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Journal of Nursing

Moral Distress in Nursing and Available Support Systems

Brynne Underhill and Jennifer Finkle [email protected]


Moral Distress in Nursing and Available Support Systems


Moral distress is a key issue facing nursing today; it affects the way nurses care for their patients and the number of nurses who stay in the profession (Gutierrez, 2005; Hamric & Blackhall, 2007).  Moral distress was first described as a feeling that nurses experience in situations where they know what the morally right action is but cannot take it because of organizational barriers (Jameton, 1984).  Hamric and Blackhall (2007) found that although other health professions, such as physicians, experience moral distress, nurses experience it in a different, more debilitating way.   Unlike physicians, nurses are not easily able to leave patients in distressing situations.  Therefore, they are greatly affected by these encounters, resulting in higher ratings and frequencies of moral distress than physicians (Hamric & Blackhall, 2007).  Nurses not only suffer the effects of moral distress while taking care of patients in ethically questionable situations, but also continue to experience negative consequences of these situations after they have occurred.


Moral distress is a systemic problem in nursing and can affect the quality of care and workplace environment of nurses.  It can lead to nurses withdrawing and avoiding patients and their families (Gutierrez, 2005).  Moral distress also impacts the quality of life of the nurse.  It can influence nurse’s self-image, spirituality, and physical well-being (Elpern, Covert, & Kleinpell, 2005).  The result of these negative consequences is an increase in nurse burnout and more nurses leaving the profession.  Hamric and Blackhall (2007) found that almost half of the registered nurses they sampled had either left their position or considered leaving due to moral distress issues.  At a time when the United States is facing an impending nursing shortage, it is important that moral distress issues are addressed to prevent further nurses from changing careers (Buerhaus, 2009). 


How do nurses prevent or cope with moral distress?  Many coping strategies were suggested throughout the literature, including ethics debriefing sessions, clinical supervision, ethics committee consultations, ethics education, and unit-based ethics conversations (Bell & Breslin, 2008; Grady et al., 2008; Wocial, Hancock, Bledsoe, Chamness, & Helft, 2010).  Fox, Myers, and Pearlman (2007) found that 81% of general hospitals and all hospitals with more than four hundred beds had ethics consultation services.  Although these services were widely available, they varied considerably between hospitals and within institutions in terms of how different cases were handled.  In addition, only 28% of hospitals had developed processes to look at whether these resources were effective in dealing with ethical conflicts.  Research that directly examined whether consultation services decreased feelings of moral distress was also not available.  A small number of articles examined how specific coping and prevention strategies affected concepts similar to moral distress.


Grady et al. (2008) suggested that nurses with ethics training could be more equipped to handle morally distressing situations.  These researchers found that nurses who had received some form of ethics education reported higher moral action scores than those with no ethics education.  Nurses with ethics education also reported higher confidence scores in making moral decisions and reported that they were more likely to use hospital consultation resources than those with no ethics education.  Wocial et al. (2010) examined nurses participating in unit-based ethics conversations (UBECs) centered on coping with moral dilemmas.  These researchers found that nurses who participated in UBECs (group discussions with other nurses led by a clinical ethics expert) felt these sessions improved their ability to handle ethical issues in their practice and made them more prepared to deal with future moral issues.  They also found that those nurses who participated in UBECs were one and a half times more likely to seek outside consultation for an ethical issue than those who did not participate in UBECs.  These researchers felt that UBECs increased nurses’ moral agency, which helped them address morally challenging situations in practice.


Both ethics education and UBECs contributed to nurses feeling as though they could take action toward resolving ethical conflicts and utilize ethics consultation services (Grady et al., 2008; Wocial et al., 2010).  Although this is the case, just because nurses feel more prepared to take action does not automatically mean their feelings of moral distress would be reduced.  In fact, there are impediments even after a nurse has decided to seek help.  Gordon and Hamric (2006) found that ethics consultation services were directed towards physicians and nurses requesting such consultations often felt backlash from doing so.  After asking for a consultation, many of these nurses feared negative consequences ranging from being reprimanded by physicians to losing their jobs.  This fear and uncertainty could increase rather than decrease nurses’ feelings of moral distress.  Fox et al. (2007) found that 76% of consultation services in hospitals required that physicians be alerted to the fact that there was a request for an ethics consult.  The way these services are structured impacts how effective they are and whether they will in turn help decrease nurses’ feelings of moral distress. 


