When I think about moral distress, I’d describe it as a gnawing, distraught feeling born of perceived injustice. The underlying catalysts are highly variable and include lack of essential resources necessary to provide the standard of care to patients, interpersonal or inter-professional conflict, especially involving ethically challenging situations with patients, families, providers, or co-workers, as well as errors and disturbing treatment decisions. It encompasses a constellation of emotions that nurses have likely felt since the dawn of our profession. If left to fester without effective intervention, moral distress can lead to disillusionment, disenchantment, and even disengagement with the nursing profession.
Over 30 plus years of practice, I’ve not only observed moral distress in colleagues, but have experienced it personally on several occasions. Until relatively recently, I didn’t have a name for it. My earliest memories of what I’d now term moral distress typically stemmed from being a party to treatment decisions that I simply couldn’t fathom -- they involved care that was either too aggressive (and seemingly abusive) for patients who simply had no hope for any type of recovery, or care that was not aggressive enough in patients who did. These were the days before evidence-based care pathways or palliative care services existed. I felt outraged that the hospital I worked for at that time didn’t seem to address these issues with the medical staff. A nurse, seasonedand hardened by her own years of enduring ethically challenging assignments, brushed off my distress as reality shock. “Just do what’s ordered; that’s our job,” she advised. But my own professional framework wouldn’t allow me to be satisfied with that advice since I felt the patients deserved so much more. As this situation recurred repeatedly, I felt something had to change, but I didn’t know how to affect change at that point in time. Simply being mad wasn’t constructive.
Sadly, the way many nurses, especially ones in their formative years, handle this type of challenge is by jumping ship in their search for calmer seas or greener pastures. The true reality shock, in my opinion, is that no sea is always calm or pasture always greener. The secret is learning how to cope with resilience and fortitude, and at the same time, derive strategies to tackle the root causes of the situations that lead to moral distress in an effective manner.
Mentoring and supportive relationships are essential among colleagues, nursing educators, and leaders to help individuals in the throes of moral distress to sort out their feelings, identify the causative factors, plan the resolution, and regain their own healthy emotional balance. Sometimes employee assistance programs are the best options to help nurses deal with the emotional toll in highly sensitive and confidential matters when discussions with colleagues or leaders wouldn’t be conducive to the open dialogue needed to sort out feelings and develop potential solutions.
For nurse leaders, listening and observation skills are key to identify problem situations and the impact they have on the staff. Ongoing vigilance and diligence are necessary to deal with the issues in our healthcare facilities that cause moral distress in nurses. Frankly, these issues should be very visible in the priority scheme of all healthcare leaders. The solutions aren’t always straightforward, quick or easy, but they are essential to preserving quality and safety in patient care, as well as nursing itself as a long-term career choice.
Linda Laskowski-Jones, RN, MS, ACNS-BC, CEN, FAWM