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As long as healthcare professionals have experienced constraints to acting ethically in everyday practice, they have experienced high levels of stress. It was not until 1984 that the term moral distress was used to describe the inability to translate moral decision-making and choice into action. While the majority of studies of moral distress are found in the nursing literature, we now know that moral distress is experienced, in varying degrees, by all healthcare professionals and with varying consequences. This entry deﬁnes moral distress, moral residue, moral courage, and moral resilience; explores the causes and consequences of moral distress; recommends tools to measure moral distress; and ﬁnally suggests strategies and resources for resolving moral distress and promoting resilience.
If to do were as easy as to know what were good to do, chapels had been churches, and poor men’s cottages princes’ palaces. – Portia, The Merchant of Venice, Act 1, scene 2
It is not uncommon to ﬁnd oneself in an ethically challenging situation where one knows the right course of action but impediments make it difﬁcult or impossible to act in this manner. The situations that give rise to moral distress are many and varied. Reﬂect for a moment on all the parents in refugee camps who know that good parents care for their children but who watch children die everyday of hunger, exposure to the weather, and treatable diseases – because families lack access to safe housing, nutrition, hygiene, and healthcare. Reﬂect on the health leaders in recent West African countries ravaged by Ebola. Many knew what needed to be done to protect the healthy and to care for those who contracted Ebola, but woefully inadequate resources prevented most of these measures from being enacted in a timely fashion. And ﬁnally, reﬂect on the experiences of doctors and nurses working in critical care units who know when it is time for a patient to transition to purely palliative goals but who are forced to continue what are now death-prolonging technologies due to the wishes of the patient’s family who cannot accept that a loved one is dying. In each instance people know what to do but are unable to act on this knowledge. The distress that results is the topic of this research paper .
Philosopher Andrew Jameton (1984) is credited with publishing the ﬁrst deﬁnition of moral distress when he sorted the moral and ethical problems in the hospital into moral uncertainty (where one is unsure of what moral principles or values apply or even what the moral problem is), moral dilemmas (when two or more moral principles apply but support mutually inconsistent courses of action), and moral distress. “Moral distress arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (p. 6). Having spent long hours listening to the narratives of nurses working in a large hospital in the USA, Jameton was struck by the societal and institutional factors that made so many nurses feel powerless to effect right action. The early discussions of moral distress thus centered on questions of accountability and responsibility.
In recent years effort has been taken to distinguish moral distress from more generic experiences of distress, common to many health professionals. Rushton (2006) is careful to state that moral distress occurs when clinicians are unable to translate their moral choices into moral action. Acting in a manner contrary to one’s personal and professional values undermines the individual’s integrity and authenticity. With this deﬁnition of moral distress, the impediments to acting morally may be internal (an individual’s deﬁcient moral agency) or external (Jameton’s institutional constraints).
Internal And External Constraints
Whereas Jameton focused on the institutional constraints that made it difﬁcult for nurses to pursue the right course of action, nurse ethicists Epstein and Hamric (2009) identiﬁed both internal and external constraints (Table 1).
Table 1. Internal and external constraints to ethical practice
A nurse is working on a chronically understaffed oncology unit in a hospital that has frozen hires – even when longtime employees retire. Her workload is usually two or three patients more than best practice dictates. Everyday she has to balance meeting basic patient needs and advocating for patients and families who require a change in the plan of care. Compounding her situation is the fact that nurses who speak up are treated as troublemakers. The prevailing wisdom offered to new staff is not to “rock the boat.” Nurse leadership has a history of not supporting nurses trying to effect change. All of these variables are external constraints that make it difﬁcult for nurses to practice ethically.
A nurse who believes that the plan of care for a patient is no longer meeting the patient’s needs may fail to advocate for the patient because she lacks the courage to confront the attending physician or because she is culturally socialized to follow orders and to not question her physician colleagues. Similarly, a nurse who has stopped caring and now accepts that she is powerless to effect change may feel twinges of distress and regret, but is unlikely to try to advocate for needed change in the plan of care. In each of these situations, internal constraints make it difﬁcult for the nurses involved to translate their moral reasoning into moral action.
Consequences Of Not Addressing Moral Distress
The failure to address moral distress affects all nurses. They lose their capacity for caring, avoid patient contact, and fail to give good physical care; they experience physical and psychological problems and physically withdraw from the bedside, barely meeting the patient’s basic physical needs. Moral distress is a particular type of suffering. Unrelieved moral distress jeopardizes nurses’ sense of self-worth and threatens their integrity: “It is the anguish over the injury or threat to the injury to the self and thus the meaning of the self that is at the core of suffering… Such a disruption may manifest itself as a change in an individual’s relationships, autonomy, image of moral well-being, or character or self-esteem” (Rushton 2006, p. 162).
