Question

All health care providers can experience moral distress. Recognizing moral distress in self and others and acting on it may promote a healthy work environment. Discuss strategies to recognize moral distress in yourself or others. What steps would you take to address moral distress on your unit?

Answer 1

Numerous examples of moral distress emerge in everyday clinical practice² including continued life support, even when it may not be in the best interests of the patient; inadequate communication about end-of-life care among providers, patients, and families; inappropriate use of health care resources; inadequate staffing; and false hope given to patients and families. A key component in recognizing moral distress is a sense of powerlessness.

These constraints can be internal, such as anxiety or self-doubt about creating conflict, or external, related to power imbalances in the workplace.³ One can distinguish between a moral dilemma, in which there are multiple choices to make and the correct path may not be clear, and moral distress, in which the path is clear, but the ability to implement a solution is somehow blocked.

Recognizing Moral Distress

Moral distress often involves feelings of frustration and anger , which are fairly easy to recognize. Under the surface, and more difficult to identify, are the feelings that threaten one’s moral integrity—feeling belittled, unimportant, or unintelligent. Unfortunately, these feelings are often borne alone as professionals are often hesitant to speak openly about their impotence. As a result, morally distressed individuals may also feel isolated, an additional threat to their integrity.

One complicating factor which adds to the feeling of isolation is that in any given situation, not everyone will be morally distressed. Because values and obligations are perceived differently by various members of the healthcare team, moral distress is an experience of the individual rather than an experience of the situation. There are equally likely to be nurses who are not morally distressed. The nurses who do not feel moral distress are not morally insensitive or deficient persons. In other situations, they may experience significant moral distress.

Strategy	Implementation
Speak up!	Identify the problem, gather the facts, and voice your opinion
Be deliberate	Know who you need to speak with and know what you need to speak about
Be accountable	Sometimes, our actions are not quite right. Be ready to accept the consequences, should things not turn out the way you had planned.
Build support networks	Find colleagues who support you or who support acting to address moral distress. Speak with one authoritative voice.
Focus on changes in the work environment	Focusing on the work environment will be more productive than focusing on an individual patient. Remember, similar problems tend to occur over and over. It’s not usually the patient, but the system, that needs changing.
Participate in moral distress education	Attend forums and discussions about moral distress. Learn all you can about it.
Make it interdisciplinary	Many causes of moral distress are interdisciplinary. Nursing alone cannot change the work environment. Multiple views and collaboration are needed to improve a system, especially a complex one, such as a hospital unit.
Find root causes	What are the common causes of moral distress in your unit? Target those.
Develop policies	Develop policies to encourage open discussion, interdisciplinary collaboration, and the initiation of ethics consultations.
Design a workshop	Train nursing staff to recognize moral distress, identify barriers to change, and create a plan for action.