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Recognizing and Addressing Moral Distress in Nursing Practice: Personal, Professional, and Organizational Factors

CATHERINE ROBICHAUX

LEARNING OBJECTIVES AND OUTCOMES

In a 2009 investigation, 71.6% of nurses and physicians from 24 countries reported experiencing an ethical conflict the week before completing the study survey (Azoulay et al., 2009). Current sources of ethical conflict reflect advances in technology, consumers’ expectations of medical care, differing values/goals, poor communication, disruptive provider behaviors, and a business-focused model of health care, among others (Pavlish, Hellyer, et al., 2015). As a nurse, you may encounter such conflicts on a daily basis and believe you know what kind of ethical action is needed, but are unable to act on that knowledge. This inaction may result in feelings of moral distress.

CASE SCENARIO

Despite its apparent prevalence across nursing specialties and among all health care disciplines, both nationally and internationally, moral distress remains a contested concept. For some, the notion of moral distress remains ambiguous and they maintain that further examination will not contribute to quality deliberation or ethical nursing practice (Johnstone & Hutchinson, 2015; Pauly, Varcoe, & Storch, 2012). Others propose that inattention to moral distress among nurses and other providers will continue to result in burnout and/or leaving the profession (Whitehead, Herbertson, Hamric, Epstein, & Fisher, 2015). To bridge this gap, Peter (2015) suggests that our understanding of moral distress has expanded and may serve as a window through which nurses and others can describe the nuances of their ethical experiences. She proposes that perhaps “we have asked too much of this concept [moral distress] by attempting to articulate more about the nature of nurses’ ethical lives than it can reliably hold” (p. 3). Although recognition of moral distress is essential, developing and implementing interventions to reduce its impact is critical. Thus, the purpose of this chapter is to describe the origins of moral distress, its contributing factors, and potential interventions designed to mitigate its deleterious effects on ethical nursing practice.

RESPONSES TO ETHICAL SITUATIONS

Question to Consider Before Reading On

1.   How would you describe Marcia’s initial responses in this situation?

As initially described by philosopher Andrew Jameton in his book, Nursing Practice: The Ethical Issues (1984), and experienced by Marcia in the Case Scenario, moral distress can occur when a nurse or other provider believes he or she knows what ethical action is needed but is unable to act on that knowledge. Recall that in Chapters 1 and 2 we discussed Rest’s four-component model (FCM, 1986) for developing ethical skills or competence in nursing practice: sensitivity, judgment, motivation, and action. Moral distress inhibits or impedes motivation, resulting in inaction. This response to an ethical situation differs from other reactions described by Jameton (1984) and Rushton & Kurtz (2015), moral/ethical uncertainty, dilemmas, and conflicts, presented in Box 4.1.

CASE SCENARIO (CONTINUED)

Box 4.1

Responses to Ethical Situations

Sources: Jameton (1984); Rushton and Kurtz (2015).

As discussed in Chapter 1, an ethical or moral dilemma occurs when there are two competing principles or values that are in opposition to one another. While each option may be ethically viable, only one may be chosen and the nurse may feel that he or she is compromising one value for another. Nursing care situations in which patient autonomy may be compromised to maintain safety and prevent harm are examples of possible ethical dilemmas. Differing values or goals of the organization may also conflict with those of the nurse or other provider. In the Case Scenario, Marcia may feel that her core values of protecting patients and maintaining professional standards conflict with the educational institution’s goal of retaining students.

Providers and others involved in an ethical dilemma may have opposing views about how the situation should be resolved, resulting in moral conflict. As Rushton and Kurtz (2015) observe, conflicts generally arise over disagreements about the goals of care or perceived treatment outcomes. They describe resuscitation status as a decision that may result in conflict among or within health care team members and the patient/family. The decision to resuscitate extremely premature infants provides an example of this potential moral conflict (Molloy, Evans, & Coughlin, 2015). Those involved in the decision may have differing opinions regarding whether the benefits of resuscitation outweigh the risks of possible long-term health issues and compromised quality of life for the infants and families. The intensely emotional nature of such conflicts makes reasoning very difficult. In the communication process necessary to address these ethical conflicts, it is critical that those involved are not required to abandon their core values or professional integrity.

