Moral Distress

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 Learning Objectives
t the end of this unit the learner will be able to:
Describe concepts related to moral distress.
Distinguish between moral distress and psychological distress
Distinguish between moral distress and ethical dilemma.
Identify sources of moral distress in nursing.
Discuss the effects of moral distress on nurses.
Explain methods used to address moral distress.

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 What is Moral Distress?
• Moral distress is a phenomenon in which one knows the
right action to take, but unable to take that action.

• It occurs due to the presence of constraints that prevent

from taking actions that one perceives to be morally right.

• The psychological characteristics of moral distress involve

frustration, anger, guilt, anxiety, withdrawal, and self-blame.
self

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 Moral Distress Vs Psychological Distress

Moral distress certainly involves psychological distress, but it

results from perceived violation of one’s core values and duties,
concurrent with a feeling of being constrained from taking
ethically appropriate action.

Psychological distress describes emotional reactions to situations

but does not necessarily involve violation of core values and
duties.

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 Moral Distress Vs Ethical Dilemma

Moral Distress Ethical Dilemma

• Occurs when an individual
identifies the ethically
appropriate action but feels
unable to take that action.
• One recognizes that a
problem exists, and that two
or more ethically justifiable
but mutually opposing
actions can be taken.

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 Sources of Moral Distress
• Common sources of moral distress for nurses are:
Continued
Continued life support even though it is not in the best interest of
the patient
Inadequate
Inadequate communication about end-of-life
end care between
providers and patients and families
Inappropriate
Inappropriate use of healthcare resources
Inadequate
Inadequate staffing or staff who are not adequately trained to
provide the required care
Inadequate
Inadequate pain relief provided to patients
False
False hope given to patients and families

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 Sources of Moral Distress --- Continued
• A key element in moral distress is the individual’s sense of
powerlessness, the inability to carry out the action perceived
as ethically appropriate.

• The feeling of powerlessness occurs because of constraints

on a nurse’s behavior.

• Constraints can be internal or external in nature.

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 Sources of Moral Distress --- Continued
• Internal constraints that contribute to moral distress can be:
fear of losing one’s job,
self-doubt
doubt or lack of confidence/powerlesssness,
confidence/
anxiety
anxiety about creating conflict,
lack of assertiveness,
socialization to follow orders,
lack
lack of understanding of the full situation

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 Sources of Moral Distress --- Continued
• External constraints that contribute to moral distress include
inadequate staffing,
hierarchies
hierarchies within the healthcare system,
lack
lack of collegial relationships/power imbalance,
lack of administrative support,
policies
policies and priorities that conflict with care needs,
compromised
compromised care due to pressure to reduce costs,
fear of litigation.

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 Effects of Moral Distress
• The psychological manifestations of moral distress are easily
recognized.

• But, difficult to identify are the feelings that threaten one’s

moral integrity such as feeling belittled, unimportant, or
unintelligent.

• Moral distress often tends to linger a condition known as

moral residue

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 Effects of Moral Distress --- Continued
• Moral residue is the lingering feelings of the moral wound of
having had to act against one’s values.
It is long-lasting
lasting and powerfully integrated into one’s thoughts and
views of the self.

• The failure to address moral distress affects all nurses to the

extent that they:
lose their capacity for caring,
avoid patient contact, and
fail to give the required care

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 Strategies to Address 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 • Find colleagues who support you or who support acting to
networks address moral distress.
• Speak with one authoritative voice.

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 Strategies to --- Continued

Strategy Implementation
ocus on changes in • Focusing on the work environment will be more productive th
he work environment 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 changin
Participate in moral • Attend forums and discussions about moral distress.
distress education • Learn all you can about it.
Make it • Many causes of moral distress are interdisciplinary.
nterdisciplinary • 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.

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 Strategies to --- Continued
Strategy Implementation
ind 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.

Source: Epstein & Delgado, 2010

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