CONFIGURACIÓN DE FTP

thought of in two categories: environmental and administrative. Although often interconnected, the environmental and administrative barriers are both components of what are more broadly defined as organizational barriers, but they represent distinct aspects from an institutional perspective that can affect the practitioner in either a positive or negative way.

Perhaps one of the best examples of an environmental barrier that has been recognized and corrected where possible relates to the physical environment of nursing homes. Interestingly enough, over fifty years ago, Cumming and Cumming wrote about the therapeutic effect that an environment can have on both patients and staff, and noted that grim physical structures did nothing to improve the well-being of either the patients or the caregivers themselves.38

One effort to create a therapeutic environment within the nursing home was developed by Bill Thomas and his wife, Jude, in the 1990s. As a physician working in nursing homes, Thomas was struck by the same lack of any plant, animal, or even human interaction that would enrich the lives of both the residents/patients and the staff. Thomas and his wife developed what is now known and widely embraced as the “The Eden Alternative.” This philosophy requires each community that adopts this process to commit to following a comprehensive 10-stage process which are the principles of the Eden Alternative, as follows:

1) The three plagues of loneliness, helplessness and boredom account for the bulk of suffering among our elders.

2) An Elder-centered community commits to creating a Human Habitat where life revolves around close and continuing contact with plants, animals and children. It is these

3) Loving companionship is the antidote to loneliness. Elders deserve easy access to human and animal companionship.

4) An Elder-centered community creates opportunity to give as well as receive care. This is the antidote to helplessness.

5) An Elder-centered community imbues daily life with variety and spontaneity by creating an environment in which unexpected and unpredictable interactions and happenings can take place. This is the antidote to boredom.

6) Meaningless activity corrodes the human spirit. The opportunity to do things that we find meaningful is essential to human health.

7) Medical treatment should be the servant of genuine human caring, never its master. 8) An Elder-centered community honors its Elders by de-emphasizing top-down

bureaucratic authority, seeking instead to place the maximum possible decision-making authority into the hands of the Elders or into the hands of those closest to them.

9) Creating an Elder-centered community is a never-ending process. Human growth must never be separated from human life.

10) Wise leadership is the lifeblood of any struggle against the three plagues. For it, there can be no substitute.39

In adopting the principles of the Eden Alternative, as stated above, the organization itself commits to humanizing the work environment to the benefit of both the residents and the staff. It should be further noted that by placing the emphasis on the care that is given, by de-emphasizing a top-down bureaucratic authority and in their words, “by acknowledging the simple truth that human growth must never be separated from human life,” Thomas and his wife have designed a

framework that has the added benefit of addressing many of the organizational practices thought to reduce incidents of moral distress within the workplace.40

Administratively, organizations have many resources at their disposal that could serve to break down any barriers thought to contribute to incidents of moral distress. Research indicates, however, that although the current practices within healthcare require increasing expertise on the part of practitioners, many healthcare organizations lack standardized policies, systems, and structures designed to support the practitioner in making increasingly complex decisions regarding care.41

Kalvemark et al. sought to break down the causes of moral distress into their component parts—specifically, to separate the moral or ethical aspect of the distress from the actual stress or stressor leading to the distress. Kalvemark et al. conducted their study using focus groups from the clinical departments cardiology, hematology, and pharmacy, which are all at the same

location in Sweden (Uppsala/Stockholm) and which have from five to seven practitioners in each group. The focus groups were asked specific questions regarding their experience of stress, and even more specific questions about what leads them to experience ethical or moral distress. The answers were categorized and summarized as follows: 1) lack of resources, including

insufficient staff, insufficient availability of beds, and lack of time to devote to patients due to administrative responsibilities; 2) difficulty in complying with rules and regulations owing to the constraints noted above; 3) conflicts of interest resulting from conflicts in values and hierarchy; 4) economic constraints relating to not being able to provide the optimal care because of the cost of the medicine (respondents explained further by saying that if the best medicine were to be given, some other service would have to be cut to make up the cost of the medication); 5) justifying breaking the rules in order to act in what they believe is the best interest of the patient;

6) strained professional relations among doctors and the nurses if and when nurses question physicians’ orders because they do not share the same values regarding end-of-life decision making; and 7) lack of support structures within the organization for providing meaningful discussions when ethical dilemmas do arise that could lead to experiences of moral distress.42

These findings are relevant to the current thesis in that they help to separate those causes that are related to the individual from those that can be controlled or reduced by the organization. In attempting to isolate the organization and its impact on the individual, nurses have been implicated in blaming “the system” for the constraints within which they work, defining the system as being comprised of the bureaucracy or the organization itself, the insurance companies, and even more broadly, the entire American healthcare system.43 _{In their 1986}

research, Yarling and McElmurry created a term for this phenomena, “hospitalonian captivity,” which they used to refer to the restrictions that are put on the healthcare provider causing them to feel powerless and voiceless.44 _{Not being able to identify and label a specific source of the}

stress can in itself make efforts to reduce the stress much more difficult. Often the causes of the moral distress rest in more than one place and may in fact result from a combination of

organizational, environmental and individual barriers. As noted by Kalvemark et al., while it is true that doctors, nurses and other staff members do not always agree on what each believes constitutes a moral issue, differing views regarding commitment to the patient versus

commitment to the organization can further complicate agreement as to what each believes is the morally appropriate course of action.45