Although not every nurse would be able to provide a concise definition of moral distress, most would be able to describe more than one clinical experience that exemplifies the elements of moral distress. Consider the following excerpt from a longer case description about being forced to give a patient medication that caused the patient, and the nurse, great pain: “However, since bringing this reaction to the physician’s attention several times and with the same refusal, I continued to administer the daily dosage. Attempts to have our nursing Director intervene also brought negative results. Consequently, only death resolved this patient problem. Seeing this little lady writhe in pain has haunted me for years. Had I to do over, I would have charted but withheld the drug.”1 The nurse understands what she believes is the right moral action but encounters seemingly intractable obstacles that prevent her from doing what is morally correct.
What is Moral Distress?
The concept of moral distress first appeared in the literature in the late 1970s and early 1980s when contemporary bioethics was born and found its way into nursing education programs. The faculty who taught these ethics courses in nursing programs noted the need for content that focused on the particular clinical experiences of nurses. One seemingly unique moral experience for nurses was a sense of distress caused by trying to pursue a course of morally correct action and being prevented from doing so by institutional barriers or other types of constraints. Andrew Jameton first described moral distress in 19772 and later coined the phrase in 1984 in his book, Nursing Practice: The Ethical Issues.3
Since then, there have been various definitions of moral distress and considerable breadth in its conception. Furthermore, there has been extensive research on the negative impact, or fall-out of moral distress on nurses such as emotional stress, frustration, burn-out, and attrition and the negative impact of moral distress on patient care and outcomes.4 Additional research has identified moral distress in other health professions including medicine and pharmacy.5,6 The experience of being “caught in the middle” or “between a rock and a hard place” are not unique to nursing yet because of their intimate contact with patients and the amount of time nurses spend with patients, they often find themselves in a mediator role between the powerless and powerful in health care.
The Need for Ethics Education
Remedies for moral distress include a range of promising interventions including ethics education for nurses so that they can better articulate the underlying ethical issues in conflict in a case; and the establishment of nursing governance structures and magnet status models that bolster nursing authority in inpatient settings. Two recent shifts in the scholarly work on moral distress include a focus on 1) the institutional setting in which nurses and other health professionals interact to create a healthy work environment and 2) the role of moral resilience as a possible remedy or counterbalance to the effects of moral distress that includes nurses abandoning the profession. The first of these changes in the evolution of scholarship on moral distress, is a focus on restructuring the health care work environment. If the work environment is “morally habitable,” then everyone benefits including patients, families, nurses, health professionals and administrators.7 Sustained work in the area of creating a healthy environment in which everyone has a voice and is treated with mutual respect can be found in the American Association of Critical Care Nurses’ Standards for Establishing and Sustaining Healthy Work Environments.8
Turning from changing the clinical setting to reduce moral distress, a relatively new concept, moral resilience, is the focus of current scholarship as a remedy to moral distress and its negative consequences. As with the development of the concept of moral distress, moral resilience has not yet been concisely defined. Rushton has defined moral resilience as “the capacity of an individual to sustain or restore their integrity in response to moral complexity, confusion, distress or setbacks."9 The work in moral resilience is ongoing. The culmination of a four-year collaborative effort between the Johns Hopkins School of Nursing and Berman Institute of Ethics, the American Journal of Nursing, and the Journal of Christian Nursing, along with the American Association of Critical-Care Nurses and the American Nurses Association was a conference held in Baltimore in August, 2016. Amy Haddad, PhD, RN, Director of the Master of Science in Health Care Ethics at Creighton University, was one of 46 scholars who were invited to participate in this intense workshop called “State of the Science Symposium: Transforming Moral Distress to Moral Resiliency in Nursing.” Read more about the symposium’s aims and outcomes.
The online Master of Science in Health Care Ethics program at Creighton focuses on foundational skills to identify the moral components of clinical quandaries so that students can clearly describe values that are in apparent conflict in clinical settings in which they work with their colleagues, administrators, or patients and families.
1Haddad, A. (1988). Ethical problems in nursing. University of Nebraska Dissertation, p. 81.
2Jameton, A. (1977). The nurse: When roles and rules conflict. The Hastings Center Report 7(4):22-23.
3Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice-Hall.
4Huffman, D.M. & Ritternmeyer, L. (2012). How professional nurses working in a hospital environment experience moral distress: A systematic review. Critical Care Nursing Clinics of North America 35(2):91-100.
5Berger, J.T. (2014). Moral distress in medical education and training. Journal of General Internal Medicine, 29(2):395-398.
6Sporrong, S.K., Hoglund, A.T. & Arnetz, B. (2006). Measuring moral distress in pharmacy and clinical practice. Nursing Ethics, 13(4): 416-427.
7Peter, E. & Liaschenko, J. (2013. Moral distress reexamined: A feminist interpretation of nurses’ identities, relationships, and responsibilities. Bioethical Inquiry 10:337-345.
8American Association of Critical Care Nurses. Standards for establishing and sustaining healthy work environments. The complete standards document is available for download at www.aacn.org
9Rushton, C. (2016). Moral resilience: A capacity for navigating moral distress in critical care. AACN Advanced Critical Care, 27(1), 111-119, p. 116.