Questions to Consider Before Reading On

1.   How would you define moral distress?

2.   Do you believe you have experienced moral distress?

3.   How did you learn to deal with it in your initial nursing program or in continuing education since you graduated?

DEFINING MORAL DISTRESS

In describing the origins of the concept of moral distress, Jameton (2013) discusses the introduction of bioethics courses in medical school curricula in the 1970s and 1980s. Faculty teaching these courses recognized that nurses and nursing students were very interested in the study of ethics and, consequently, the courses were offered campus wide. Although often labeled “medical ethics,” many more nurses enrolled in these courses than students in other health care professions. While faculty had previously taught major ethical theories and representative dilemmas that highlighted the central role of the physician, the predominance of nurses in the classroom shifted that focus. As a result, Jameton notes, Davis and Aroskar published one of the first modern nursing ethics books in 1978, Ethical Dilemmas and Nursing Practice.

Jameton (2013) observes that nurses in the ethics courses discussed concerns that were practical and relational in nature. As the time period (1970s–1980s) coincided with a beginning interest in feminism and feminist ethics, these concerns also included issues of powerlessness, inequality, and bureaucratic constraints on ethical nursing practice. Although many students had several years of clinical experience, Jameton states “they expressed little confidence in their own views” on ethical issues and expected to “receive little support from physicians or nursing administrators” (p. 298). The concept of moral distress then appeared to represent a more comprehensive depiction of nurses’ moral problems and challenges.

While the original definition of moral distress is credited to Jameton (1984), both he and Fowler (2015) maintain that Kramer’s 1974 work on reality shock in nursing predates his identification of the phenomenon. Kramer’s seminal research explored the transition of recently graduated nurses into the workforce and “the discrepancy and shock like reactions that follow” (p. 19) when they realized that their professional values and identity were not congruent with or supported by the immediate practice environment and/or employing organization. Given the increasing complexity of the current health care environment, many contend that this reality shock continues and is perhaps even more serious today (Dyess & Sherman, 2010; Kramer, Brewer, & Maguire, 2013). This experience of reality shock is reflected in Jameton’s definition of moral distress, “one knows the right thing to do but institutional constraints make it nearly impossible to pursue the right course of action” (p. 6). As Epstein and Delgado (2009) observe, with moral distress, the appropriate or right action has been identified and discussion of the precipitating ethical situation is less critical. Rather, addressing moral distress requires consideration of both personal and professional factors and identification of organizational constraints.

CAUSES OF MORAL DISTRESS

Personal and Professional Factors

While Jameton’s original definition of moral distress focused on organizational constraints on moral action, others propose that personal factors also hinder ethical practice (Epstein & Hamric, 2009; Rushton & Kurtz, 2015; Webster & Bayliss, 2000). In addition to those personal characteristics and internal constraints discussed in Chapter 2, such as individual values, protecting one’s position, or lack of ethical sensitivity, these authors include perceived powerlessness, past experiences, and emotional stability.

Perceived Powerlessness

The often hierarchal nature of the health care system contributes to power differentials based on whose work may be considered more important (Pavlish, Brown-Saltzman, et al., 2015). As a result, nurses may feel that they have little influence on directing patient care or on decision making in general. Implementing the decisions of others while lacking authority and experiencing increased responsibility may contribute to moral distress. In the Case Scenario, Marcia may feel powerless as she is “just a student” and has to adhere to the decisions of the dean and faculty while feeling responsible for the impact of Jackie’s incompetence on present and future patient care.

