Moral Distress Among Nurses
Introduction
"I was just going through the motions. Just giving physical care. Very short with patients. Some I avoided. . . I just didn't have the motivation," says one nurse as she describes the experience of moral distress (Kelly, 1998, p. 10). Moral distress is a serious problem in nursing. It may be a significant contributing factor to loss of nurses' integrity, and dissatisfaction with their work. It may also contribute to problems with nurse-patient relationships and thus affect the quality, quantity, and cost of nursing care. Moving into the twenty-first century, a significant nursing shortage affects the delivery of health care services and leads to questions about the future of the profession. Some studies indicate that moral distress is a major contributor to nurses leaving their work setting and even the profession. The purpose of this paper is to discuss the concept of moral distress as a basis for shedding light on this significant ethical issue confronting nursing.
Definitions
Though the human condition of moral distress certainly existed before Andrew Jameton put a name to it, his description of moral distress is the first instance of this concept appearing in the nursing literature. In his 1984 ethics text for nurses, Jameton delineated three different types of moral problems: moral uncertainty, moral dilemma, and moral distress.
The term moral distress originated when Jameton recognized that nurses' stories of "moral dilemmas" did not meet the criteria for "dilemma." Jameton concluded that nurses were compelled to tell these stories because of their profound suffering and their beliefs about importance of the situations (1993). Jameton initially defined moral distress as follows: "Moral distress arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action" (1984, p. 6). Based upon Jameton's work, Wilkinson (1987-88) further stipulated that nurses experience moral distress when their actions violate personal beliefs. Jameton (1993) agreed with Wilkinson's stipulation, saying that in cases of moral distress, nurses participate in the action which they have judged to be morally wrong.
Refining the definitions or offering examples for clarification, nearly every subsequent source relies on either Jameton's or Wilkinson's definitions. Following are some examples: Fenton writes, "Moral distress is the disturbing emotional response which arises when one is required to act in a manner which violates personal beliefs and values about right and wrong" (1988, p. 8). Others create definitions through example-sometimes substituting the terms dilemma or stress for moral distress. Davies et. al. (1996) describe nurses' experiences with children dying of terminal illness as follows, ". . .they struggled with the dilemma [moral distress] between their obligation to follow physicians' orders and their duty to provide a comfortable death. Nurses' [moral] distress was compounded by following orders that were in conflict with their belief that children should be allowed to die peacefully without unnecessary pain. Nurses felt they had violated nurse/patient relationships when they were forced to continue to inflict suffering beyond the point of a possible cure" (p. 502). Erlen and Sereika write, "Nurses do not know how to implement what they deem to be the right action to take" (1997, p. 953). Table 1 shows the historical development of the concept in nursing literature.
Table 1. Historical Development
| Date |
Author(s) |
Major Contributions |
|
1984 |
Jameton |
Distinguished moral distress from moral dilemma. Identified the nurse's moral judgment and institutional constraint as major factors. |
|
1987-88 |
Wilkinson |
Identified the experience of moral distress as a psychological disequilibrium and negative feeling state. Stipulated that nurses' actions violate personal beliefs. |
|
1993 |
Jameton |
Further stipulates the role of the nurse's participation in the action judged to be morally wrong as a causative agent of moral distress |
|
1994 |
Millette |
Used Wilkinson's definition in combination with Yarling and McElmurry's exploration of nurses' capacity to implement decisions. Contends that nurses are not free to act as moral agents because of institutional forces. |
|
1995 & 2001 |
Corley |
Created Moral Distress Scale based upon Jameton's definition and the work of Wilkinson. Differentiated between most frequently occurring and most distressing situations which lead to moral distress. |
|
1995 |
Liaschenko |
Identified source of moral distress as occurring when nurses become "artificial persons" who speak and act for others with the result of risk of loss of moral integrity. |
|
2000 |
Penticuff & Waldren |
Found that nurses' ethical practice is influenced by the setting in which they practice including their perceptions of their influence and value within the institution, administrative support, views concerning quality of care, ethics resources, and satisfaction with practice environment. |
Utilizing a synthesis of these early definitions, a new definition of moral distress is proposed as follows: Moral distress is the pain or anguish affecting the mind, body or relationships in response to a situation in which the person is aware of a moral problem, acknowledges moral responsibility, and makes a moral judgment about the correct action; yet, as a result of real or perceived constraints, participates in perceived moral wrongdoing.
Significance
Though moral problems of all types are difficult, situations involving moral distress may be the most difficult ones facing nurses. Moral distress may result in unfavorable outcomes for both nurses and patients. Some studies show that, as a result of moral distress, nurses experience physical and psychological problems, sometimes for many years. (Kelly, 1998; Wilkinson, 1987-88; Perkin, Young, Freier, Allen & Orr, 1997; Fenton, 1988; Davies, et al., 1996; Krishnasamy, 1999; Anderson, 1990). More important, there is anecdotal evidence that nurses' moral distress affects quality of patient care and subsequent health outcomes. There is evidence that some nurses loose their capacity for caring, avoid patient contact, and fail to give good physical care as a result of moral distress. Nurses may physically withdraw from the bedside, barely meeting the patient's basic physical needs, or may leave the profession altogether (Redman & Fry, 2000; Hefferman & Heilig, 1999; Kelly, 1998; Wilkinson, 1987-88; Millette, 1994; Corley, 1995). Some relate burnout to nurses' experience of moral distress and suggest that many nurses leave the profession as a result (Wilkinson, 1987; Millette, 1994; Corley, 1995). Loss of nurses from the workforce is an indirect but strong threat to patient care. The nursing shortage is compounded by a health care system in which increasingly complex technology is used to care for patients who are very old, very young, or very sick. Those in society with the greatest need are the ones who suffer most acutely when nursing care disintegrates.
