1. The Challenge of Moral Distress in Nursing
Nekeisha Dacres
Florida Atlantic University

2. Moral distress has two parts
Jameton (1984) defined “moral distress” as a concrete phenomenon in which one knows the right action to take, but is constrained from taking it.
Moral distress has two parts
Initial distress: occurs as the situation unfolds
Reactive distress: also known as “moral residue”, the situation has ended but the distress remains
What is Moral Distress?
(Jameton, 1984)

3. Background: Moral Distress
Trademark of moral distress is the manifestation of constraints either internal (personal) or external (institutional) that prevents one from taking action that one perceives to be morally right.
Moral distress is the result of a perceived violation of one’s core values
Congruent with feelings of being constrained from taking ethically appropriate action
Background: Moral Distress
(Epstein & Hamric, 2009)
Moral distress manifests itself in individual variations
Psychological characteristics involve frustration, anger, guilt, anxiety, withdrawal, and self blame
There is a direct correlation between shifts in the institutional ethical climate and moral distress in nursing

4. The Problem of Moral Distress
The problem of moral distress indicates that there is a lack of meaningful ethical discussion that includes all perspectives and stakeholders.
Resulting in morally distressed nurses behaving in an ethically inappropriate manner because their views are not respected
According to Epstein and Hamric (2009), nurses experiencing moral distress may respond in certain ways
Lack of engagement: negative perception of institutional climate
High nurse turnover: change positions/ lack of retention
Advocates for change: continue to raise objections and voice concerns about situations
Burnout: leading to safety issues such as medication errors
Withdrawal of self from patients impacting their level of care, decisions to stay in nursing, or leave the profession
The Problem of Moral Distress
(Epstein & Hurst, 2017)

5. Researchers have shown that moral distress is a wide spread problem for all health care providers including nurses, pharmacists, social workers, and physicians in a wide range of acute and community health care setting
Hanna (2004) suggested that successful management of moral distress can be an opportunity for personal change and growth
Hamric (2010) observed that nurses are in less powerful positions in the health care hierarchy, so it may be that the phenomena of moral distress has emerged as a focus of concern because nurses are often conceptualized as victims
Specific situations that give rise to moral distress vary based on position and profession; and the extent and degree of moral distress experienced varies across disciplines (Brazil, Kassalainen, Ploeg, & Marshall, 2010)
Rodney and Street (2004) found that nurses often found it difficult to enact their professional and ethical values as a consequence of constraints within their practice environments
Perceptions of moral distress have been found to vary with perceptions of the ethical climate (Corley, Minick, Elswick, & Jacobs, 2005)
McCarthy and Deady (2008) cautioned researchers to differentiate moral distress from emotional distress which may occur in a stressful work environment but may not have an ethical element.
Recommendations both to support individual abilities to cope with moral distress and to improve health care environments through strategies aimed at ethics education and the provision of ethics resources
Literature Review
Performed literature search of over 510 articles and reviews using CINAHL.

6. Nursing Situations: Sources of Moral Distress
Continued life support that is not beneficial to the patient
Lack of communication about end of life care between providers, patients, and families
Inappropriate use/lack of healthcare resources
Inadequate staffing
Inadequately trained staff
Inadequate pain relief provided to patients
False hope given to patients and families
Concierge care: value placed on financial gains from patients rather than equal accessibility of resources
Nursing Situations: Sources of Moral Distress
(Pauly, Varcoe, & Storch, 2012)

7. Measuring Moral Distress
Moral Distress Scale (mds)
Prior to the development of the Moral Distress Scale, no scale existed to measure moral concepts
Based on Jameton’s (1984) conceptualization of moral distress guiding the development of the moral distress scale
MDS consists of 32 items in a 7-point Likert format; a higher score reflects a higher level of normal distress.
Measuring Moral Distress
(Corley, Elswick, Gorman, & Clor, 2001)
Revised Version of Moral Distress scale (mds-r)
Composed of three main categories of root causes:
clinical situations (e.g. continuing to provide aggressive care in situations of futility, providing care not in the patient's best interest and working with incompetent care providers)
internal constraints (e.g. perceived powerlessness, lack of assertiveness)
external constraints (e.g. power hierarchies or institutional policies)
(Lusignani, Giannì, Re, & Buffon, 2017)