Past Experiences

In studies exploring moral distress in nursing, several researchers found that those who had been in practice for a longer period experienced more moral distress than those newer to the profession (Epstein & Delgado, 2010; Sauerland, Marotta, Peinemann, Berndt, & Robichaux, 2014; Sauerland, Marotta, Peinemann, Berndt, & Robichaux, 2015). As those past experiences causing moral distress may recur, nurses can have a “here we go again” response associated with dread, helplessness, and disengagement. These recurrent ethical situations may or may not be resolved and the painful feelings linger, resulting in moral residue. As defined by Webster and Bayliss (2000), moral residue is “that which each of us carries with us from those times in our lives when in the face of moral distress we have seriously compromised ourselves or allowed ourselves to be compromised” (p. 208). Frequent situations associated with moral distress and residue include providing aggressive, prolonged futile care, working with incompetent clinicians, and conflicts with other health care providers (Hamric, Borchers, & Epstein, 2012; Sauerland et al., 2014, 2015; Whitehead et al., 2015).

While nurses and other providers who have been practicing longer may have higher levels of moral distress, those newer to the profession may also be susceptible to its damaging effects. Indeed, the resulting “reality shock” and moral distress experienced by novice nurses have been identified among undergraduate nursing students who report witnessing poor nursing practice and experiencing bullying from preceptors (Grady, 2014; Sasso et al., 2015; Yoes, 2012). Students and recent graduates may not have sufficient experience and coping skills to address such morally distressing situations and/or may not be aware of existing resources to assist them.

CASE SCENARIO (CONTINUED)

Emotional Stability

Rushton and Kurtz (2015) state that a nurse’s ability to remain mentally and emotionally stable in morally distressing situations may also be a factor in his or her experience of moral distress. Feeling helpless or unable to act in these circumstances can initiate stress responses such as “fight (anger), flight (abandonment), or freeze (numbing)” (p. 13). The fact that nurses are expected to be stoic and endure without overt reaction may add to these overwhelming stress responses. The experience of emergency department (ED) nurses working in resuscitation rooms provides a graphic example of struggling to maintain emotional control in these situations.

Houghtaling (2012) describes the moral suffering of nurses in the ED, who often witness unnecessary suffering and must perform painful procedures while “literally holding themselves together”: “When seconds are all these nurses have, there is no time to premeditate or look inward; they must perform—whether or not they agree with the care practices that are carried out in the situation immediately unfolding around them” (p. 235). The stress and pressure to endure in such scenarios may cause the nurse to vent his or her frustration on another staff member and/or experience moral distress and moral residue. Houghtaling suggests that when nurses learn to recognize highly volatile and morally, ethically charged dilemmas, they may become more effective in finding skills within themselves to maintain a sense of well-being and balance. Strategies to increase resilience and mental/emotional stability when experiencing moral distress are discussed in the section on addressing moral distress.

Organizational Factors

Question to Consider Before Reading On

1.   How would you describe the ethical climate in the organization in which you currently work or have worked in the past?

Ethical climate is described as the organizational conditions and practices in which problems with ethical implications are identified, discussed, and decided (Olson, 1998). As discussed in Chapter 2, moral distress can be exacerbated in organizations with a deficient ethical climate. Fear of reprisal for actions and/or limited access to ethics resources when dealing with ethical situations can result in moral distress. Additional institutional factors include lack of ethical, supervisory support, inadequate and/or incompetent staff, excessive workloads, and bullying, lateral violence, incivility, and workplace violence (Hamric, 2014; Whitehead et al., 2015). These organizational influences may create sources of moral distress and inhibit its resolution. Several of these factors are discussed in more detail as follows.

Lack of Ethical, Supervisory Support

Question to Consider Before Reading On

1.   What level of ethical, supervisory support have you received where you are currently employed or have been employed in the past?

Effective, supportive leadership is essential to ethical nursing practice and is associated with a healthy work environment, improved patient safety and satisfaction, and decreased nurse turnover (Laschinger & Smith, 2013; Zook, 2014). Lack of such leadership can contribute to or directly cause moral distress (De Veer, Francke, Struijs, & Willems, 2013; Galletta, Portoghese, Battistelli, & Leiter, 2013). As noted previously, if the nurse feels that he or she will not be supported when speaking up in an ethical situation, patient safety may be compromised and nurse moral integrity impaired.

