Moral Distress

Recently, moral distress has been a topic widely discussed in the literature as a serious problem for nurses.2–5 Nurses face multiple challenges on a daily basis: emergency situations, tension from conflict with others, complex clinical cases, new technologies, increasing regulatory requirements, acquisition of new skills/knowledge, staffing issues, financial constraints, workplace violence, to name a few. This care environment has led to increasingly complex moral and ethical dilemmas.⁵ In addition, they frequently may experience emotional outbursts from patients, families, co-workers, and feel a lack of control and “burnt out.”^2,5 Moral distress occurs when a person knows the ethically appropriate action to take but cannot act on it. It also manifests when a nurse acts in a manner contrary to personal and professional values. As a result, there can be significant emotional and physical stress that leads to feelings of loss of personal integrity and dissatisfaction with the work environment. Relationships with co-workers and patients are affected, and the quality of care can be negatively affected. There is also a great impact on personal relationships and family life; nurses experiencing moral distress may resign their position or leave the profession entirely.³

It is therefore important that nurses recognize moral distress and actively seek strategies to address the issue through institutional, personal, and professional organizational resources. Knowledge and application of ethical principles and guidelines can assist the nurse in daily practice when ethical dilemmas occur. Box 2-1 provides a position statement on moral distress, promulgated by the American Association of Critical-Care Nurses (AACN).⁶ The document is evidence-based, providing additional references for the reader. There is also a reference to ensuring that support to alleviate moral distress is present in a healthy work environment (see Chapter 1). Actions are listed for direct care staff nurses as well as employers.

The AACN has created a framework—The 4A’s to Rise Above Moral Distress—to support nurses who are experiencing moral distress (Figure 2-1). ASK, the first stage, is a self-awareness and reflection period in which one becomes more aware of the distress and its effects on oneself. Specific areas to address are physical, spiritual, emotional, and behavioral responses. During stage two, AFFIRM, one affirms the distress and makes a commitment to take care of oneself. In stage three, ASSESS, one needs to identify the timing and context of when the stressors occur; determine the severity of the distress; and examine one’s readiness to act. The final stage, ACT, consists of preparation, the action itself, and maintaining the desired change. Although the model was created by AACN, it is a framework that can be used in diverse settings and by various health care professionals.⁷ McCue⁸ reported using this model as a resource for resolving an issue between a chief nurse executive and chief executive officer. In this case, the impact of the outcome was at the organizational level.

Moral Courage

In order to avoid moral distress, nurses must feel free to advocate for themselves, their patients, co-workers, and a safe and effective work environment. Lachman and colleagues describes moral courage as “the willingness to stand up for and act according to one’s ethical beliefs when moral principles are threatened, regardless of the perceived or actual risks (such as stress, anxiety, isolation from colleagues, or threats to employment)”.^9,p24 They describe organizational cultures that support moral courage, the importance of peer support, education, and policies that can support moral courage of staff. Other authors have reported that moral courage is needed in everyday practice and that one must act ethically even in the presence of risk.^4,10

Autonomy

The concept of autonomy appears in all ancient writings and early Greek philosophy. In health care, autonomy can be defined as an agreement to respect another’s right to self-determine a course of action and the support of independent decision making¹¹ without coercion or interference from others. Autonomy is a freedom of choice or a self-determination that is a basic human right. It can be experienced in all human life events.

The critical care nurse is often “caught in the middle” in ethical situations, and promoting autonomous decision making is one of those situations. As the nurse works closely with patients and families to promote autonomous decision making, another crucial element becomes clear. Patients and families must have all of the information about a particular situation before they can make a decision that is best for them. They should be given all the pertinent information and facts, and they must have a clear understanding of what was presented. This is where the nurse is a most important member of the health care team—as patient advocate, the nurse provides more information as needed, clarifies points, reinforces information, and provides support during the decision-making process. Box 2-3 presents the Nursing Interventions Classification (NIC) feature on nursing intervention activities that facilitate decision making.

Beneficence

The concept of doing good and preventing harm to patients is the sine qua non for the nursing profession. However, the ethical principle of beneficence—which requires a nurse to promote the well-being of patients—points to the importance of this duty for the health care professional. The principle of beneficence presupposes compassion; taking positive action to help others; desire to do good. It is the core principle of patient advocacy.¹¹ Harms and benefits are balanced, leading to positive or beneficial outcomes. In approaching issues related to beneficence, conflict with another principle, that of autonomy, is common. Paternalism exists when the nurse or physician makes a decision for the patient without consulting the patient.

Traditional health care has been based on a paternalistic approach to patients. Many patients are still more comfortable in deferring all decisions about care and treatment to their health care provider. Active involvement by various organizations, agencies, and consumer groups in regard to health care has demonstrated a trend toward the public’s need and desire for more information about health care in general and more information about alternative treatments and providers. Paternalism may always be a possibility in the health care setting, but enlightened consumers are causing a change in this practice.

In the critical care setting, many instances of and possibilities for paternalistic actions by the nurse exist. Postoperative care, which is designed to assist the patient with achieving a quick recovery, is a good example. Encouraging the patient to turn, cough, and deep breathe and increasing the patient’s activity in the form of dangling, sitting in a chair, and ambulating are all paternalistic actions when the patient is experiencing pain and sleep deprivation and wanting to be left alone. However, the benefits and harms sometimes must be balanced. In these instances, the duty to do no harm—which is the next principle to be discussed—takes precedence over the need to avoid paternalistic actions. When ethical principles are in conflict, the nurse must weigh all the benefits and choose the best principle to follow.

