Nurse’s moral integrity is threatened by the devastating

phenomenon of ‘moral distress’. 80% of RN’s

experience moral distress (Corley, 2002). The major

ethical dilemma for RNs is that they are unable to

practice nursing (Curtin in Peter & Liaschenko, 2004).

Purpose of Presentation:

·          Examine concepts within moral distress

• Discuss impact & resolution of moral distress/residue

Vignettes:

1.       Due to a heavy patient load, the palliative nurse does

       not have to time to companion her patient in his

       spiritual pain.

2.       Teary-eyed, the nurse recollects an event years ago.  An

        ICU patient was transferred to the unit due to ICU bed

        shortages. The nurse expressed her fears & concerns

        re: lack of expertise & equipment in the event of a crisis

        to the unit manger and ICU.  ICU nurses labeled the

        nurse as a “whiner”. An emergent situation did arise

        & the nurse was unable to resuscitate the patient. The

        patient died needlessly.

3.       The new long-term care nurse witnesses abuse of the

        geriatric patients; the manager ignores her concerns.

Definitions:

·          Moral integrity – “a focal virtue that relates to soundness,

Reliability, wholeness, an integration of character, and

Fidelity in adherence to moral norms” (Burkhardt & Nathaniel,

1998, p. 391)

·          Moral distress – “the reaction to a situation in which there are

moral problems that seem to have clear solutions, yet one is

unable to follow one’s moral belief because of external

constraints” (Burkhardt & Nathaniel, 1998, p. ??)

·          Moral residue – carry with us a time of moral distress that

one compromised oneself or allowed oneself to be comprised.

(CNA, 2003).

·          Moral outrage – emotional turbulence and rage when an

Attempt to solve the moral problem is denied to preserve

The status quo of submarginal performance (Johnstone, 1999).

Moral Distress Model

Corley, M. (2002). Nurse moral distress: A proposed theory &

Research agenda.  Nursing Ethics, 9(6), p. 644.

Picture of boxes with words “figure 1 model for a theory of moral distress”

Sources of Moral Distress

Preconditions:

1.       Sensitive to patient vulnerability, lack autonomy,

        disregard patient choice

2.       External factors prevent what think is best

3.       No control over situation

4.       No regards to patient personhood

Examples:

·          Powerlessness due to low level in hierarchy

·          Nurse-patient relationship devalued

·          Clash with institutional policies, corporate values

·          Lack staff ,resources & legal support

·          Cost containment

·          Personal inhibition, fear judgment of others

·          Lack interdisciplinary recognition & collaboration

(Austin, Bergum & Goldberg, 2003; Burkhardt & Nathaniel, 1998; CNA 2003,

 Corley, 2002; Georges & Grypdonck, 2002;Lutzen, Cronqvist, Magnusson &

Anderson, 2003;  Peter & Liaschenko, 2004; Redman & Hill, 1997)

Consequences of Moral Distress

·          Anger, frustration, job dissatisfaction, poor performance

·          Erode confidence, self worth, depression, nightmares

·          Embarrassment, shame

·          ‘Psychological doubling’ (disengage, disconnect from self)

·          increased absenteeism & disability (burn out)

·          increased cardiovascular disease, diarrhea, headaches, etc.

·          dehumanization

·          increases errors due to distress fatigue

·          silence, apathy

·          job loss, leave profession of nursing

·          moral residue, moral outrage

(Austin, Bergum & Goldberg, 2003; Burkhardt & Nathaniel, 1998; Holly, 1998;

Lutzen, Cronqvist, Magnusson & Andeson, 2003; MacPhail, 2003; Rowe, 2003)

Recommendations to Ameliorate or Resolve Moral Distress

1.       Personal – reflect & examine values & how arrived at,

               refer to professional code of ethics to clarify

2.       Education – courses to address institutional realities, legal

aspects of nursing, professional issues, teach reflective

skills/strategies to label feelings, political implications of social

space that RNs occupy.

3.       Research – create nursing theoretical validation as nursing

has borrowed from other disciplines, create theory base to

construct interventions and discuss contributing factors, test

concepts to add to nursing knowledge (eg. ethical knowing),

longitudinal tracking of issues and how resolved, clinical

significance of moral distress, phenomenological

experiences and coping strategies, studies to include greater

variety of practice settings, role of emotion in moral decision-making,

4.       Create Moral community – appoint staff nurses to ethical committees,

contribute to policy-making and decision-making of institution, gain

support from other RNs to reduce oppressive silence, management

create supportive environment for divergent opinions, increase

dialogue & story-telling to explore experiences to reduce isolation

& silence, interdisciplinary meetings, consider relational

ethics/emotions/ethics of care in patient care.

