healthcare environment what transformations do you see that nurses can capitalize on that will strengthen their professional and moral identity? In the current healthcare environment, there are more nurses than ever before in positions of leadership and influence. Those in these roles, when they are good role models, can strengthen the professional and moral identity of nurses. More opportunities exist for nurses to develop their leadership capabilities through professional organizations and educational opportunities, making it more possible to find ways to capitalize on these changes.

Denise Dudzinski, PhD, MTS. 

Dr. Dudzinski is Professor and Chair of the Department of Bioethics & Humanities at the University of Washington School of Medicine and Chief of the UW Medicine Ethics Consultation Service, which is active in three hospitals.

Interviewed on November, 2018 by Ellen Robinson, RN, PhD

Given disparities in health care coverage, discharge planning particularly for the most vulnerable might be a growing source of moral distress for nurses and social workers. Do you have any advice how they can navigate ‘ethically and practically’ in their roles, in doing their best for their patients?  When for example they are no longer able to achieve previously satisfactory plans for their patients,let alone an ideal?  Can clinicians survive philosophically in this space, avoiding compassion fatigue and overall discouragement? 

It is the earnest striving to care and advocate for your patients that is virtuous, even if the goal is not achieved.  If we honor our actions more than the outcomes, we can find peace.  This does not mean we do not grieve when we cannot rectify the injustices that leave our patients vulnerable to illness. We help each other through this grief but keep the virtue of our actions foremost in mind.

In your experience, have you observed nurses act as advocates for their patients? Do you have advice for how nurses can enhance their roles in promoting advocacy, particularly under challenging circumstances of patient vulnerability?  

Yes, nurses constantly advocate for their patients.  My advice is for nurses to think of themselves as experts at all times, standing alongside other experts (doctors, social workers, etc.) in a common mission to advocate for patients.  Experts routinely talk with each other and occasionally disagree.  It’s normal.  But if nurses feel like they’re broaching a hard issue with an expert (the doctor) but they do not feel like one themselves, it can feel too risky.  Nurses are experts. Period.

Recently you wrote about ‘Repairing Difficult Patient-clinician Relationships’, suggesting that clinicians take responsibility for initiating the repair. Can you talk about the challenges in taking up this responsibility for nurses and social workers? What can help nurses and social workers take up their roles?

If we start by treating patients as though they need our help even when they act like they don’t, the whole tenor of the relationship changes. A nurse’s genuine care and concern can repair the relationship as long as self-care is planned ahead of time. When you know a tough interaction is coming, what will you need beforehand to put you in a compassionate mindset – and afterward, to help you find some equilibrium again?

Come join us for Denise Dudzinski’s Plenary “Tackling Moral Distress with the Moral Distress Map” at NNEC 2019.

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Our first interview was with Hui-Wen Sato, MSN, MPH, RN, CCRN.  Hui-Wen is a pediatric intensive care unit (PICU) nurse. Prior to becoming a nurse, she conducted research amongst the frail elderly in nursing homes, which included toileting, feeding, and exercise interventions to demonstrate the need for greater staffing levels. The research work motivated her to become a bedside nurse, as she found herself drawn to both the science and the art of skillful, wholehearted nursing. Hui-Wen now passionate about giving voice to the oft-hidden heart experience of nurses as they work in vulnerable closeness to the sick, suffering, and dying. As such, her writing has been featured in Off the Charts, the blog for the American Journal of Nursing (AJN), and the Oxford Handbook of Meaningful Work.
Interviewed on October 2018 by Carol Taylor, RN, PhD

The theme of this year’s conference is vulnerability and presence.  In what ways does this theme resonate with you?
I have had so many conversations with nurse colleagues, and so many internal dialogues, trying to work through the very raw and legitimate question of “How do I stay in such heartbreaking and heavy work over the long haul without shutting myself down?” As we prepared to be nurses, not many of our educators or preceptors talked about how hard, how challenging, how confusing vulnerability could be. There tends to be a quiet assumption that every nurse simply needs to find her/his own way with vulnerability. The majority of the preparation as a nurse was teaching critical thinking and technical skills – not so much in cultivating the power of presence. Yet I believe every nurse finds him/herself wrestling deeply with the issues of vulnerability and presence, the longer we spend with the sick, suffering and dying.   We have long needed a conference that brings us into rich, open, safe and shared conversations about vulnerability and presence as nurses. We need this for ourselves as much as we need it for our patients and their families.

You’ve been to this conference before.  What would you like to say to nurses who are thinking about  attending for the first time—or deciding about whether or not to return?
This conference is extraordinary to me in the courage and hope with which it tackles some of the deepest internal challenges we face as nurses, as human beings. It gives such intentional space for open acknowledgement and exploration of the issues that we so often do not have time to talk through with colleagues in the midst of such busy work days, but experiences we carry with us all the time. We grieve, hope, and vision together in this conference for the preservation and advancement of the true heart of nursing, and that is a truly sacred experience of community.

You’re a practicing nurse.  What are some of the everyday ethical challenges you encounter and can you describe what helps you stay centered so that you can advocate effectively for patients, families, your colleagues and yourself?
I work in a pediatric intensive care unit, where so many parents understandably hold on to so much hope that modern medicine can keep their critically ill child with them for as long as possible. We see many children placed on life support with debatable quality of life. We see children who are abused and yet family members want “everything done” when they appear to only have a lifetime of suffering or minimal engagement with the world ahead. As I am constantly revisiting what helps me stay centered, a few key factors come to mind: 1.) It serves me better to take more time asking questions of families and colleagues and listening carefully before I allow myself to jump to conclusions about an ethically challenging case. This has often helped me filter out voices of people who do not actually know the real situation, and helped me build greater empathy for those most closely involved in the decision-making.  2.) I am learning the value of the very hard work of communicating my own concerns to patients’ families and to colleagues in ethical dilemmas, rather than staying silent. I try to do this with a constant posture of humility and openness to hear the other perspectives, but it helps me resolve some of my own ethical tension when I give myself permission to speak up in a way that is clear but not antagonistic.  3.) I recognize that I cannot avoid ethical dilemmas or grief if I want to be a nurse, so this is not an expectation I hold of myself or of the profession. I try to pursue love, wisdom, humility and compassion above all as I learn to navigate the gray areas together with all of my amazing colleagues.

All nurses are reporting heavy caseloads and multiple demands on their time, energy and expertise. If we believe that we owe every human we encounter the gift of our compassionate and healing presence, how can we keep ourselves energized and focused?  Do you have secrets to share?

I am growing increasingly convinced that it is through entering into what seems to be the hardest things that we ultimately find ourselves more energized and focused than if we avoided them. Avoiding them simply leaves me feeling muddled and weighed down. If I am honest, I can easily use all my nursing “tasks” as a reason for me to shy away from pulling up a chair next to a grieving or “angry” family member, because the tasks will always be there. Quite frankly, performing the tasks come more naturally than opening myself up to hard conversations, to vulnerability and presence with a stranger. But every time I have chosen to spend even just 5-10 minutes listening closely to a family member, I find myself with such a deeper understanding of why we all are where we are with the patient’s care, and how it seems we ought to proceed. It helps me focus and prioritize my tasks better because I understand better what is important to the patient and family, not just to me.

Come join us for Hui-Wen’s Closing “Creating Safe Spaces for Vulnerability and Presence” at NNEC 2019.

Questions, please email Janine Mariz Burog at JBurog@mednet.ucla.edu