What Is Moral Distress

Student Voices

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N O UNIT, hospital, or occupation is immune to moral distress. Using the following case study, this

article examines moral distress in nursing students who are completing their clinical rotations, including the definition of moral distress, signs and symptoms, and relief methods.

Case study During a day shift on the telemetry unit, Jamie, a third-semester nursing student, starts her first shift with Tom, an RN with 2 years of experi- ence. After patient handoff, they head into the first patient room for an hour-long visit, including assessment, medications, and patient education. Although she was told by her clinical instructor to follow Tom’s lead, Jamie is uncom- fortable with not first seeing all four assigned patients briefly. She felt they should at least look in on each of the four patients before spending a lengthy amount of time with one of them. Since this is her first time on the telemetry unit and she is a nursing student, Jamie does not want to begin the shift in conflict with Tom. Jamie feels guilty and powerless, which can eventually lead to moral distress.1

Although Jamie trusted that Tom had a plan to assess all the patients, they stayed in the first patient’s room for 60 minutes. The next hour was spent in the second patient’s room. When they finished assessing and delivering care to that patient, Tom sat down and documented in the electronic health record. As the discomfort of not seeing all patients built up, Jamie knew she had to say

something to Tom, at the very least, to mitigate her own distress. When Jamie asked whether they should assess the third patient, Tom simply stated that the telemetry monitor will let them know if anything is wrong. Feeling the patients were inadequate- ly cared for, Jamie dealt with an in- ternal constraint that left her feeling frustrated and unhelpful not only to the patients but also to Tom.

What is moral distress? Moral distress is knowing the ethical action to take but being unable to act on it.2 In these scenarios, an individu- al acts contrary to their personal and

professional values, thereby under- mining their integrity and authentic- ity.3 Nurses typically experience moral distress several times per month, which can lead to poor patient care, decreased job satisfac- tion, staffing turnover, burnout, and psychological distress.2,4-6

Moral distress can occur in all areas of nursing and for a variety of reasons, including end-of-life challenges, team conflicts, decision- making hierarchies, and ethical dilemmas.2 Examples include working in a high-acuity ED with insufficient resources.2,7,8

Often in these situations, the nurse or nursing student feels powerless due to internal constraints (e.g., lack of

knowledge or support), external constraints (e.g., staffing or supply issues), clinical constraints (e.g., feeling care is not helping the client), or seeing others giving a false sense of hope to a patient or their family.7

These feelings can linger and build over time, leading to a breaking point for the nurse.6

Signs of moral distress Moral distress can be noted in several ways, such as affective signs of anger, frustration, or anxiety. (See Signs of moral distress.9) There can be behavioral signs such as withdrawal, cursing, or cynicism.

Powerlessness is common, as are changes in relationships. Physical signs may include insomnia or tachycardia.9

In this case study, not assess- ing the patients in a timely man- ner caused Jamie to feel guilty and powerless as a nursing student. Even though she advocated for the patients, Jamie felt dismissed by Tom. Although Tom prioritized the pa- tients correctly and all the patients were safe and stable, the guilt and powerlessness still weighed on Jamie.

Relieving moral distress Relieving moral distress can be a challenge if individuals are unaware of the available effective interventions

What is moral distress? BY SOPHIE PARSH, RN, AND ELVIS VO

Moral distress can occur in all areas of nursing and for a variety of reasons, including end-of-life challenges, team conflicts, decision-making hierarchies, and ethical dilemmas.

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Student Voices

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of the clinical judgment involved. In this case, open communication about the situation with the RN and the clinical instructor is warranted. Jamie spoke with fellow nursing students, who confirmed that the incident was unusual and poten- tially put patients at risk. After de- briefing with fellow students, Jamie felt empowered to tell the clinical instructor what happened for fur- ther support and guidance. Speak- ing with nursing students and with the instructor eased Jamie’s worries and empowered her to speak up in the future.

A situation like Jamie’s can happen to any nurse, student, and guest on a unit. Guests, such as travel nurses and even patients, can potentially feel powerless, especially if they express concerns about unexpected outcomes.6 Openly discussing the situation with supervisors, friends, or professionals can alleviate distress.1,2

Moral distress can occur even when things do not go wrong. Having an open discussion about challenges, practicing relaxation techniques, and using resources like Code Lavender can help reduce moral distress and lead to a more positive nursing career. ■

and tools. A helpful tool for nurses and students is the 4 A’s, which was originally developed for critical care nurses but has since been used by many nurses on all units. The 4 A’s are: • Asking oneself whether he/she is experiencing moral distress • Affirming feelings of distress • Assessing the cause of the distress • Acting on the distress to relieve it.

