Nursing Care and Moral Distress
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Whats is Moral Distress,Sources of Moral Distress,Factors of Moral Distress ,Nurses Roles in Moral Distress ,Environmental Contribution in Moral Distress,Role of Nurses as Compare to Physicians Role,Psychological Factors of Moral Distress,Moral Distress and Quality of Patient Care.
Whats is Moral Distress
Moral
distress describes a feeling that occurs in relation to a particular type of
morally troubling experience. The term moral represents judgments about good or
bad (right or wrong) actions, thoughts, or character of people, particularly in
relation to human responsibilities.
The term distress signifies a profoundly
negative outcome demonstrated in affective, physical, and relationship domains.
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, because of real or perceived constraints,
participates in perceived moral wrongdoing (Nathaniel, 2004).
Sources of Moral Distress
Virtually
absent from common language usage, the term moral distress originated when
ethicist Andrew Jameton (1984) recognized that nurses’ stories about moral
dilemmas were inconsistent with the definition of dilemma.
In a moral dilemma,
one struggles to decide between two or more mutually exclusive courses of
action with equal moral weight. Jameton asked nurses to talk about moral
dilemmas in practice.
Consistently, the nurses talked about moral problems for
which they felt they clearly knew the morally correct action, but believed they
were con- strained from following their convictions (Jameton, 1993). Jameton
concluded that nurses were compelled to tell these stories because of their
profound suffering and the importance of the situations.
Jameton 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” (Jameton, 1984, p. 6).
Further refining the
concept in 1993, Jameton stipulated that, in cases of moral distress, nurses
participate in the action that they have judged to be morally wrong.
Based
upon Jameton’s work, J. M. Wilkinson (1987-88) defined moral dis tress as
“the psychological disequilibrium and negative feeling state experienced
when a person makes a moral decision but does not follow through by performing
the moral behavior indicated by that decision” (p. 16).
Further refining
the definitions and offering examples for clarification, nearly every
subsequent source relies on Jameton and/or Wilkinson’s definition of moral
distress. Situations involving moral distress may be the most difficult
problems facing nurses. Moral distress results in unfavorable outcomes for
both nurses and patients.
Because of moral distress, nurses experience physical
and psychological problems, sometimes for many years (Nathaniel, 2004;
Wilkinson, J. M., 1987-88; Fenton, 1988). Reports of the number of nurses who
experience moral dis- tress vary slightly. Between 43% and 50% of nurses leave
their units or leave nursing altogether after experiencing moral distress
(Wilkinson, Millette, 1994, Nathaniel).
Factors of Moral Distress
Moral
distress requires a complex inter play of human relationships, institutional
factors, personal attributes, and a morally troubling situation. Moral distress
occurs in high stress situations or with vulnerable patients.
Areas that
engender high overall stress levels, such as critical care or other areas with
very vulnerable patients, harbor a greater proportion of moral problems
(Bassett, C. C., 1995; Corley, 1995; Rodney, 1988; Fenton, 1988; Hefferman
& Heilig, 1999; Millette, 1994).
Moral distress has been documented in the
following specific situations: prolonging the suffering of dying patients
through the use of aggressive/heroic measures; performing un- necessary tests
and treatments; lying to patients, failing to involve nurses, patients, or
family in decisions; and incompetent or inadequate treatment by a physician
(Wilkinson, 1987-88; Bassett, C. C.; Hefferman & Heilig Rodney; Corley; Nathaniel,
2004).
Nurses Roles in Moral Distress
Individual
nurse’s sense of moral responsibility is an integral part of the moral distress
process (Wilkinson, 1987-88; Jameton, 1984). The level of nurses’ moral
distress may be influenced by their perceptions of the degree to which they are
responsible for what happens to their patients and the degree to which they are
able to say,” “it is my decision to make (Wilkinson; Hefferman &
Heilig, 1999; Jameton, 1993).
Moral
judgment is also a factor in moral distress. Moral distress is not a response
to a violation of what is unquestionably right. but rather a violation of what
the individual nurse judges to be right.
Nurses respond differently to moral
problems in terms of their moral awareness, their orientation toward
consequences rather than rules, or their orientation toward justice rather than
caring (Wilkinson, 1987-88; Millette, 1994).
Environmental Contribution in Moral Distress
Institutional
setting also contributes to moral distress, Many nurses view themselves as
powerless within hierarchical systems (Wilkinson, 1987-88; Rodney, 1988). They
perceive little support from nursing and hospital administrations (Fenton,
1988). Nurses may experience moral distress as a result of having been
socialized to follow orders, remembering the futility of past actions, or
fearing job loss.
Other organizational factors contributing to nurses’ moral
distress include their views concerning the quality of nursing and medical
care, organizational ethics resources, their satisfaction with the practice
environment, and the law and/or lawsuits (Wilkinson).
Role of Nurses as Compare to Physicians Role
Since
conflicting moral judgment is a central theme in moral distress, relationships
between nurses and physicians are the most frequently mentioned institutional
constraints (Wilkinson, 1987-88; Bassett, 1995; Corley, 1995).
Nurses
experience moral distress be- cause physicians and nurses have different moral
orientations, different decision-making perspectives, and an adversarial
relationship (Wilkinson; Bassett; Corley).
Psychological Factors of Moral Distress
Psychological
and physical sequelae and changes of behavior may be indicative of moral
distress. Psychosocial indicators of moral distress include blaming self or
others, excusing one’s actions, selfcriticism, anger, sarcasm, guilt, remorse,
frustration, sadness, withdrawal, avoidance behavior, powerlessness, burnout,
betrayal of personal values, sense of insecurity, and low self-worth
(Wilkinson, 1987-88; Fenton, 1998).
Nurses describe a need to detach
themselves emotion- ally or withdraw from the situation when they are no longer
able to deal with the stress, and may leave the unit for a less stressful area
or leave nursing altogether (Fenton; Hefferman & Heilig, 1999).
Nurses’
somatic complaints related to moral distress include weeping, palpitations,
headaches, diarrhea, and sleep disturbances (Fenton; Wilkinson; Nathaniel, 2004).
In addition, empirical evidence suggests that prolonged or repeated moral
distress leads to loss of nurses’ moral integrity (Wilkinson).
Moral Distress and Quality of Patient Care
Moral
distress also affects the quality of patient care. Some nurses lose their
capacity for caring, avoid patient contact, and fail to provide good physical
care because of moral distress. Nurses may physically withdraw from the
bedside, barely meeting patients’ basic physical needs (Hefferman & Heilig,
1999; Wilkinson, 1987-88; Millette, 1994; Corley, 1995, Nathaniel, 2004).
Moral
distress is a serious problem in nursing. It affects the individual nurse, the
patient, and the health care system. It also offers important implications for
nursing practice, education, and administration, and in the face of a nursing
shortage of crisis proportions, presents urgent and unique opportunities for
further investigation.