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  1. Karakachian, Angela MSN, RN
  2. Colbert, Alison PhD, PHCNS-BC

Article Content

GINA, RN, HAS BEEN working in the pediatric ICU since she graduated from nursing school. One month ago, one of Gina's patients was a 3-month-old boy who was comatose and endotracheally intubated, requiring mechanical ventilation. A head CT scan showed massive bilateral subdural hemorrhages. The mother's boyfriend was suspected of child abuse, and a police report was made, but no charges were filed. Now, 4 weeks after the initial injury, the little boy is showing no signs of improvement.


At work, Gina is frequently assigned to care for this patient. The physician and care team have approached the boy's mother with a difficult choice: performing a tracheostomy or withdrawing care from the infant. Despite the care team's advice to provide only comfort care to the baby, the mother insists on the tracheostomy and signs the consent form. Clearly, the mother is legally authorized to make all decisions on behalf of the child, and Gina has an obligation to provide high-quality care in accordance with those wishes. However, she personally feels deeply conflicted, as she believes the care is futile and that the baby isn't as comfortable as he could be. Every time Gina goes to work, she feels nauseated and sick; she feels both powerless and helpless. She has no one to talk to, and she doesn't know what to do.


Nurses often encounter similar situations in their careers. Despite their personal values, beliefs, and professional knowledge, they sometimes feel constrained and unable to do what they consider to be the "right thing" because of family preferences, workplace culture, lack of resources, institutional policies, and/or directives from supervisors.1 This phenomenon is known as moral distress. Nurses may feel alone when faced with this kind of dilemma, but the experience is believed to be part of daily professional life for some nurses. Moral distress varies between individuals depending on their own perceived obligations and values, and it has a negative impact on patient care and the nursing profession.2 Here, we'll examine moral distress and how nurses can address it.


Two types of moral distress

Moral distress was originally defined in 1984 as the phenomenon in which a person knows the right action to take but is constrained from taking it.3 In 1992, a distinction was made between two types of moral distress: initial and reactive.4 Initial moral distress is the acute phase when a person is faced with institutional obstacles and conflicts that cause feelings of anger, frustration, and anxiety. Once the acute phase ends, the individual may experience reactive moral distress-also known as moral residue-when the distress isn't resolved in an acceptable way.5


Although definitions have varied and evolved since the idea of moral distress was first introduced, its central meaning remains the same: moral distress is an ethical dilemma where the nurse believes he or she knows the right action to take but feels unable to act due to internal or external influences.6,7


The concept has recently garnered a lot of attention in the nursing world. Many nurses experience moral distress but fail to recognize it. Research has shown that moral distress may eventually lead to burnout and an increase in nurses' intentions to leave their jobs, and potentially the nursing profession, due to the stress and psychological impact.8,9 Nurses, administrators, and educators must be able to recognize moral distress and intervene as appropriate.


Moral vs. emotional distress

Emotional distress, which is also common in nursing, is separate and distinct from moral distress. It arises when the individual faces distressing situations, whereas moral distress develops when a person acts against his or her core values. In the case study, for example, Gina may experience emotional distress when she provides care for a child who may have been a victim of abuse. She experiences moral distress when she must provide aggressive care that she believes to be futile and inhumane. While emotional distress can be considered a healthy, normal process, moral distress is decidedly not because it reflects a violation of a person's core values and responsibilities, which can have powerful negative consequences on the individual.5


Sources of moral distress

Moral distress in nursing has been attributed to three sources: clinical situations, internal constraints, and external constraints.10


* Conflicts with other healthcare providers, controversial end-of-life decisions, excessive workload, and working with colleagues believed to be incompetent are examples of clinical situations that cause moral distress to nurses.


* Internal constraints exist within the nurse and include individual character traits such as the nurse's conscience, ethical competence, level of assertiveness, and religious values. Personal qualities, such as his or her educational level, experience, perceived powerlessness, and perceptions of autonomy are also internal constraints.


* External constraints are outside the nurse's control, such as hospital policies, interests of the patient's family members, hierarchy within the healthcare system, and poor communication between team members.



Researchers have found that the most common cause of moral distress for nurses is when a patient continues to receive aggressive treatment when he or she is unlikely to have a positive outcome.11 Gina's case is an example of moral distress caused by a clinical situation and external constraints.