In addition, institutions have other tools that nurses can use to learn how to cope with moral distress.6 For example, hospitals have created ethics committees to address moral distress among healthcare providers. In addition to following the four A’s, ethics committees offer tools to support nurses in challenging situations. To guide discussions, committees discuss the nurse’s response to the event and help nurses develop skills to address future ethical dilemmas.

Although individuals need skills to relieve distress, real-time institu- tional approaches can be a long- term solution.6 Positive impacts on reducing moral distress include adequate staffing, improving the unit’s environment, leadership sup- port, collegial relationships with staff and physicians, hospital program

participation, and empowering nurses to choose the right option despite pressure not to.4,8 Supporting staff through moral distress includes grief intervention, education programs such as critical debriefs, and work-life balance committees.2,10

Code Lavender, a crisis inter- vention tool that supports nurses at the time of stressful events, has shown to help reduce moral distress, as have yoga classes and mindfulness sessions.6,11 Code Lavender provides healing services for individuals and teams by pro- viding words of support, lavender essential oils, and spiritual care if appropriate.11,12

Mindfulness-based stress reduc- tion (MBSR) is another strategy that can decrease anxiety, depression, and perception of distress.7,13 Shown to improve the quality of life and reduce stress especially for health- care professionals, MBSR provides training on mindful meditation, yoga, reflection, and discussion.13

Discussion The nursing student in this article’s case scenario, Jamie, was unsure of how to cope with her situation. Students may feel overwhelmed and conflicted about the plan of care, especially if they are not sure

Signs of moral distress9

Affective signs Behavioral signs Cognitive/relational signs Physical signs

• anger, disdain • feeling upset • grief, crying, despair • anxiety/worry/agitation/

angst • frustration • fear • feeling hurt/devalued • low morale/discouragement

• stating concerns about issues • withdrawal/disengagement/

becoming silent • increased vigilance for patient,

family, each other • resistance to plans • persuasion • dark humor, cynicism • name-calling, cursing • heightened sense of neutrality

• uncertainty • feeling ambivalent/torn • powerlessness/

hopelessness • regret • surprise, disbelief

• frequently ill or missing work

• fatigue/poor sleep • increased heart rate

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REFERENCES

1. Burston AS, Tuckett AG. Moral distress in nursing: contributing factors, outcomes and interventions. Nurs Ethics. 2013;20(3):312-324.

2. Jameton A. What moral distress in nursing history could suggest about the future of health care. Am Med Assoc J Ethics. 2017;19(6):617-628.

3. American Association of Critical Care Nurses. Improving work environment could reduce moral distress. 2019. www.aacn.org/newsroom/ improving-work-environment-could-reduce-moral- distress.

4. Hiler CA, Hickman RL, Reimer AP, Wilson K. Predictors of moral distress in a US sample of critical care nurses. Am J Crit Care. 2018;27(1):59-66.

5. Rathert C, May DR, Chung HS. Nurse moral distress: a survey identifying predictors and potential interventions. Int J Nurs Stud. 2016;53: 39-49.

6. Wallis L. Moral distress in nursing. Am J Nurs. 2015;115(3):19-20.

7. Vaclavik EA, Staffi leno BA, Carlson E. Moral distress: using mindfulness-based stress reduction interventions to decrease nurse perceptions of distress. Clin J Oncol Nurs. 2018;22(3):326-332.

8. Wolf LA, Perhats C, Delao AM, Moon MD, Clark PR, Zavotsky KE. “It’s a burden you carry”: describing moral distress in emergency nursing. J Emerg Nurs. 2016;42(1):37-46.

9. Pavlish C, Brown-Saltzman K, So L, Wong J. SUPPORT: an evidence-based model for leaders addressing moral distress. J Nurs Adm. 2016;46(6): 313-320.

10. Adwan JZ. Pediatric nurses’ grief experience, burnout and job satisfaction. J Pediatr Nurs. 2014;29(4):329-336.

11. Stone RSB. Code Lavender: a tool for staff support. Nursing. 2018;48(4):15-17.

12. Davidson JE, Graham P, Montross-Thomas L, Norcross W, Zerbi G. Code Lavender: cultivating intentional acts of kindness in response to stressful work situations. Explore (NY). 2017;13(3):181-185.

13. Khoury B, Sharma M, Rush SE, Fournier C. Mindfulness-based stress reduction for healthy individuals: a meta-analysis. J Psychosom Res. 2015;78(6):519-528.

Sophie Parsh is an RN at the University of New Mexico in Albuquerque, N.M., and Elvis Vo is an RN at UC Davis Medical Center in Sacramento, Calif.

The authors have disclosed no fi nancial relationships related to this article.

DOI-10.1097/01.NURSE.0000791748.26732.35

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.