8. Addressing Moral Distress
The American Association of Critical Care Nurses (AACN, 2005) has targeted moral distress as a priority and has developed the 4 A’s approach to address and reduce moral distress.
The 4 A’s are adaptable and applicable in many non-critical care settings.
ASK
Review the definition and symptoms of moral distress and ask yourself whether what you are feeling is moral distress. Are your colleagues exhibiting signs of moral distress as well?
AFFIRM
Affirm your feelings about the issue. What aspect of your moral integrity is being threatened? What role could you (and should you) play?
ASSESS
Begin to put some facts together. What is the source of your moral distress? What do you think is the “right” action and why is it so? What is being done currently and why? Who are the players in this situation? Are you ready to act?
ACT
Create a plan for action and implement it. Think about potential pitfalls and strategies to get around these pitfalls.
(American Association of Critical Care Nurses, 2005)

9. Strategies to Reduce Moral Distress
Identify the problem, gather the facts, and voice your opinion
Speak up!
Know who you need to speak with and know what you need to speak about
Be deliberate
Sometimes, our actions are not quite right. Be ready to accept the consequences
Be accountable
Find colleagues who support acting to address moral distress. Speak with one authoritative voice.
Build support networks
It’s not usually the patient, but the system, that needs changing.
Focus on changes in the work environment
Attend forums and discussions about moral distress
Participate in moral distress education
Multiple views and collaboration are needed to improve a system, especially a complex one, such as a hospital unit.
Make it inter-disciplinary
Finding the common causes of moral distress
Find root causes
Develop policies to encourage open discussion and the initiation of ethics consultations.
Develop policies
Train nursing staff to recognize moral distress, identify barriers to change, and create a plan for action.
Design a workshop
Strategies to Reduce Moral Distress
(Epstein & Delgado, 2010)

10. Implications for Nurse Leaders
According to Edmondson (2015) most literature is lacking pertaining to nurse leaders' preparation to lead in a morally courageous and transformational manner in current corporate environments and hierarchies of healthcare
Nurse leaders need education on how to be morally fit both to lead and to create an environment for morally courageous actions to emerge (Edmondson, 2015)
More research is needed on moral distress in nursing leadership and how they can effect the structural climate through education and innovation
Discussions may include internal/external influencing factors, participant/observer emotions, a learning environment, a strong ethics foundation, and an environment where leadership promotes courageous acts and are recognized and rewarded.
Healthcare systems today are in need of moral leadership
As nurse leaders in the healthcare system we need to demonstrate moral courage and create environments that promote morally courageous acts
Implications for Nurse Leaders

11. Moral distress occurs when a situation unfolds where one knows the right action to take, but is constrained from taking it.
The problem of moral distress is that it violates the core values of an individual and leaves incongruent feelings which can result in lack of engagement, high nurse turnover, and burnout.
Literature reviews have shown that moral distress is a wide spread problem for all health care providers including recommendations both to support individual abilities to cope with moral distress and to improve health care environments through strategies aimed at ethics education and the provision of ethics resources
Strategies to reduce moral distress include effective communication, policy development, ethics education, multidisciplinary collaboration, and identification of root causes
Implications for nurse leaders are to examine the need for education on moral courageousness and finding a forum that encourages morally fit leadership
Moral distress is beneficial in that it opens up the need for professional dialogue to reach a resolution
Conclusion

12. References
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Brazil, K., Kassalainen, S., Ploeg, J., & Marshall, D. (2010). Moral distress experienced by health care professionals who provide home-based
palliative care. Social Science and Medicine, 71, 1667–1791.
Corley, M., Elswick, R. K., Gorman, M., & Clor, T. (2001). Development and evaluation of a moral distress scale. Journal of Advanced Nursing,
33(2), 250–256
Corley, M., Minick, P., Elswick, R. K., & Jacobs, M. (2005). Nurse moral distress and ethical work environment. Nursing Ethics, 12(4), 381–
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Epstein, E. G., & Hamric, A. B. (2009). Moral distress, Moral residue, and the crescendo effect. Journal of Clinical Ethics, 20(4),
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Hamric, A. B. (2010). Moral distress and nurse–physician relationships. American Medical Association Virtual Mentor, 12(1), 6–11.
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Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice-Hall.
Lusignani, M., Giannì, M. L., Re, L. G., & Buffon, M. L. (2017). Moral distress among nurses in medical, surgical and intensive-care units.
Journal Of Nursing Management, 25(6), doi: /jonm.12431
McCarthy, J., & Deady, R. (2008). Moral distress reconsidered. Nursing Ethics, 15(2),
Pauly, B., Varcoe, C., & Storch, J. (2012). Framing the issues: moral distress in health care. HEC Forum, 24(1), 1-11.
Rodney, P., & Street, A. (2004). The moral climate of nursing practice: Inquiry and action. In J. Storch, P. Rodney, & R. Starzomski (Eds.),
Toward a moral horizon: Nursing ethics for leadership and practice (p. 209). Toronto: Pearson Education Canada.