1. Hurst, Daniel J. ThM, MDiv

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Moral distress in healthcare, specifically in nursing, is a growing concern that's been studied at some length, yet more work needs to be done. University of Nebraska Medical Center Professor Emeritus Andrew Jameton originally defined moral distress as knowing the morally correct course of action, yet failing to act. This can be caused by institutional barriers, conflict, not wanting to disrupt the "chain-of-command" by disagreeing with a physician, intimidation, or fear of retribution. However, moral distress doesn't merely have to be a failure to act. Often, it can be caused by a caregiver's unresolved emotions regarding an event.

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Regardless of the cause, moral distress must be addressed. Repeated instances of moral distress can leave what's been termed moral residue-the lingering feelings that persist after a morally troubling situation. This residue can compound, creating a crescendo effect. Methods of alleviating and assuaging moral distress among nurses continue to emerge as the phenomenon is better understood.


Strategies to consider

Moral distress may manifest as anger, feelings of guilt over a situation, exasperation and frustration, depression or anxiety, and a loss of self-esteem. It's also been noted that moral distress can cause physical symptoms, such as headaches or stomach problems. Notably, it's the repetitive nature of morally distressing encounters that leaves nurses vulnerable to moral numbing, withdrawal from ethically sensitive situations, conscientious objection, and burnout.


Consider the following strategies to mitigate moral distress in the clinical setting.


* Talk about it. Organizational leaders must talk about moral distress and its counterpart, moral resilience. Keeping silent and not addressing the issue can cause harm. Research indicates that nurses are truly struggling with ethical issues they regularly encounter, such as end-of-life care, palliative care, communication (or lack thereof) between providers and families, and the use of healthcare resources.


* Foster a culture of reflection, open communication, and acceptance of raising ethical questions. Empowering nurses to speak up and even challenge decisions when appropriate is critical.


* Encourage ethics consults whenever a nurse is struggling with a particular decision or situation he or she has encountered. Many nurses may be unaware of the ethics resources available to them. In a 2012 single-site study of critical care and transitional care nurses (N = 50), participants identified ethics committees and other types of debriefing as resources they'd like available to help mitigate distress.


* Be aware of the American Association of Critical-Care Nurses' 4A's to Rise Above Moral Distress: ask, affirm, assess, act. The 4A's approach is largely a self-assessment tool. The first step is to ask yourself whether you're feeling moral distress, with the goal of raising your awareness of your distress. Second, in the affirm step, you confirm the distress you're experiencing and commit yourself to addressing it. In the assess step, you identify the sources and severity of distress, and your readiness to act. Finally, in the act step, you take tangible steps toward resolution.



With the situations that healthcare providers face on a daily basis, some level of moral distress is inevitable. However, leaving it to linger without properly trying to resolve it doesn't have to be unavoidable. Both proactive policies (such as talking about moral distress upon hire and regularly at workshops or staff meetings) and reactive policies (such as readily available resources for those experiencing moral distress) should be implemented.


More work to be done

Although tools exist to mitigate moral distress in nursing, we must recognize that more research needs to be conducted on their effectiveness and best practice because moral distress is a complex experience. Some empirical research on mitigating moral distress has been conducted; however, the majority of the work has been descriptive and interview- or questionnaire-based.


There are vast opportunities for empirically based research on moral distress, including research on interventions and methods of mitigating distress that promote the caregiver's moral agency and preserve moral integrity. The goal of such research would be to attain best practices for intervening and mitigating moral distress in nursing and throughout the healthcare field so that caregivers can get the assistance they need. We're still a long way from that goal, but the attention that moral distress has garnered over the last decade is an encouraging sign.


memory jogger

To help reduce moral distress, remember the AACN's 4A's.

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consider this

A 6-month old baby boy was born with a rare genetic disorder for which there's no proven therapy that typically leads to death in infancy. As the nurse manager of a pediatric ICU, the patient has been under your care since the second month of his life. Recently, he was placed on mechanical ventilation and the medical team hasn't provided any hope for further treatment to the patient's family. Many of the medical staff members want to terminate life support. However, the parents disagree on a number of treatment issues and wish to continue ventilation, earnestly believing that their child's condition will improve. Nursing staff members are becoming increasingly weary, expressing frustration about the way the case has been handled and uncertainty whether they're helping the patient or causing harm.

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The AACN's 4A's-ask, affirm, assess, act-can be a useful tool in such a situation. First, openly talk to staff members about the situation and ask if they're experiencing distress over the patient's care. Second, staff members who are experiencing distress should affirm it; it does no good to simply suppress the emotions and hope they dissipate. Third, staff members experiencing distress should assess its level. This involves introspection and being honest with oneself. Through this honesty, staff members can then act by seeking out resources to help them through the distress.




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