1. Wallis, Laura


Coping with this rising concern in health care delivery systems.


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According to Ann B. Hamric, associate dean of academic programs and professor in the School of Nursing at Virginia Commonwealth University in Richmond, moral distress occurs when a person's moral integrity is seriously compromised, either because one feels unable to act in accordance with core values and obligations or attempted actions fail to achieve the desired outcome. Each instance of moral distress leaves behind what is known as moral residue-a feeling of having compromised one's values that lingers. When the situation recurs, the residue increases-known as the crescendo effect-often leading to a breaking point. In health care, moral distress can lead to poor patient care, diminished job satisfaction, greater burnout, and more attrition among nurses and other providers.


End-of-life issues are significant flash points for moral distress, says Hamric. "We want to help people recover, manage to live with a chronic illness, or have a peaceful death," she says. But there are situations in which "families want us to aggressively treat their loved one when we believe that treatment is of no benefit. And when we do what the family insists, it feels like we are going against our core values."


Indeed, numerous studies, such as Allen and colleagues' survey study in the July/September 2013 issue of JONA's Healthcare Law, Ethics, and Regulation and several works by Hamric and her colleagues, identify extending life support when it's not in the patient's best interests or carrying out what are perceived as unnecessary tests and treatment as root causes of moral distress.


Changing technology is another contributor. For instance, although they offer great benefits, electronic health records (EHRs) can distract caregivers and take them away from patients, says Cynda Hylton Rushton, professor of clinical ethics at both the Berman Institute of Bioethics and the School of Nursing at Johns Hopkins University in Baltimore, Maryland. And studies such as that by Allen and colleagues mentioned above have indicated that, when used in place of face-to-face discussions between caregivers, EHRs can also contribute to a lack of continuity in care.


"Many nurses struggle with balancing the benefits of and potential for improved quality and length of life with the burdens-the pain, suffering, and morbidity-that may accompany many of our technologic advances and the intense side effects of medications and therapies," says Rushton.


Other common sources of moral distress include poor or inconsistent communication among health care providers, patients, and families; inadequate staffing; and providing inadequate care in order to reduce costs.



In 2005, Rushton worked with the American Association of Critical-Care Nurses in developing the "four As," a mnemonic to help nurses "rise above" moral distress (


* Ask (ask yourself whether you're feeling distressed)


* Affirm (validate your feelings and commit to addressing them)


* Assess (identify sources of distress and determine your readiness to act)


* Act (prepare to act, take action, and maintain the change, to "preserve your integrity and authenticity")



Although created specifically for critical care nurses, the approach is adaptable, and many institutions use it as a resource for dealing with ethical issues.


"The four As were an attempt to provide nurses and nurse leaders with tools to move beyond a sense of powerlessness and victimization to a structured conversation," says Rushton. "They give people a way to process [these difficult cases], and they've been very helpful. But it's not enough yet." She feels nurses now need a broader repertoire of coping mechanisms, including individual and more supportive organizational strategies.



Most successful models for dealing with moral distress are interdisciplinary, with mutual recognition of and respect for the ethical dimensions of care. Memorial University Medical Center in Savannah, Georgia, for example, has a notably successful interdisciplinary approach to moral distress. One of its essential elements is the Bioethics Nurse Liaison Program, spearheaded in 2004 by Mary Ann Bowman Beil, vice president of corporate ethics.


"We wanted to have nurses who were trained in and passionate about ethical issues in units with the highest occurrence of those issues," Beil explained. The team uses a "bioethics trigger system" to identify patients whose cases might present ethical problems early on and equips nurses to address those issues in routine ethical consultations during bedside rounds.


By identifying the triggers, says Beil, "we've automatically opened up a conversation between nursing and physicians," and nurses don't have to struggle so hard to find the right time to bring up the issues.


In addition to engaging in ethical discussions on rounds, the teams on each unit hold weekly meetings in which nurses, physicians, social workers, chaplains, and other health care staff all have voices. Approaching ethical issues as a group derails any antagonism that might otherwise result from ethics discussions.


Across the country in California, Kaiser Permanente San Diego Medical Center's medical bioethics director, Paula Goodman-Crews, has spent the past several years working with nurses to give them a language for speaking about ethical issues and help them be more comfortable doing so. "We were able to measure who was initiating [ethics consults], and most were coming from physicians," she says. "We knew there was a moral distress problem[horizontal ellipsis] but nurses didn't always feel comfortable speaking up." She has seen this pattern change through education (incorporating the four As approach, for example), conferences, and discussions in unit-based team meetings about the ethical dimensions of cases.


In addition to making ethics a regular part of the conversation for nurses, the hospital has also introduced Schwartz Center Rounds-a program from the Massachusetts-based Schwartz Center for Compassionate Healthcare-which are grand rounds-style presentations focused on the human dimensions of caring. A panel comprising a physician, a nurse, and a social worker discusses challenging cases. Research done by the Schwartz Center has shown that this approach improves teamwork and patient safety; diminishes caregivers' feelings of being alone and isolated in care; and improves compassion for colleagues, patients, and families.


A common thread in these programs is the collaborative approach-recognizing that moral distress affects nurses as well as physicians and other health care staff, though perhaps in different ways, and providing opportunities for everyone's voice to be heard and priorities to be taken seriously. Hamric points out the need for caregivers to respect each other's differences in professional obligation and focus: "As a patient, do I want a [physician to be] concerned about my survival? You bet. A nurse to be concerned about my suffering? Yes. But I want them talking to each other so they can come up with a plan that's about me, not criticizing each other."


In the September 2013 issue of the Journal of Palliative Medicine, Rushton and colleagues described a framework for dealing with the detrimental effects of moral distress on clinicians. The authors suggest 13 strategies "that might prevent or transform aversive responses to moral dilemmas and provide the stability to foster principled compassion instead of ungrounded moral outrage." Among those strategies are


* cultivating mindfulness to regulate emotional responses.


* cultivating "compassionate intention" by engaging in practices that encourage kindness, gratefulness, and generosity, among other "prosocial emotions."


* distinguishing yourself from others, such as patients and families.


* refining your moral-reasoning skills.


* taking care of your own basic health and social needs.


* fostering systems within the organization to address ethical dilemmas.



That last strategy is the only one of the 13 that involves the larger system, yet it reinforces the notion that moral distress cannot be dealt with in a vacuum. Although individuals can and should do their best to cope with their feelings of distress, the most encouraging long-term solutions also appear to include institutional approaches that address ethical dilemmas not just theoretically but in real time.-Laura Wallis