Running head: THE CHALLENGE OF MORAL DISTRESS IN NURSING 1

The Challenge of Moral Distress in Nursing

NURS300 student

Fayetteville State University

NUR 300 D46

Spring 2020
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Abstract

Moral distress, a phenomenon that occurs when the ethical thing to do does not seem to

be an option, is a challenge nurses face throughout their careers. Moral distress and its residual

effects lead to increased burnout, deterioration of communication between staff and peers, higher

staff turnover and decrease in the quality of patient care (Wallis, L. 2015). The effects of

repeated instances of moral distress can further lead to a residual effect known as moral residue

and when left unresolved can be followed by what’s termed as a crescendo effect. We will

explore moral distress, it’s history, examples of common sources and strategies developed

through studies for nurses to implement in their personal dilemmas of real or perceived ethical

incongruencies while still embracing their own deeply held personal and moral beliefs.

Keywords: Moral distress, Moral residue, moral resilience

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The Challenge of Moral Distress in Nursing

Introduction

The intent of this paper is to understand the issue of moral distress, its process, and the

implications it has on nurses, patients and their families, the nursing profession itself and the

organizations we work for. While ethical discussions and debates between healthcare providers

are seen as productive, collaborative ways to improve healthcare and its delivery, moral distress

occurs when the issues are no longer being addressed sufficiently (Epstein E. G., Delgado, S.,

2010). Each time nurses feel they are compromising their ethical values it leads to moral residue

and when the situations are repeatedly left unresolved it leads to what’s referred to as the

crescendo effect and it’s this buildup of ethical dilemmas that contribute to nurses leaving their

jobs and as nurses continue to feel helpless and unsupported in their efforts they may even

consider leaving the profession all together (Wallis, 2015). Moral distress, a worldwide

phenomenon, is a problem experienced not only in nursing but in all fields of healthcare.

Literature Review

Issue

Through much research, moral distress has been found to be extensive throughout

nursing affecting not only nurses but other healthcare disciplines and their ancillary services as

well, including, but not limited to, physicians, physical therapists, psychiatry, social workers,

pharmacists, etc. (Rushton, C.H, Caldwell, M Kurtz, M., 2016). Moral distress effects such a

broad range of healthcare providers it can be attributed in part to the deterioration of the

collaborative and unified work between the disciplines ultimately resulting in less than desired or
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negative outcomes for the patient (Rushton, et al. 2016). It is imperative to find and implement

solutions for moral distress and its destructive effects.

Historical Background

Ethical issues in nursing have been a problem dealt with since the beginning of the

profession, but it wasn’t until the 1970’s that we see it becoming more recognized and publicly

addressed. In 1978, addressing the issue of moral distress but not yet having a name for it,

nursing professors Anne Davis and Mila Aroskar published a book titled Ethical Dilemmas &

Nursing Practice. But it was in his book, Nursing Practice: The Ethical Issues, that Andrew

Jameton (1984) gave it the name “moral distress” and defined it as a phenomenon that occurs

when the nurse knows the ethical and moral thing to do but is prevented from taking the action

she or he knows is right (Epstein E. G., Delgado, S., 2010). Since the late 1970’s moral distress

has had an ever-growing awareness and many scholars have studied this phenomenon in effort to

try to raise more awareness and identify ways to address and resolve the destruction it causes to

the nurse, the nursing profession, the organizations they work for and the patients they serve.

Current Trends

A few examples of current issues that can lead to moral distress for nurses include unsafe

patient loads due to staffing shortages and unrealistic expectations. Inadequate communication

and increasing incivility between staff. Providing unnecessary tests, treatments, and medications

to patients out of fear of litigation or push back verses true need. Providing lifesaving measures

to patients not expected to benefit or to resume any type of quality of life or life at all. Working

with incompetent or inadequately trained co-workers. Lack of leadership support and

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acknowledgement. The feeling of not having a voice or a safe platform to discuss concerns are

all but a few of the issues leading to moral distress faced by healthcare workers today.

