Moral Distress in Nursing Care

Afza.Malik GDA

Nursing Care and Moral Distress

Moral Distress in Nursing Care

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.

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