Apply Guido’s MORAL model to resolve the dilemma presented in the case study described in EXERCISE 4–3 (Guido textbook). How might the nurses in this scenario respond to the physician’s request? How would this scenario begin to cause moral distress among the nursing staff, and what are the positive actions that the nurses might begin to take to prevent moral distress?

MORAL DISTRESS Nurses experience stress in clinical practice settings as they are confronted with situations involving ethical dilemmas. Moral stress most often occurs when faced with situations in which two ethical principles compete, such as when the nurse is balancing the patient’s autonomy issues with attempting to do what the nurse knows is in the patient’s best interest. Though the dilemmas are stressful, nurses can and do make decisions and implement those decisions. Moral distress, first described within the discipline of nursing by Jameton (1984), is a negative state of painful psychological imbalance seen when nurses make moral decisions, but are unable to implement these decisions because of real or perceived institutional constraints. This author acknowledged that there are three categories in this phenomenon: moral uncertainty, moral dilemma, and moral distress. Moral uncertainty is characterized by an uneasy feeling wherein the individual questions the right course of action. Generally, this uncertainty is short lived. Moral dilemma, according to Jameton (1984), is characterized by conflicting but morally justifiable courses of action. In such a dilemma, the individual is uncertain about which course of action should be enacted. Moral distress involves the individual knowing the ethical course of action to take, but the individual cannot implement the action because of institutional obstacles. Seen as a major issue in nursing today, moral distress is experienced when nurses are unable to provide what they perceive to be best for a given patient. Examples of moral distress include constraints caused by financial pressures, limited patient care resources, disagreements among family members regarding appropriate patient interventions, and/or limitations imposed by primary health care providers. Moral distress may also be experienced when actions nurses perform violate their personal beliefs. A study by Zuzelo (2007) concluded that the primary sources of moral distress included the following: • Resenting physician reluctance to address death and dying • Feeling frustrated in a subordinate role • Confronting physicians • Ignoring patients’ wishes • Feeling frustrated with family members • Treating patients as experiments • Working with staff members perceived as inadequate (pp. 353 – 356). These themes were present in nurses practicing in multiple care settings who work with various populations of patients across the lifespan. A later study by Pauly and colleagues (2009) concluded that high levels of moral distress for nurses in clinical settings involved “nurses’ own feelings of competency and their confidence in the competence of registered nurses” (p. 569). Corley (2002) had found in an earlier study that lack of adequate education in nursing ethics, specifically in being able to apply ethical decision-making models, may also account for some of the moral distress experienced by nurses in clinical settings. He further noted that there is a relationship between moral distress, nurse satisfaction, and nurse attrition. Moral distress may be further subdivided into initial moral distress and reactive moral distress (Jameton, 1993). Nurses who are experiencing initial moral distress generally experience frustration, anger, and anxiety when confronted with value conflicts and institutional obstacles. This frustration, anger, and anxiety result from being prevented from doing what the nurse sees as the correct course of action. Reactive distress incorporates negative feelings when the nurse is unable to act on his or her initial distress. Reactive distress involves the inability to identify the ethical issues involved or may result from a lack of knowledge regarding possible alternative actions. Signs and symptoms of reactive moral distress include powerlessness, guilt, loss of self-worth, self-criticism, and low self-esteem and physiologic responses such as crying, depression, loss of sleep, nightmares, and loss of appetite. In extreme cases, moral distress may culminate in moral outrage, causing burnout and inability to effectively care for patients. The impact of moral distress among nurses can be quite serious. There is evidence that moral distress com-

promises patient care and that moral distress may be manifested in such behaviors as avoiding or withdrawing from patients (McAndrew, Leske, & Garcia, 2011). Their study noted that nurses who experienced moral distress may avoid aspects of patient care, decreasing the nurse’s role as patient advocate and further contributing to patient discomfort and suffering. The study noted that there was a negative relationship with all aspects of professional practice except for foundations for quality care. The authors, though, additionally noted that in this study the tool used for the study measures foundations for quality care such as clinically competent care and availability of ongoing education for nurses rather than nurse reports about the quality of care actually delivered to patients. Thus, they recommended that further research explore the issue of moral distress and its influence on quality of care provided to patients and family members. There are several strategies for beginning to address moral distress in clinical practice settings. Nurses who feel empowered to voice their ethical concerns within their institutions may experience less moral distress. Storch, Rodney, Brown, and Starzomski (2002) concluded that nurses will continue to feel moral distress in clinical settings. This conclusion was based on the participant nurses’ ongoing concerns about the ethical nature of the institution, appropriate resource utilization, and lack of time for working directly with patients. These researchers noted, though, that there is an important relationship between ethics and power. When nurses have the ability to raise legitimate ethical concerns, power is manifested in ways that affect quality practice environments and allows the nurses to better cope with moral distress. Additional aspects that may assist in reducing moral distress among nurses in nursing care settings include educating nurses about the concept and offering opportunities to discuss moral distress in neutral settings. Information about moral distress should be part of orientation programs for new employees. Other means of reducing moral distress include identifying and addressing impediments to delivery of quality nursing care, incorporating conflict resolution and mediation techniques so that nurses can work through their concerns and bring them to closure, and allowing nurses to serve on the institution ethics committees. This latter means of working with moral distress encourages nurses not only to identify and understand resources that are available to them, but also to use these valuable resources. These strategies may also improve working relationships with peers, management staff, and other members of the interdisciplinary health care team. Finally, establishing systems that value the active participation of nurses in clinical and ethical decision making,

encouraging and rewarding collaborative teamwork, and open communications assist nurses in appropriately dealing with moral distress. Individual nurses, though, have learned to employ additional strategies in preserving their dignity and in compensating patients for perceived wrongdoing (McCarthy & Deady, 2008). These strategies include self-care, such as working on a part-time basis and accepting personal limitations; assertiveness; collective action; and reexamining basic nursing ethical values. Lutzen and colleagues (2003) noted that moral distress can also be an energizing factor that results in the person having an enhanced feeling of accomplishment of professional goals. They concluded that moral distress may begin to make individuals more aware of their own beliefs and strive to handle ethical issues more effectively in future encounters. EXERCISE 4–3 Mrs. R., an 87-year-old patient, has a past history that includes coronary artery disease, a previous stroke, and advanced Alzheimer’s disease. Ten days ago, Mrs. R. was hospitalized for aspiration pneumonia and has been ventilator dependent since being admitted to the intensive care unit in a small rural hospital. Family members visit daily and have repeatedly voiced their concern to the nursing staff about the continued ventilator support that Mrs. R. is receiving, most notably the fact that Mrs. R. would never have wanted such care. They also note that Mrs. R. has not recognized them in past months and that they plan to visit less in future days, but can be contacted should any change in Mrs. R.’s condition occur. Her primary physician has practiced in this community for multiple years; he is well-known for his reluctance to discontinue any type of life support for any patient. When questioned, Dr. G.’s consistent response is, if this were his frail 92-year-old mother, he would prescribe the very same treatment for her. Dr. G. has now requested that the nurses talk to the family about moving Mrs. R. to a major medical center, where she can receive more advanced care, including vigorous rehabilitation and physical therapy, so that she may eventually return to a long-term nursing care facility. How might the nurses in this scenario respond to the physician’s request? How would this scenario begin to cause moral distress among the nursing staff and what are the positive actions that the nurses should begin to take to prevent moral distress.

Guido, Ginny Wacker, JD, MSN, RN. Legal and Ethical Issues in Nursing (Legal Issues in Nursing ( Guido)) (p. 48). Pearson Education. Kindle Edition.

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