The costs of unrelieved moral distress are high. Some nurses leave their positions and even their profession. Those who remain in the workplace may experience poor communication, lack of trust, high turnover rates, defensiveness, and lack of collaboration across disciplines. In some cases, nurses experience abusive behaviors, disrespectful communication, or worse. These personal consequences are combined with erosion of team cohesion, intensifying the distress of the situation. Ultimately, as with all unresolved interprofessional conﬂicts, the quality of patient care suffers (Rushton 2006). Ulrich et al. (2007) studied the relationships between ethical climate, ethics stress, and job satisfaction of nurses and social workers and found signiﬁcant correlations between high stress and low satisfaction and commitment.
Moral Residue And The Crescendo Effect
Webster and Baylis (2000) seem to be the ﬁrst ethicists to use the term moral residue. They poignantly describe the experience of compromised integrity that involves the setting aside or violation of deeply held (and publicly professed) beliefs, values, and principles that can sear the heart. “The passage of time may blunt the acute distress, the profound uncertainty and fear, the guilt, the remorse, but our experience suggest that people who have lived through serious moral compromise carry the remnants of the experience for many years, if not a lifetime (p. 223).” Their description of the moral residue experienced by a medical student who was told to repeat a pelvic exam on a patient who was anesthetized in the operating room (she was one of ﬁve students so instructed) is memorable. When asked to describe her experience of being compromised, she replied, “It must feel something like a woman who had been sexually violated. You can’t get rid of the feeling that you are now somehow dirty or unclean. In the deepest part of yourself, you feel you will never be the same and you carry this with you for the rest of your life” (p. 223). Webster and Baylis conclude that the resultant serious moral compromise irreversibly alters the self, “One does not experience serious moral compromise and survive as the person one was” (p. 224). It is the experience of being “dirty or unclean” that Webster and Baylis termed moral residue.
Epstein and Hamric (2009), in an article entitled, “Moral Distress, Moral Residue, and the Crescendo Effect,” aptly describe the experience of healthcare professionals who repeatedly encounter a problematic patient scenario and throw their arms up into the air crying, “Here we go again.” They recognize that previous scenarios have led to unresolved distress and are reluctant to once again walk a path that leads only to moral residue. This is called the crescendo effect. Nurses working in critical care units often experience the crescendo effect. Family members who refuse to believe that a loved one is dying and who fail to authorize a transition to purely palliative goals when this is appropriate create moral distress for professional caregivers. Caregivers who experience this phenomenon frequently complain of the crescendo effect.
Epstein and Delgado (2010) write that the moral residue crescendo occurs after repeated situations of moral distress. Each time such a situation resolves, the level of residual distress increases. “Exacerbating moral residue is the fact that morally distressing problems in a given clinical setting tend to be similar over time. Additionally new situations remind providers of their powerlessness in past situations and the crescendo builds.”
Interestingly, the Canadian nurses who composed Canada’s Code of Ethics for Registered Nurses (Canadian Nurses Association 2008) preface the code with a discussion of types of ethical experiences and situations. Included in this list are ethical problems, ethical or moral uncertainty, ethical dilemmas or questions, ethical or moral distress, ethical or moral residue, ethical or moral disengagement, ethical violations, and ethical or moral courage. The Canadian authors believe that if nurses “can name the type of ethical concern being experienced they are better able to discuss it with colleagues and supervisors, take steps to address it at an early stage, and receive support and guidance in dealing with it (p. 5).” It is important to recognize that if moral distress continues and is unresolved, it leads to moral residue and eventually moral disengagement, all of which compromise valued health outcomes for patients and their professional caregivers.
Cultures That Support Ethical Practice
Corley (2002) nuanced the discussion of moral distress by writing that nurses experience moral distress when nurses know what is best for a patient, but this course of action conﬂicts with what is best for the organization, other healthcare professionals, the family, or society as a whole. Her work on assessing the ethics environment in practice settings focused attention on the need to create and sustain cultures that support rather than hinder ethical practice. In August 2014, 50 nursing leaders came together in Baltimore, MD, for a summit meeting on nursing ethics in the twenty-ﬁrst century. The goals of the summit were to “identify the strategic nursing ethics priorities (clinical practice, education, research, and public policy) for the profession and create a blueprint for the future that key individuals and professional organizations will adopt and implement to build capacity within nursing; create and support ethically principled, healthy, sustainable work environments; and contribute to the best possible patient, family, and community outcomes” (http://www.bioethicsinstitute.org/ nursing-ethics-summit-report). Nurses participating in the summit made promises to carry on this work – to themselves, to each other, and to the profession. It is interesting to read the promises nurses continue to make on this website when they sign the pledge.
