The Unnamed Frustration, Fatigue, and Anxiety (1)

Consider these medical situations that nurses have been involved in:

A child is admitted to ER with possible symptoms of abuse. A doctor allows the patient to be discharged despite the nurse’s intuition about the situation. The child returns to the ER 2 days later dead on arrival. (2)

A patient was in severe enough pain to be crying out. Increased ammonia levels caused him mental confusion. The doctors wanted to monitor his mental state and ordered that pain medication be withheld. Twelve hours later he died. (3)

Readers could list many more situations like this in the various settings where nurses practice. These situations involve peers, patients, caregivers, and administration. The resultant feelings of frustration and helplessness have given rise to the term moral distress. Factors included in this phrase are cognitive dissonance, and psychological disequilibrium. But behind those fancy scientific terms lie the real crux of the matter. The nurse feels helpless, angry, and dissatisfied. Moral distress occurs when a nurse reaches a moral decision but is unable to execute her values, training, and knowledge. In other words the nursing goal is stymied and now a less than ideal outcome must be accepted. The nurse is impacted because she/he is the most involved in care, sees the consequences first hand, and because ethics are the basis of the nursing profession.

There are many reasons why a nurse might be unable to carry out maximum nursing care. Some factors are external, some internal. Nurse must collaborate with doctors and other professional colleagues. Nurses must deal with employer policy and sometimes consider cost of care. Another factor contributing to constraint are advances in technology which can increase life expectancy, but also affects the trajectory of chronic disease. Health care is expensive and medical centers have budget requirements which affect staffing levels. Nurses are pressed for time. There could be culture and values mismatch or challenges between patients, caregivers and nurses.

Moral distress in nurses is often created when there are 2 conflicting principles. For example, nurses must often choose between honoring patient autonomy and giving the best nursing care which to some extent relies on patient compliance. What if the patient is non compliant? Nurses must sometimes weigh legality and morality, for example, doctors might order tests because of the perceived possibility of legal action, but the nurse believes they are unnecessary.

Nurse researchers have developed a way to measure moral distress in nurses using the Moral Distress scale. It measures frequency and intensity of moral distress, using a Likert scale of 0-6. The most frequent situation that causes moral distress in nurses is unnecessary patient suffering, or circumstances that constrain action to relieve patient suffering.

One study researched risk factors and early warning signs of situations that could lead to possible moral distress. The researchers reasoned that if the situation could be identified early enough it could be solved in a proactive instead of an after the fact reactive manner. Moral distress in nurses would be avoided and the quality of care would be better. Medical centers would benefit from dealing with moral distress of medical staff to increase the likelihood of better work engagement and job satisfaction.

In the study the risk factors that can lead to moral distress were classified in the following categories: Individual risk factors were patient vulnerability listed as decreased mental functioning or psychiatric condition, elderly or very young, developmentally delayed, English as a second language, no relatives, homeless. End of life, suffering, and failed treatment are also individual risk factors.

Family risk factors can include the family being against the treatment plan, family uncertainty, stubbornness or unrealistic expectations, caregiver disagreement, caregivers not honoring patient wishes, denying comfort care or family indifference.

There are risk factors at the professional level which include team conflict, unethical behavior, over optimism by peers, stubbornness, fear of litigation, ignoring patient wishes or advance directives.

Risks exist at the system level as well with polices either vague or strict, limited resources, and lack of professional collaboration.

Helping nurses identify risk factors and early indicators of situations that could escalate into ethical dilemmas will avert moral distress. As indicated in this space in a previous article, nursing intuition is a scientifically valid phenomenon. Empowering nurses to proactively manage patient situations where moral distress can occur would be beneficial to everyone involved.

The early indications of a possible ethical dilemma are categorized as follows: Signs of conflict, which can include arguing between family members or medical staff, family expressing anger and mistrust of the staff, and nurses objecting to either prescribed treatment or family decisions. Patient suffering is another indication, for example unrelieved discomfort, or pain from different treatments and their complications, anxiety, and labored breathing.

Poor communication and unrealistic expectations from either patient or family are also early indications of possible ethical challenges. Ethical violations include not honoring patient autonomy, right to information, and standard of care. If the patient is treated without respect, or fraud is committed these are also signs of an ethical challenge.

Signs of nurse distress include the nurse believing treatment is futile, expressing concern over patient suffering, feeling powerless in the organizational structure of the medical center, and feeling regret that the nurse didn’t advocate enough for the patient.

Moral distress must be addressed both at the institutional and individual level.  For institutions moral distress is a factor in nurse burnout, turnover, and nurse retention. This can only exacerbate the upcoming lack of health care providers in the near future. But more importantly, moral distress affects nurses’ perception of themselves and the care they provide. Could it alter a nurse’s professional self image?  Can nurses compartmentalize self perception so that moral compromise in one’s professional life does not impact one’s ‘true’ self? Can nurses end up acting for pragmatic reasons alone due to moral distress?

The purpose of this space is always to end on a hopeful note, however. There is hope that nurses are identifying and coping positively with moral distress. Moral distress situations can prompt nurses to take action and become more assertive in changing their workplace to increase understanding of these situations. The self awareness that comes from reflection on one’s practice can lead to professional self development, and strength of character. Of course this is not going to occur without some changes at the employer level. Part 2 will deal with those innovative people and institutions that have pioneered the nursing professional championing ethics in the workplace.

• (1) http://www.nursezone.com/nursing-news-events/more-features/Making-the-Ethics-      Call-Benefits-Nurses-and-Patients_37298.aspx
• (2) Zuzelo P. Exploring the Moral Distress of Registered Nurses Nursing Ethics Vol. 14 No, 3 2007, p 344-359
• (3) Ibid
• Rice E. Determinants of Moral Distress in Medical and Surgical Nurses at an Adult Acute Tertiary Care Hospital Journal of Nursing Management Vol. 16  2008 p 260-373
• Lawrence L. Work Engagement, Moral Distress, Education Level, and Critical Reflective Practice in Intensive Care Nurses Nursing Forum Vol. Vol. 46 No. 4 Oct-Dec 2011 p 256-268