Moral residue and the crescendo effect

What happens when moral distress continues for an extended period? Moral residue occurs when individuals feel they've allowed themselves to seriously compromise their core values.12 Nurses who repeatedly experience moral distress may lose their moral identity leading to moral residue, which has powerful and long-lasting consequences. Moral residue is related to anxiety, depression, and burnout. Understandably, it also leads nurses to withdraw from any ethically challenging situations.13,14


The moral residue crescendo effect is the increase of moral distress and the increase of moral residue. With the end of the patient's crisis, nurses' moral distress decreases, but the painful feelings remain. New situations cause stronger reactions because they remind them of past distress. Every morally difficult case is experienced in the context of the previous unresolved situation, creating the moral residue crescendo effect.5


Consequences of moral distress on nurses

The manifestations of moral distress vary from one person to another depending on each individual's physiologic and psychological characteristics and their unique life experiences. Moral distress has been consistently related to negative consequences in nurses and in the healthcare system. Broadly, nurses who experience moral distress are stressed and, therefore, predisposed to illnesses.5,15 Moral distress may cause nurses to have feelings of anger and frustration.16 Moral distress can also contribute to nurses' self-doubt, loss of self-confidence, and loss of self-esteem.17 Moral distress may lead nurses to feel hopeless and helpless, which in turn contributes to depression.17


On an organizational level, moral distress has been attributed to deterioration of teamwork and decreased quality of care, which can jeopardize patient safety.10


Developing moral resilience

Moral resilience is a person's ability to restore or sustain his or her moral integrity and to recover from morally distressing situations.18 Nurses must learn to respond to ethically challenging situations in ways that help them protect their integrity, minimize their suffering, and provide the highest quality of care to their patients. Gina's moral distress is related to the infant's mother not accepting the healthcare team's recommendations. Moral resilience will help her recognize that the patient's family has a justifiable, permissible, and legitimate point of view. Fully recognizing that the mother's decision is also ethical (even if it's in direct contradiction to her own position) will help Gina support their preferences while maintaining her own professional responsibilities. This shift in thinking doesn't mean that Gina is denying her personal views, but it's allowing her to expand the possibilities, preserve her integrity, and increase her moral resiliency.18


The take-away: What does this mean for Gina?

Gina's feelings of helplessness can be more easily understood when viewed through the lens of moral distress. She was in a situation where her personal values conflicted with the care she was being asked to provide for her patient, and she felt powerless. She had to reevaluate her approach to care for her patient. Because of her strong emotional response to the situation, she'd likely benefit from some professional guidance. For example, in response to the demand for interventions, the American Association of Critical Care Nurses (AACN) introduced the "The 4 A's to Rise Above Moral Distress."19 In brief, the AACN advises nurses to:20


* Ask: Is this moral distress? Am I feeling frustrated because I can't provide the care I think I should be providing? During this step, the nurse becomes aware of the moral distress that he or she is experiencing.


* Affirm: Recognize the moral distress for what it is and accept the professional and personal obligation to resolve it.


* Assess: View the situation from the perspective of all involved parties, including family members, healthcare providers, and administrators. The goal is to identify the source of the distress, potential interventions, and the risks and benefits of taking action.


* Act: Take deliberate action to address the ambivalence and to try to reconcile differences.



This approach can provide nurses with a framework with which to view moral distress and a process that may let them move forward in a way that doesn't require them to compromise their core values.


Gina knew she was experiencing some kind of conflict, but she couldn't decide how best to handle it. She went to talk to her unit manager, a mentor who'd provided guidance in the past. Her unit manager introduced her to the "4 A's." Together, they saw that Gina was experiencing both emotional and moral distress in caring for this gravely ill infant, and that she needed to examine both types of distress.


Her unit manager helped Gina view the situation from the mother's perspective, reminding Gina that the mother has the responsibility and the authority to make medical decisions on behalf of her child. Gina realized that although the boyfriend was suspected of child abuse, she wasn't privy to the specifics of the case and that her role wasn't to investigate or pass judgment. Rather, she should respect the mother's wishes with the understanding that the mother is better situated than anyone else to make the decisions that are in her child's best interest.


To resolve her moral conflict, Gina decided to focus on more open conversation with the mother, who shared for the first time that she hadn't lost hope for her child, wasn't ready to let go, and felt terribly guilty and ashamed. As a result of the more open lines of communication, Gina was better able to accept that although the mother's decision was different from her own professional opinion and the physician's recommendations, the mother's determination to continue life-sustaining treatment should be respected. The conversation also revealed the mother's need for more support and counseling.


The unit manager helped Gina understand the role of the hospital's ethics committee, which could be called on if the situation continued unresolved and if the treatment team believes that outside consultation is needed. This also helped Gina resolve her moral distress without jeopardizing her core values.


Ethically challenging situations will never be eradicated in Gina's job or from nursing in general; in fact, advances in care, new technology, and growing knowledge in fields like genetics and genomics suggest that we'll see an increase in such dilemmas. To ensure the highest quality and most ethically sound care, nurses must be able to confront difficult situations in a manner that respects the point of view of the patient, the family, and other providers without undermining their moral integrity.




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