Nonmaleficence

The ethical principle of nonmaleficence, which dictates that the nurse prevent harm and correct harmful situations, is a prima facie duty for the nurse. Thoughtfulness and care are necessary, as is balancing risks and benefits, which was discussed earlier. Beneficence and nonmaleficence are on two ends of a continuum and are often adhered to differently, depending on the views of the practitioner.

A practitioner may consider long-term consequences and the good to society as a whole, or the principle and its effect on the single individual in the situation. Such complex problems as quality of life versus sanctity of life are always difficult to analyze in the critical care setting, as well as in noncritical care settings.

Veracity

Veracity, or truth-telling, is an important ethical principle that underlies the nurse-patient relationship. Veracity is important when soliciting informed consent, because the patient needs to be aware of all potential risks and benefits to be derived from specific treatments or their alternatives. The critical care nurse can be in the middle of a situation in which all of the facts and information about a particular treatment option are not disclosed.

Sometimes, information has been given accurately to the patient and family but has been delivered with bias or in a way that is misleading. Veracity must guide all areas of practice for the nurse—that is, colleague relationships and employee relationships, as well as the nurse-patient relationship.

Fidelity

Another ethical principle that is closely related to autonomy and veracity is fidelity. Fidelity, or faithfulness and promise-keeping to patients, is an essential aspect of nursing. The American Nurses Association (ANA) states that this principle requires loyalty, fairness, truthfulness, advocacy, and dedication to our patients. It involves an agreement to keep our promises. Fidelity refers to the concept of keeping a commitment and is based on the virtue of caring.¹¹ It forms a bond between individuals and is the basis of all professional and personal relationships. Regardless of the amount of autonomy that patients have in critical care areas, they still depend on the nurse for many types of physical care and emotional support. A trusting relationship that establishes and maintains an open atmosphere is one that is positive for all involved.

Like all of the other principles, fidelity extends to the family of the critical care patient. When a promise is made to family members that they will be called if an emergency arises or that they will be informed of any other special events concerning the patient, the nurse must make every effort to follow through on the promise. Fidelity upholds the nurse-family relationship and reflects positively on the nursing profession as a whole and on the institution in which the nurse is employed.

Confidentiality is one element of fidelity that is based on traditional health care professional ethics. Confidentiality is described as a right whereby patient information may be shared only with those involved in the care of the patient. An exception to this guideline might occur if the welfare of others would be put at risk by keeping patient information confidential. In this situation, the nurse must balance ethical principles and weigh risks and benefits. Special circumstances, such as the existence of mandatory reporting laws, guide the nurse in certain situations.

Privacy also has been described as being inherent in the principle of fidelity. It may be closely aligned with confidentiality of patient information and a patient’s right to privacy of his or her person, as in maintaining privacy for the patient by pulling the curtains around the bed or making sure that he or she is adequately covered. The ANA summary and principle on privacy and confidentiality are found in Box 2-4.

Box 2-4

Ana Statement on Privacy and Confidentiality

Summary: Advances in technology, including computerized medical databases, the Internet, and telehealth, have opened the door to potential, unintentional breaches of private/confidential health information. Protection of privacy/confidentiality is essential to the trusting relationship between health care providers and patients. Quality patient care requires the communication of relevant information between health professionals and/or health systems. Nurses and other health professionals who regularly work with patients and their confidential medical records should contribute to the development of standards, policies, and laws that protect patient privacy and the confidentiality of health records/information.

Background

Recent developments in technology have changed the delivery of health care and the system used to record and retrieve health information. In addition to using paper medical records, health professionals, hospitals and insurers routinely use computers, phones, faxes, and other methods or recording and transferring information. In many instances, this information—which could include medical diagnoses, prescriptions, or insurance information—is readily available to anyone (including clerical and other staff) who walks by a fax machine or logs on to a computer. This lack of privacy has the potential to undermine patients’ relationships with providers and adversely affect the quality of care. Patients may also fear that the exposure of personal health information, including the results of genetic tests that are becoming increasing available, could result in the loss or denial of health insurance, job discrimination or personal embarrassment.

In keeping with the nursing profession’s commitment to patient advocacy and the trust that is essential to the preservation of the high quality of care patients have come to expect from registered nurses, the American Nurses Association supports the following principles with respect to patient privacy and confidentiality:

• A patient’s right to privacy with respect to individually identifiable health information, including genetic information, should be established statutorily. Individuals should retain the right to decide to whom, and under what circumstances, their individually identifiable health information will be disclosed. Confidentiality protections should extend not only to health records, but also to all other individually identifiable health information, including genetic information, clinical research records, and mental health therapy notes.

• Use and disclosure of individually identifiable health information should be limited.

• A patient should have the right to access his or her own health information and the right to supplement such information so that they are able to make informed health care decisions, to correct erroneous information, and to address discrepancies that they perceive.

• Patients should receive written, easily understood notification of how their health records are used and when their individually identifiable health information is disclosed to third parties.

• The use or disclosure of individually identifiable health information absent an individual’s informed consent should be prohibited. Exceptions should be permitted only if a person’s life is endangered, if there is a threat to the public, or if there is a compelling law enforcement need. In the case of such exceptions, information should be limited to the minimum amount necessary.

• Appropriate safeguards should be developed and required for the use, disclosure and storage of personal health information.

• Legislative or regulatory protections on individually identifiable health information should not unnecessarily impede public health efforts or clinical, medical, nursing, or quality of care research.

• Strong and enforceable remedies for violations of privacy protections should be established, and health care professionals who report violations should be protected from retaliation.

• Federal legislation should provide a floor for the protection of individual privacy and confidentiality rights, not a ceiling. Federal legislation should not preempt any other federal or state law or regulation that offers greater protection.

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