Not A Nursing Or A USA Phenomenon
Regrettably, moral distress is not an uncommon experience for healthcare professionals – nurses, doctors, social workers, clergy, and other members of the healthcare team. In one study, one in three nurses experienced moral distress. In another study, nearly half the nurses studied left their units or nursing altogether because of moral distress (Rushton 2006).
Dr. Pauline Chen wrote an article in the 2009 New York Times reﬂecting physicians’ experience of moral distress.
Last month, a physician who serves as an ethics consultant told me about a growing concern in her hospital. Doctors and nurses “feel trapped,” she said, by the competing demands of administrators, insurance companies, lawyers, patients’ families and even one another. “And they are forced to compromise on what they believe is right for patients.” She called the problem “moral distress.” Since that discussion, I have not been able to stop noticing moral distress
Suddenly articles on moral distress in all of the health professions began appearing in both the scholarly and popular literature and in the USA and beyond.
Wiggle ton et al. (2010) published a study of the reasons 64 fourth-year medical students gave for not taking action in the face of distressing situations. Among their reasons:
- Because I wanted to be perceived as a “team player”
- Because I wanted to preserve my relationship with an attending and/or a resident
- Because taking action might have negatively affected my evaluation
- Because I did not want to be disrespectful of my attending and/or resident
- Because I felt that my concerns or questions were due to incomplete knowledge and judgment
- Because I played a subordinate role on the team
Not Limited To Healthcare
Philosopher Andrew Jameton (2013) who is credited with coining the term moral distress recently broadened its application when he wrote that the concept of moral distress can be extended from clinical settings to larger environmental concerns affecting healthcare:
Moral distress – a common experience in complex societies – arises when individuals have clear moral judgments about societal practices, but have difﬁculty in ﬁnding avenue in which to express concerns. Since health care is large in scale and climate change is proving to be a major environmental problem, scaling down health care is inevitably a necessary element for mitigating climate change (Jameton 2013).
Jameton links the distress to those concerned about climate change and healthcare experience to the difﬁculty of ﬁnding forums to discuss these concerns.
Strategies For Addressing Moral Distress
Naming the experience of distress; recognizing that it is a common phenomenon of competent, caring, and responsible humans; and seeking help to resolve the source of the distress build capacity and resilience. At the institutional level, it is helpful to identify mentors and other resources available to individuals experiencing distress. Epstein and Hamric (2009) recommend addressing root causes in institutional or unit cultures that perpetuate moral distress and damage collaboration among team members and developing policies to encourage any provider to raise ethical concerns or initiate ethics consultation.
Today a number of resources are being developed locally and in larger venues to intentionally address moral distress in healthcare. Helft et al. (2009) developed unit-based ethics conversations to facilitate the naming of recurrent sources of distress and conversations about how best to resolve them. The article is distinctive in that very practical suggestions are made about how to facilitate these conversations. The article also demonstrates the need for mechanisms other than traditional ethics consultation services to address sources of distress. Similarly, Epstein and Delgado (2010) describe the moral distress consult service at their institution. This service meets with unit personnel, discusses the issue at hand, and helps the staff to strategize to decrease the current moral distress, to bring attention to the fact that morally distressing situations tend to recur, and to begin to think about how to prevent or reduce future situations.
On a larger scale, Rosenthal and Clay (2015) launched The Moral Distress Education Project, which, as of September 2015, was viewed by over 760 users from 29 different states in the USA and parts of Canada. The aim of the project is to educate, inform, and destigmatize moral distress. The program includes a self-guided web documentary in which core multidisciplinary experts on moral distress were interviewed and multiple resources. It can be viewed at: http://moraldistressproject.med.uky.edu/moral-distress-home
The Moral Courage Conundrum
In recent years an interesting dialogue and debate have begun on the need for moral courage, the commitment to stand up for and act upon one’s ethical beliefs. In healthcare, moral courage entails the willingness to fully support ethical responsibilities essential to professional values. Exemplars of the two positions are nurse ethicists Ann Hamric and Vicki Lachman. According to Lachman (2010), so long as we are human, there will always be a need for moral courage and we thus need to be intentional about developing moral courage. According to Hamric we should all be able to practice in environments where we do not need to be courageous in order to be ethical. Hamric sees telling caregivers that they need to be courageous in difﬁcult circumstances as a backhanded endorsement of oppression (Hamric et al. 2015).
