The Silver Lining of Moral Distress: An Opportunity For Progress in Patient Care

Every day nurses make decisions regarding patient care. Nurses want to relieve patient suffering, provide useful care, and be an advocate for their patients. They want to do these to the best of their ability, knowledge and caring.

Yet often nurses are prevented from reaching their ideal level of care by circumstances not of their own making. Some researchers have suggested that one component of moral challenges is conflict, whether that conflict is internal or between two or more parties. Conflict is such an important factor in health care that the Joint Commission has made conflict resolution a priority in improving the quality of patient care. For example, a nurse must discontinue care because of hospital policy when the patient cannot pay. What about nurses who assist a doctor in medical procedures when the doctor has not obtained informed consent? There have also been cases where a nurse’s clinical judgment has not been taken into account when the patient’s condition was deteriorating. The result of the inaction of the other medical staff has caused medical emergencies. How does the nurse feel in a situation like that?

These ethical challenges and unresolved conflict cause nurses moral distress, which can be on their minds for years after the situation has passed. Nurses have various ways of coping with moral distress such as getting angry, blaming themselves or their bosses, switching units or employers, working less hours, getting a position where they are not involved with patients, or quitting. None of these are helpful to anyone. Yet there are examples in the health care system where recognition of moral distress in nurses has led to progress in patient care. In response, what innovations have medical centers put in place? It starts with productive collaborative communication among all stakeholders. Nurses have reported less moral distress in medical centers that have structures in place that allow nurses to communicate concerns before they become a moral dilemma or challenge. If there is dedicated time after a situation where nurses can debrief, discuss, and reflect this goes a long way towards relieving moral distress. Another important avenue is to include nurses in the planning of the workflow to help prevent moral challenges and detect situations that could lead to conflict. A significant number of these problems arise due to organizational barriers that nurses must work around, for example, staffing levels and staff composition.

 Some medical centers have established nurse manager support. Nurse managers can be critical in helping nurses deal with moral distress if they are properly trained and have experience. Some workplaces have established ethics committees which include different members of the care team. Typically these committees deal with the most challenging and difficult cases. Some medical centers have created a nurse ethicist position.

One innovation that other employers could benefit from studying is the partnership created by Clarian Health, Indiana University School of Nursing, and the Fairbanks Center for Medical Ethics. In 2006 they decided to combine their resources to create a program in nursing ethics that would operate in their hospitals, provide education to upcoming nurses, and conduct research as well. They created a nurse ethicist position.

 This position allows a bridge between nurse and leaders in administration. The program ensures that nurses are able to access the attention and resources they need to provide ethical care. This journey begins with helping nurses at the bedside recognize and cope with ethical conflict and moral distress.

 The clinical component of the program has two parts, a formal structure of the nurse ethicist being part of the ethics committee which provides follow up for nurses who were involved with ethics consultation. There is also the subcommittee which nurses can consult less formally to help them cope with peer interaction or moral distress, and to obtain ethical advice. Nurses can also access a monthly column in the nursing newsletter. Every other month they can submit questions. This column also might report on informal discussion with nurses. The other month of the bimonthly rotation deals with workplace policies that have an ethical component.

 The nursing ethics program also includes a fellowship program that the staff can participate in which is open to all staff. The focus of the fellowship is clinical ethics. Each year six applicants are chosen for the nine month part time program.

 The program also created unit based Ethics Conversations. These Conversations are a therapeutic space where discussions are facilitated on ethical dilemmas. These conversations are where participants can gain confidence in their ability to positively cope with ethical challenges. This is a key pillar of the program to give nurses the tools to cope independently when these situations arise to help them become self sufficient in resolving moral distress.

 The nurse ethicist also follows up with new nurses shortly after they are hired in the form of journal clubs and in services. Examples of the topics chosen by nurses for these in services are dealing with a noncompliant patient, advance directives, and whether family should be present during CPR. Reaction to the program has been so positive that Clarian Health had their first nursing ethics conference which also had positive feedback. The nurse ethicist is also responsible for evaluating nursing ethical health system wide, through surveys and interviews. Part of this evaluation includes assessing how much moral distress nurses experience and the power and authority dynamics of nurse doctor relationships.

 Nurses who take action as opposed to not doing anything will experience less moral distress. Successful resolution of moral dilemmas can lead to a strengthening of character and professional values, and a sense of accomplishment. Successful resolution can also help a nurse become more aware of their own values and increase determination which can lead to personal and professional growth. It is important to view ethical dilemmas as learning opportunities and to find meaning in them. Of all medical professionals, nurses are in the best position to initiate closure, progress, and resolution in these situations to gain insight for the future. The employers that support nurses in this endeavor will provide the best care. The nurse administrator can both encourage nurses to bring up ethical concerns and provide crucial insight into the daily challenges that nurses face at the bedside. Organizational culture can support nurse advocacy. Employers that assist nurses to use the language of ethics in manner that fosters progress in nursing care will be the leaders in patient care quality.

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