It is imperative that nurses restructure these services so that they are useful in addressing ethical issues that significantly impact the profession.  Nurses make up the second largest group of health professionals on ethics consultation committees, only slightly surpassed by physicians (Fox et al., 2007).  Nurses must use their presence on these committees to make the issue of combating moral distress a priority.  Nurses must insist that proper protocols are put in place to evaluate the effectiveness of consultation services, and specifically look at whether they help alleviate distress among nurses.  If consultation services are effective in reducing moral distress, nurses must work at increasing the availability of these services.  On average, consultation services nationwide only handled three cases per year (Fox et al., 2007).  There are many issues, which hinder nurses’ abilities to utilize these programs, such as not being frequently available or inaccessible on weekends and after normal business hours (Zuzelo, 2007).  These issues must be resolved to increase participation if these programs are found to be beneficial to nurses.  If these services are not effective in decreasing moral distress, nurses must look at reorganizing them in a way that will help nurses solve ethical dilemmas and decrease conflict that arises when these issues are not resolved.


Many researchers have identified moral distress as an issue that needs to be addressed and have proposed solutions for preventing and coping with this issue (Bell & Breslin, 2008; Grady et al., 2008; Wocial et al., 2010).  Both ethics education and UBECs have been shown to increase moral agency, confidence in making ethical decisions, and likelihood of seeking outside consultation services (Grady et al., 2008; Wocial et al., 2010).  These strategies lead nurses to take action and may decrease their feelings of powerlessness (Russell, 2012).  Research also shows that hurdles exist in getting help once a nurse has decided to seek outside resources.  Attaining an ethics consultation, for example, may lead to further distress and is not always available when needed (Gordon & Hamric, 2006; Zuzelo, 2007). 


Nurses make up a large percentage of ethics committee members nationwide (Fox et al., 2007).  Thus, it is imperative that nurses use their presence on ethics committees to formulate protocols for evaluating the effectiveness of these services and reorganizing them in a way that is beneficial to the profession.  Nurses must also collaborate with their professional organizations and shared governance in spreading awareness of the significance of this issue and the necessity of having appropriate resources for nurses.  Decreasing moral distress should be a priority and nurses have the ability to impact how moral conflicts are resolved.


 


 


References


Bell, J. & Breslin, J. M. (2008). Healthcare provider moral distress as a leadership challenge. JONA’S Healthcare Law, Ethics, and Regulation, 10(4), 94-99.


Buerhaus, P. I. (2009). Current and future state of the U.S. nursing workforce. Journal of the American Medical Association, 300(20), 2422-2424.


Elpern, E., Covert, B., & Kleinpell, R. (2005). Moral distress of staff nurses in a medical intensive care unit.  American Journal of Critical Care, 14, 523-530.


Fox, E., Myers, S., & Pearlman, R. A. (2007). Ethics consultation in United States hospitals: a national survey.  The American Journal of Bioethics, 7(2), 13-25.  doi: 10.1080/15265160601109085


Gordon, E. J. & Hamric, A. B. (2006). The courage to stand up: The cultural politics of nurses’ access to ethics consultation. The Journal of Clinical Ethics, 17(3), 231-254.


Grady, C., Danis, M., Soeken, K. L., O’Donnell, P., Taylor, C., Farrar, A., & Ulrich, C. M. (2008). Does ethics education influence the moral action of practicing nurses and social workers? American Journal of Bioethics, 8(4), 4-11. doi: 10.1080/15265160802166017


Gutierrez, K. (2005). Critical care nurses’ perceptions of and responses to moral distress. Dimensions of Critical Care Nursing, 24 (5), 229-241.


Hamric, A. & Blackhall, L. (2007). Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate. Critical Care Medicine, 35 (2), 422-429.  doi: 10.1097/01.CCM.0000254722.50608.2D


Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice Hall.


Russell, A. (2012). Moral distress in neuroscience nursing: An evolutionary concept analysis.  Journal of Neuroscience Nursing, 44 (1), 15-24.  doi: 10.1097/JNN.0b013e31823ae4cb


Wocial, L. D., Hancock, M., Bledsoe, P. D., Chamness, A. R., & Helft, P. R. (2010). An evaluation of unit-based ethics conversations. JONA’S Healthcare Law, Ethics, and Regulation, 12(2), 48-56.


Zuzelo, P. (2007).  Exploring the moral distress of registered nurses.  Nursing Ethics, 14 (3), 344-359.  doi: 10.1177/0969733007075870


 


 

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