Many suggest that prolonged or repeated moral distress leads to loss of nurses' moral integrity. The term moral integrity means soundness, reliability, wholeness, and integration of moral character over time. This signifies being faithful to coherent, integrated moral values and actively defending them when they are threatened. A person of moral integrity is not "disordered or disoriented by moral conflict and is faithful to the standards of the common morality as well as to personal moral ideals" (Beauchamp & Childress, 1994, p. 473). Deficiencies in moral integrity represent a break in the connections between moral convictions and actions. Moral distress may be a direct result of what nurses perceive as their participation in moral wrongdoing.
Reports of the number of nurses who experience moral distress vary and the percentages below only acquire meaning in terms of actual sample size. Redman & Fry report that at least one-third of nurses in their study (n = 470) experienced moral distress (2000). Nearly fifty percent of nurses in another study (n = 760) report that they had acted against their consciences in providing care to the terminally ill (Solomon, O'Donnell, Jennings, Guilfoy, Wolf, Nolan, Jackson, Koch-Waeser & Donnelley, 1993). Possibly heralding the present nursing shortage, Wilkinson's (1987-1988) and Millette's (1994) qualitative studies indicate that 45 percent ( n = 24) to 50 percent ( n = 24) of nurses in their respective samples left their units or nursing altogether because of moral distress.
In a recent report on the nursing shortage, the U.S. Government Accounting Office reported that nurses' sources of dissatisfaction include poor working conditions such as inadequate staffing, heavy workloads, increased use of overtime, and lack of sufficient support staff (U.S. GAO, 2001). Although on the surface these sources of dissatisfaction may not seem to be related to moral distress, a review of research literature suggests that such situations may actually be contributing causes of moral distress. Moral distress, in turn, may cause nurses to leave the work force, thus compounding the nursing shortage creating a self-perpetuating downward spiral.
Summary
Literature over the past two decades has shown that moral distress is a significant cause of emotional suffering among nurses, possibly causing nurses to give poor nursing care, change positions frequently or leave the profession entirely. Moral distress is a serious problem in nursing. It may be a significant contributing factor to nurses' feelings of loss of integrity and dissatisfaction with their work. It may also contribute to problems with nurses' relationships with patients and others and may thus affect the quality, quantity, and cost of nursing care. Research is needed to further clarify the concept of moral distress, identify situations which may contribute to the problem, and predict which nurses may be more likely to suffer its consequences.
References
Anderson, S. L. (1990). Patient advocacy and whistle-blowing in nursing: Help for the helpers. Nursing Forum, 25, 5-13.
Corley, M. C. (1995). Moral distress of critical care nurses. American Journal of Critical Care, 4, 280-285.
Corley, M. C., Elswick, R. K., Gorman, M.& Clor, T. (2001). Development and evaluation of a moral distress scale. Journal of Advanced Nursing, 33(2). 250-256.
Davies, B., Clarke, D., Connaughty, S., Cook, K., MacKenzie, B., McCormick, J., O'Loane, M., & Stutzer, C. (1996). Caring for dying children: Nurses' experiences. Pediatric Nursing, 22, 500-507.
Erlen, J. A. &. Sereika, S. M.(1997). Critical care nurses, ethical decision-making and stress. Journal of Advanced Nursing, 26, 953-961.
Fenton, M. (1988). Moral distress in clinical practice: Implications for the nurse administrator. Canadian Journal of Nursing Administration, 1, 8-11.
Hefferman, P. & Heilig, S. (1999). Giving "moral distress" a voice: Ethical concerns among neonatal intensive care unit personnel. Cambridge Quarterly of Healthcare Ethics, 8, 173-178.
Jameton, A. (1984). Nursing Practice: The Ethical Issues. Englewood Cliffs, NJ: Prentice-Hall.
Jameton, A. (1993). Dilemmas of moral distress: Moral responsibility and nursing practice. Clinical Issues in Perinatal and Womens' Health Nursing, 4, 542-551.
Kelly, B. (1998). Preserving moral integrity: A follow-up study with new graduate nurses. Journal of Advanced Nursing, 28, 1134-1145.
Krishnasamy, M. (1999). Nursing, morality, and emotions: Phase I and phase II clinical trials and patients with cancer. Cancer Nursing, 22, 251-259.
Liaschenko, J. (1995). Artificial personhood: Nursing ethics in a medical world. Nursing Ethics, 2, 185-196.
Millette, B. E. (1994). Using Gilligan's framework to analyze nurses' stories of moral choices. Western Journal of Nursing Research, 16(6). 660-674.
Penticuff, J. H. &. Waldren, M.. (2000) Influence of practice environment and nurse characteristics on perinatal nurses' responses to ethical dilemmas. Nursing Research, 49(2), 64-72.
Perkin, R. M., Young, T., Freier, M. C., Allen, J., & Orr, R. D. (1997). Stress and distress in pediatric nurses: lessons from Baby K. American Journal of Critical Care, 6, 225-232.
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Soloman, M., O'Donnell, L., Jennings, B., Guilfoy, V., Wolf, S. M., Nolan, K., Jackson, R., Koch-Weser, D., & Donnelley, S. (1993). Decisions near the end of life: Professional views on life sustaining treatments. American Journal of Public Health, 83. 14-25.
U.S. General Accounting Office. (July, 2001). Nursing workforce: Emerging nurse shortages due to multiple factors. Report to the Chairman, Subcommittee on Health, Committee on Ways and Means, House of Representatives. (Publication No. GAO-01-944). Washington, DC: Author.
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