Moral distress (nursing)

Moral distress is a philosophical and emotional concept primarily related to healthcare professionals. It involves feelings of mental distress that result when a caregiver is unable to provide appropriate care for a patient because of policies, procedures, poor communication, or other related obstacles. Moral distress arises in situations where medical professionals’ moral understanding about what is best for a patient’s care is not in line with the approved methodology. Moral distress is most common within the nursing profession. Nurses often complain of being unable to fulfill their duties to their patients due to issues such as conflicts in values, institutional oversights, staffing policies, professional disagreements, and mounting workplace pressure resulting from problems such as understaffing. Many nurses define this dilemma as having to go against their moral compasses, resulting in feelings of being unable to do the right thing despite wanting to do so.

Background

Discussions about moral distress in the healthcare profession within medical literature date back to the late twentieth century. Many scholars believe the concept dates back further, however. Philosopher Andrew Jameton is considered the originator of the phrase “moral distress” and was the first to expand on its dynamics. Jameton’s 1984 book Nursing Practice: The Ethical Issues defined moral distress as a “psychological disequilibrium” in which a nurse feels distressed after recognizing an ethically suitable action for their patient but being unable to take that action. Obstacles to the action can be internal factors, such as one’s own personal beliefs, or external factors such as institutional restrictions. Moral distress occurs when a nurse knows what action is needed but cannot act. Although nurses are most commonly affected by moral distress, the term applies to others working within the medical field.

Moral distress is distinct from an ethical dilemma. An ethical dilemma applies to situations in which a health professional must consider the most ethical alternative course of action prior to that action being taken. Moral distress specifically refers to the feelings that emerge after an ethically appropriate action is not taken. It includes social and organizational factors involved in the situation alongside the personal feelings of accountability an individual feels. Moral distress also differs from emotional distress. Emotional distress is more common and does not have an ethical element, primarily emerging from a highly stressful work environment. Moral distress features a moral component as the main source of distress.

Moral distress can lead to moral residue, a residual feeling of distress that remains with a healthcare professional long after an incident has occurred. Moral residue affects the way a person thinks and feels about themselves and poses a threat to a person’s moral integrity. This destruction to a person’s clearly defined values can lead to low self-worth and affect a person’s ability to do their job, potentially having a damaging effect on the person’s career. If episodes of moral distress are repeated over time, personal and professional damage is more likely to occur.

Overview

A number of constraints are tied to the development of moral distress among healthcare professionals. Internal constraints can include problems being assertive, self-doubt, perceptions of powerlessness, a strict mindset for following orders, and an incomplete grasp of a situation. External constraints can include institutional policies or priorities that conflict with a patient’s care needs, fear of legal action, lack of administrative support, poor relations with colleagues, healthcare system hierarchies, and inadequate staffing.

Some of the most frequently cited causes of moral distress in a clinical setting include:

• Continuing to place a patient on life support when the action is not in the patient’s best interest
• Undertaking lifesaving actions only to prolong a patient’s inevitable death
• Poor communication with patients and families about end-of-life care
• Following the wishes of family members in fear of litigation
• Being unable to provide adequate pain relief to a patient
• Offering false hope to patients and families
• Inappropriate use of institutional resources
• Insufficient staffing or poorly trained staff

Moral distress can cause feelings of isolation and devaluation. Some healthcare professionals describe feeling a sense of compassion fatigue and resignation. Moral distress can also affect the efficiency of a workplace setting, leading to poor communication and trust problems among colleagues. This, in turn, can result in high turnover rates among staff and poor collaboration between clinical disciplines, contributing to broader workforce shortages in healthcare. Moral distress can lead to burnout, where professionals are left in a state of exhaustion physically, mentally, and emotionally. This reduces the professional’s effectiveness and can even cause them to leave the profession.

Research regarding moral distress often focuses on the signs and effects of moral distress as well as the underlying forces at work. Little research has been dedicated to understanding how to alleviate moral distress in the past, but with the rise in awareness, researchers have begun devising a number of strategies aimed at resolving moral distress in healthy ways. Personal strategies that help address moral distress include speaking up and recognizing the moral distress being experienced. It is also important that this distress is discussed with other parties involved in the situation.

A healthcare professional should have a support network that encourages speaking up and making sure one’s voice is heard. Communication among healthcare team members is also key to ensuring moral distress is addressed appropriately. Communication also works to address problematic methods that perpetuate moral distress and impede team-member collaboration. Institutionally, experts suggest organizations develop policies that better address medical ethics, such as allowing a healthcare provider to initiate an ethics consultation. Policies such as these and changes that focus on preserving a provider’s moral integrity can help alleviate moral distress.

Bibliography

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