Moral Distress: What It Is And What To Do About It
Nurses have to make decisions all the time and situations arise where decisions on what to do can feel daunting, especially when they feel unethical. How do you cope with taking actions you may be uncomfortable with, but are either asked or required to take? Director of ANA’s Center for Ethics and Human Rights, Liz Stokes, PhD, JD, MA, RN, explains how moral distress affects us and how to work through it.
What is moral distress?
Moral distress is the emotional state that arises from a situation when a nurse feels that the ethically correct action to take is different from what he or she is tasked with doing. When policies or procedures prevent a nurse from doing what he or she thinks is right, that presents a moral dilemma. This conundrum, dubbed “moral distress,” can make nurses feel powerless, anxious, and even depressed.
Often times, nurses spend several hours a day with patients and families. They experience the joy, but also the suffering and stress that sickness can cause them,” says Stokes. “The intimate nature of the nurse-patient relationship contributes to the prevalence of moral distress.”
When do nurses experience it?
Nurses can experience moral distress in any setting, but those who work in intensive care, emergency room, or operating room settings feel it the most. Here are a few situations in which moral distress can occur:
- A school nurse suggests a course of treatment for a sick student, but the child’s family can’t afford treatment or refuses to take the student to the doctor.
- A critical care nurse is asked to perform a painful procedure that the nurse feels may cause more harm than good on a patient who has a poor outcome for survival.
- A nurse educator may determine that a nursing student about to graduate is not eligible to pass a particular course, which could cause him or her to fail the program and reflect poorly on the school.
Symptoms of moral distress
Moral distress is an issue that affects emotions and can cause anxiety, but there are physical symptoms as well, including:
- Gastrointestinal issues
Once nurses identify moral distress, Stokes says they’re better equipped to overcome it. Coping with moral distress includes cultivating both moral courage and resilience:
- Moral courage is developing the strength to speak up despite the fear of repercussions.
- Moral resilience is the internal capacity that nurses have to restore and sustain their personal integrity in response to moral distress.
How to cope
“When nurses experience moral distress, it's important that they feel supported. They have to be able to address the issue in a safe and nonjudgmental space. That’s going to vary on the individual level,” says Stokes.
Depending on the organization, nurses may be able to reach out to their ethics committee or even page an ethicist when a moral distress situation arises. These trained ethicists can help nurses find their voice and talk through their feelings and symptoms.
“Speaking to an expert or ethicist will not change the outcome of the situation,” says Stokes. For example, if a physician makes a determination that a patient needs a particular treatment, that decision may stand. “However, the moral distress consult may help mitigate the nurse’s symptoms, help the nurse develop resilience, and strengthen their ethical confidence to deal with these feelings. It’s important to build that resilience, since morally distressing situations are part of the profession,” says Stokes.
Nurses can also use the American Association of Critical-Care Nurses (AACN) Framework. It includes four A's.
- Ask yourself, "Am I feeling distressed or showing signs of suffering?"
- Affirm it. You may say to yourself, “Yes, I’m feeling this distress and I'm going to make a commitment to address it."
- Assess your ability to make a change. Ask yourself, "What can I do personally? How can I contribute if this is organization wide? How can I contribute to my organization to try to mitigate moral distress?" Do a deep dive to understand the root causes of the distress.
- Act. Take personal responsibility to try to implement the changes that you desire.
Stokes also recommends that nurses take a look at their code of ethics if they’re not sure how to respond to a particular situation. You also may find comfort in The Moral Distress Education Project. The University of Kentucky interviewed moral distress experts from across the U.S. in short documentary-style videos. The goal of the project is to elevate the understanding of moral distress and to help viewers of the videos process their own experiences.
Do you remember a time you’ve struggled with moral distress? Tell us about it in our discussion or post in our private Facebook group.
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American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive Statements.
McCue, C., MS, RN, CNE. (n.d.). Using the AACN Framework to Alleviate Moral Distress.
Welcome to the Moral Distress Education Project. (n.d.).