Significance of Issue

Moral distress is a significant problem for nurses and other healthcare providers. It is

noted to not only lead to emotional stress, mental exhaustion and high rates of burnout, but

manifests itself physically, spiritually and behaviorally (Rushton, et al. 2016). If left unresolved

the emotional manifestations of resentment, feelings of defeat and fault, moral distress can

debilitate the individual nurse and affect not only their professional lives but their personal lives

as well. Physical manifestations can lead to minor and major illnesses and behavioral

manifestations can lead to violence toward self or others. We have a moral obligation to

ourselves, our co-workers, our patients and our profession to remedy this destructive toxin.

Influences on Nursing Practice

Unfortunately, moral distress has a highly negative influence on nursing practice. Many

negative manifestations that can lead to the deterioration of spiritual health may cause a decrease

in integrity and feeling of connection to moral self or higher power (Rushton, et al. 2016).

Behavioral and emotional manifestations may present as passive aggressiveness toward

coworkers and even toward patients. The moral decline is professionally and personally

sabotaging, can lead to negative consequences such as increased call outs, medical errors, high

burnout, high turnover rates, less than optimal patient outcomes and other negative

consequences. Moral distress is not something that can be overlooked.

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Controversies

Research continues to look at whether the greatest cause of moral distress is initiated

internally or externally, however, it is noted through studies that a lack of supportive quality

leadership, organizational policies and working with ineffectual team members is found to have a

large effect on the level and frequency of moral distress (Woods. M, 2020). Moral distress can

only be overcome by a joint effort by the team and that team must include leadership and the

organization. It must be acknowledged and managed and leadership must be engaged.

Strategies

Nurses can and do learn to use their feelings of frustration as a platform to seek out ways

to effect change. Some of those nurses are now scholars who are effecting change through

research and collaboration to develop formulas and options for coping with and addressing the

toxic issue of moral distress. Self-awareness is an important start to overcoming moral distress.

As noted by Epstein & Delgado (2010) in 2004, the American Association of Critical Care

Nurses Ethics Workgroup put together a model they call the Four A’s. The Four A’s, Ask,

Affirm, Assess, and Act, starts with asking yourself how you feel, affirming those feelings,

assessing the situation and acting to effect a change in a professional manner (Epstein &

Delgado, 2010). In other studies, a system of resiliency is promoted. Nurses are resilient. We

have the capacity to overcome and rise to the challenge of pulling ourselves out of the difficulties

and formulating solutions. Our greatest success comes from collaborative work with the support

of peers, other disciplines with whom we work, leadership and organizational support.
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My Position

This topic is important to the continued successful growth and professionalism of

nursing. It has the capacity to cause a lot of destruction but where there is a problem there is a

solution. Sometimes that solution is buried deep, but nurses come from a history of great strength

and resiliency. Throughout history we have overcome insurmountable obstacles and I want to

remain a part of the solution. Exposing this problem is empowering and is the beginning of

change. This has been very educational for me and my goal is to educate others and start the

process of effecting a healthy change in my own work environment.

Conclusion

Though moral distress is extremely damaging to nursing and healthcare all together it

also affords nurses the opportunity for tremendous growth and can show how strong, creative,

and resilient we are. With the proper education, awareness and support nurses can be empowered

to effect change for themselves, their patients, peers and the environment in which they work.

.
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References

Davis, A., & Aroskar, M. (2008, August 8). Ethical dilemmas and nursing practice. . Retrieved

from https://www.worldcat.org/title/ethical-dilemmas-and-nursing-

practice/oclc/729927681

Epstein, E. G., & Delgado, S. (2010). Understanding and addressing moral distress. Retrieved

from

https://ojin.nursingworld.org/MainMenuCategories/EthicsStandards/Resources/Courage-

and-Distress/Understanding-Moral-Distress.html

Rushton, C. H., Caldwell, M., & Kurtz, M. (2016, July). Moral Distress A Catalyst in Building

Moral Resilience. The American Journal of Nursing, 116(7), 40-49.

http://dx.doi.org/10.1097/01.NAJ.0000484933.40476.5b

Wallis, L. (2015, March). Moral distress in nursing. American Journal of Nursing, 115(3).

http://dx.doi.org/10.1097/01.NAJ.0000461804.96483.ba

Woods, M. (2020). Moral distress revisited the viewpoints and responses of nurses. International

Nursing Review, 67(1), 68-75. http://dx.doi.org/10.1111/inr.12545