While supportive, ethical leadership has been examined extensively in the business literature, it has received far less attention in nursing (Makaroff, Storch, Pauly, & Newton, 2014; Storch, Makaroff, Pauly, & Newton, 2013). Although leadership theories discussed in nursing contain moral components and behaviors, ethical leaders focus explicitly on ethical obligations and guidelines and hold others accountable to do the same. Thus, their potential impact goes beyond simply increasing sensitivity to ethical issues and standards. Peers and employees trust ethical leaders and display more positive attitudes and greater job performance because of this heightened trust. In addition, these nurse leaders may influence the ethical conduct of others by modeling critical thinking and action regarding situations with ethical content (Zheng et al., 2015). The importance of ethical, supervisory support and leadership to ethical nursing practice is discussed more fully in Chapter 10.

CASE SCENARIO (CONTINUED)

Inadequate and/or Incompetent Staff

Questions to Consider Before Reading On

1.   Have you ever worked with incompetent staff?

2.   What was the outcome?

3.   Use the Box 4.2 to assess any personal, professional, or organizational factors that are present where you are employed that may lead to moral distress.

Several studies that have used the original Moral Distress Scale (MDS; Corley, Elswick, Gorman, & Clor, 2001) or the revised version (MDS-R; Hamric et al., 2012) or a qualitative, open-ended survey reported that nurses and other providers identified working with inadequate and/or incompetent staff as both highly distressing and occurring frequently (Sauerland et al., 2014, 2015; Wilson, Goettemoeller, Bevan, & McCord, 2013). In addition, research participants described providers who offered less than optimal treatment that did not meet the standard of care, witnessing poor patient care because of inadequate staff communication. Despite the prodigious amount of research documenting the direct relationship between inadequate registered nurse staffing and poor patient outcomes and increased mortality, this issue remains an ongoing concern (Dent, 2015; Needleman, 2015; West et al., 2014). As discussed in Chapter 10, the American Nurses Association (2012) and several specialty organizations (Thompson & Davidson, 2014) have proposed guidelines and strategies for adequate and competent nurse staffing. In addition, federal legislation regarding safe nurse staffing is presently under review in the U.S. Senate (Registered Nurse Safe Staffing Act of 2015).

Continued work is needed to develop an optimal staffing model that integrates site specific variables such as acuity, provider preparation, and the relational work of nursing, among other factors (Malloch, 2015; Needleman, 2015). As Malloch observes, much of the work of nursing is relational and therefore difficult to measure and integrate in a staffing model. In addition, nursing requires critical thinking, the synthesis of disparate data items, teamwork coordination around episodes of patient care, and ensuring safe navigation through the health care system. This complexity requires not only innovative measures, but new classifications of the work of nursing (Archibald, Caine, & Scott, 2014). Meanwhile, nurses may remain caught between their obligations to care for a potentially unsafe number of patients and maintaining their professional and ethical integrity. The Code of Ethics (2015a) is explicit in identifying the frontline nurse and nurse administrator’s responsibility to take action in situations of incompetent or unsafe care (Box 4.2). Developing and contributing to moral environments that support and encourage such action is essential to ethical practice.

Box 4.2

Recognizing and Addressing Moral Distress in Nursing Practice: Personal, Professional, and Organizational Factors

Source: ANA (2015a).

Bullying, Lateral Violence, Incivility, and Workplace Violence

Question to Consider Before Reading On

1.   What types of bullying, lateral violence, incivility, and/or violence have you witnessed or experienced in your work place?