The capacity to recover, adapt, and even thrive in the face of threats, misfortune, or challenging times is termed resilience. Moral resilience is the developed capacity to respond well to morally distressing experiences and to emerge strong. While there are numerous guides about developing resilience, the American Psychological Association’s (2015) ten ways to build resilience are often cited. Included in their list are the importance of cultivating good relationships, accepting that change is a part of living and refusing to view crises as insurmountable, nurturing a positive view of self and taking care of self, and keeping things in perspective. Increasingly healthcare leaders are becoming intentional about cultivating resilience in themselves and their staffs. Wicks and Buck (2013) suggest resilience practices related to self-awareness, alone time, mindfulness, and a healthy sense of perspective, as an essential component of self-care for executives.
Healthcare professionals who sacriﬁce personal and professional values in everyday practice in order to survive do grave harm to their moral integrity and authenticity. The fact that we now have a name for this experience, moral distress, and the residue that accumulate when moral distress is unresolved is moving many to explore options to promote moral resilience. Literally at stake in these efforts are the health, well-being, and integrity of healthcare professionals and the well-being of the patients, families, and communities served.
- American Psychological Association. (2015). The road to resilience. Available at: http://www.apa.org/helpcenter/ road-resilience.aspx
- Canadian Nurses Association. (2008). Code of ethics for registered nurses. Ottawa: Author.
- Chen, P.W. (2009, February 5). When Doctors and Nurses can’t do the right thing. The New York Times.
- Corley, M. C. (2002). Nurse moral distress: A proposed theory and research agenda. Nursing Ethics, 9(6), 636–650.
- Epstein, E. G., & Hamric, A. B. (2009). Moral distress, moral residue, and the crescendo effect. The Journal of Clinical Ethics, 20(4), 330–342.
- Epstein, E.G., & Delgado, S. (2010, September 30). Understanding and addressing moral distress. OJIN: The Online Journal of Issues in Nursing, 15(3), Manuscript 1.
- Hamric, A. B., Arras, J. D., & Mohrmann, M. E. (2015). Must we be courageous? Hastings Center Report, 45(3), 33–40.
- Helft, P. R., Bledsoe, P. D., Hancock, M., & Wocial, L. D. (2009). Facilitated ethics conversations: A novel program for managing moral distress in bedside nursing staff. JONA’S Healthcare Law, Ethics and Regulation, 11(1), 27–33.
- Jameton, A. (1984). Nursing practice, the ethical issues. Englewood Cliffs: Prentice-Hall.
- Jameton, A. (2013). A reﬂection on moral distress in nursing together with a current application of the concept. Journal of Bioethical Inquiry, 10(3), 297–308.
- Lachman, V. D. (2010, September 30). Strategies necessary for moral courage. The Online Journal of Nursing, 15(3), Manuscript 3.
- Rosenthal, M. S., & Clay, M. C. (2015). The moral distress education project. Retrieved from http://moraldistresspro ject.med.uky.edu/moral-distress-home. Accessed 17 Sept 2015.
- Rushton, C. H. (2006). Deﬁning and addressing moral distress: Tools for critical care nursing leaders. Advanced Critical Care, 17(2), 161–168.
- Ulrich, C. M., O’Donnell, P., Taylor, C., Farrar, A., Danis, M., & Grady, C. (2007). Ethical climate, ethics stress, and the job satisfaction of nurses and social workers in the United States. Social Science & Medicine, 65, 1708–1719.
- Webster, G., & Bayliss, F. (2000). Moral residue. In S. Rubin & L. Zoloth (Eds.), Margin of error: The ethics of mistakes in the practice of medicine. Hagerstown: University Publishing Group.
- Wicks, R. J., & Buck, T. C. (2013). Riding the dragon: Enhancing resilient leadership and sensible self-care in the health care executive. Frontiers of Health Services Management, 30(2), 3–13.
- Wiggleton, C., Petrusa, E., Loomis, K., Tarpley, J., Tarpley, M., O’Gorman, M. L., & Miller, B. (2010). Medical students’ experiences of moral distress: Development of a web-based survey. Academic Medicine, 85(1), 111–117.
- Edmonson, C. (2010, September 30). Moral courage and the nurse leader. OJIN: The Online Journal of Issues in Nursing, 15(3), Manuscript 5.
- Pavlish, C., Brown-Saltzman, K., Hersh, M., Shirk, M., & Nudelman, O. (2011). Early indicators and risk factors for ethical issues in nursing practice. Journal of Nursing Scholarship, 43(1), 13–21.
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