(Brighid, 1998; CNA, 2003; Corley, 2002; Holly, 1993; Krishasamy, 1999; Peter & Liaschenko,

2004; Redman & Hill, 1997; Rumbold, 1999).

Moral Distress Scale Exercise

Refer to the following condensed ‘moral distress scale’. Corley, et al, (2000) discovered that the greatest  number of RN responses were to : “the number of staff is so low that care is inadequate” and “carrying out physician orders for unnecessary tests and treatments for terminally ill patients”. Do you agree with Corley, et al? Check off the items that you have experienced in your career:

___ Work in a situation where the number of staff is so low that care is inadequate

___ Carry out the physician’s orders for unnecessary tests and treatments for terminally ill patients

___ Assist the physician who is your opinion is providing incompetent care

___ Work with ‘unsafe’ levels of nurse staffing

___ Follow the physician’s request not to discuss death with a dying patient who asks about dying

___ Carry out the physicians order for unnecessary tests and treatments

___ Follow the physician’s request not to tell the patient the truth when he/she asks for it

___Observe without intervening when health care personnel do not respect the patient’s dignity

___ Carry out a work assignment in which I do not feel professionally competent

___  Ignore situations of suspected patient abuse by care givers

___ Ignore situations in which I suspect that patients have not been given adequate information to insure

        informed consent

___ Avoid taking any action when I learn that a nurse colleague has made a medication error and does

       not  report it

___ Give medication intravenously to a patient who refused to take the medication orally

        Corley, Elswick, Gorman & Clor  (2000, p.254).

Questions

1.       What is the moral duty of nurses when faced with choices

to follow policy or to follow patient request/good nursing

care?

2.       Why is moral distress not openly discussed?

3.       Are emotions a part of moral integrity?

4.       What do you believe to be the most effective

way to ameliorate, resolve or cope with moral

distress & moral residue?

5.     Are there benefits to moral distress/moral residue?

References

Austin, W., Bergum, V., & Goldberg, L. (2003).  Unable to answer the call of our patients: Mental health

     nurses experience of moral distress.  Nursing Inquiry, 10 (3), 177-183.

Brighid, K. (1998).  Preserving moral integrity: A follow-up study with new graduate nurses. Journal of

     Advanced Nursing, 28 (5), 1134-1145.

Burkhardt, M & Nathaniel, A. (1998).  Ethics & Issues in Contemporary Nursing. Albany, NY: Delmar

     Publishers.

Canadian Nurses Association (2003).  Ethical distress in health care environments.  Retrieved

     March 25, 2005 from

     http://cnaaiic.ca/cna/documents/pdf/publications/Ethics_Pract_Ethical_Distress_Oct_2003_e.pdf _

Corley, M. (2002).  Nurse moral distress: A proposed theory & research agenda.  Nursing Ethics,

     9 (6), 636-650.

Corley, M., Elswick, R., Gorman, M. & Clor, T. (2001).  Development and evaluation of a moral distress

     scale.  Journal of Advanced Nursing, 33 (2), 250-256.

Georges, J. & Grypdonck, M. (2002).  Moral problems experienced by nurses when caring for terminally

     Ill people: A literature review.  Nursing Ethics, 9 (2), 155-178.

Holly, C. (1993).  The ethical quandaries of acute care nursing practice.  Journal of Professional Nursing,

     9 (2), 110-115.

Johnstone, M. (1999).  Bioethics: A nursing perspective. (3^rd ed.).  Orlando, FL: Harcourt/Saunders.

Krishnasamy, M. (1999).  Nursing, morality, and emotions: Phase I and phase II clinical trials and patients

     with cancer.  Cancer Nursing, 22 (4), 251-259.

Lutzen, K., Cronqvist, A., Magnusson, A. & Anderson, L.  (2003).  Moral stress: Synthesis of a concept.

     Nursing Ethics, 10 (3), 312-322.

MacPhail, S. (2003).  Recognizing moral distress and moral residue in practice.  Health Ethics Today,

     13 (2), 5-7.

Peter, E. & Liaschenko, J. (2004).  Perils of proximity: A spatiotemporal analysis of moral distress and

     moral ambiguity.  Nursing Inquiry, 11 (4), 218-225.

Redman, B. & Hill, M.  (1997).  Studies of ethical conflicts by nursing practice settings or roles.  Western

     Journal of Nursing Research, 19 (2), 243-248.

Rowe, J.  (2003).  The suffering of the healer.  Nursing Forum, 38 (4), 16-20.

Rumbold, G. (1999).  Ethics in nursing practice.  (3^rd ed.). London, UK: Harcourt Brace and Company

     Limited.