Rushton and Kurtz (2015) suggest that nurses’ support or lack of support for one another can affect the level of moral distress in the health care environment. The complexity of patient care demands that all health care professionals work together collaboratively as a team; however, that is often not the reality. The old adage of “nurses eat their young” still exists and, sadly, remains quite robust. Indeed, the health care professions have one of the highest levels of bullying in the workplace (Farouque & Burgio, 2013) and with incivility, and lateral violence behaviors, contribute to and result in moral distress. It is difficult to find a recent professional journal in any health care discipline that does not contain an article on these and other disruptive behaviors, their effects on the quality of patient care, and the morale of providers (Fink-Samnick, 2015; Trossman, 2015; Van Norman, 2015).

The terms bullying, lateral or horizontal violence, and incivility are often used interchangeably. Although there are commonalities among these behaviors, there are also differences. Bullying is repeated, long-term, health-harming mistreatment of one or more persons by one or more perpetrators and is marked by behavior that is threatening, humiliating, or intimidating. Bullying can be a reflection of the hierarchal system in health care and other organizations in which those who occupy higher levels or are more experienced bully individuals who are new and/or at lower levels. Recent graduates continue to be victims of bullying despite overwhelming evidence that these behaviors contribute to moral distress, turnover, and leaving the profession. In addition, as seen in Box 4.2, bullying and other destructive conduct are a direct violation of the Code of Ethics and countermand Quality and Safety Education for Nurses (QSEN) competencies associated with teamwork and collaboration (Box 4.3).

Lateral or horizontal violence is described as “Unkind, discourteous, antagonistic interactions between nurses who work at comparable organizational levels and commonly characterized as divisive backbiting and infighting” (Alspach, 2007, p. 13). While behaviors associated with lateral violence, such as sarcastic comments and withholding support, are similar to those used in bullying, the perpetrator and victim are at comparable levels in the organization or unit.

The prevalence of bullying and lateral violence behaviors in nursing has been attributed to prior victimization and oppressed group theory, among other reasons. Being the recipient of such destructive conduct may cause the nurse to retaliate in kind with a peer or other employee, thus continuing the cycle of victimization and moral distress. Oppressed group theory proposes that people who are victims of a situation of dominance turn on each other rather than confront the system, which oppresses them both. If the nurse in these situations is unable to speak up because of fear of retribution and is forced to work under such duress, he or she may experience moral distress. Dellasaga and Volpe (2013) note that those who repeatedly witness bullying and lateral violence may also experience moral distress if they are reluctant to intervene for fear of becoming a victim themselves.

Disrespectful and uncivil interactions in health care not only contribute to an unethical, morally distressing environment but also jeopardize patient safety. For example, a new graduate makes a medication error because he or she did not want to clarify the dosage with his or her preceptor for fear of being ridiculed again. Dr. R. continually berates and intimidates the perioperative staff, “fostering an atmosphere in which medical errors become more likely and interpersonal interactions erode the primary goal of putting the patients’ welfare foremost” (Van Norman, 2015, p. 215). Studies have reported startling statistics indicating a direct relationship between these egregious behaviors, adverse events, and staff turnover. In Rosenstein’s (2010) survey of over 4,500 respondents (nurses, physicians, pharmacists, and administrators) from more than 100 hospitals, 67% identified a strong relationship with adverse event occurrence, while 27% felt that the behaviors contributed to patient mortality. Rawson, Thompson, Sostre, and Deitte (2013) estimated that in a 400-bed hospital, the combined costs of disruptive physician behaviors resulting in staff turnover, medication errors, and procedural errors exceeded $1 million annually. According to a recent national survey (Nursing Solutions Incorporated, 2016), the average cost of turnover for a bedside registered nurse ranges from $37,700 to $58,400, resulting in the average hospital losing $5.2 million to $8.1 million.

Box 4.3

Recognizing and Addressing Moral Distress in Nursing Practice: Relevant QSEN Competencies

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Teamwork and Collaboration

Definition: Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care.

Act with integrity, consistency, and respect for differing views. (Skills)

Appreciate importance of intra- and interprofessional collaboration. (Attitudes)

Value the perspectives and expertise of all health team members. (Attitudes)

Initiate actions to resolve conflict. (Skills)

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