Ethics empowerment: deal with moral distress.
In October 2009, I had the honor of presenting at the TNA convention in Chattanooga. I spoke on moral distress in nursing. My main point was that dealing with it needs to be a priority in healthcare. After the talk, a young woman came and introduced herself and told me she used to be a nurse, but now worked as a lawyer. She went on to say that she wished someone had talked to her about moral distress in nursing and helped her find ways to deal with it. She speculated that had that happened, she might still be a nurse. While she was happy working in health law, there was also some regret. Her comments have stayed with me. I think of her often, and it makes me sad to think there was no help for her.
Moral distress occurs when there is a lack of attention to ethics, and it takes a toll. Studies indicate that anywhere from 12-50% of nurses leave nursing because of it or because of what is described as ethics stress. Numbers like these should tell us, should scream at us, as a profession, as well as those that employ nurses, that moral distress must be recognized and dealt with. Because of the complicated nature of health care, of caring for human beings, promoting their well being, and being with them at life's end, some amount of stress is normal. Because there is also conflict, especially at the end of life, ethical dilemmas become occupational stress--ethics stress. Such stress can have physical, psychological, social, and spiritual consequences. There are also consequences to the organization. Think about how much it costs to recruit and train a nurse, and then lose him or her. In addition, moral distress can lead to decreased productivity, inability to focus, and feelings of incompetence and self-doubt. If this is the reputation of your institution, that everyone leaves because of the moral distress, who would want to work there?
Other Names, Same Problem
Moral distress happens when a person knows the right thing to do, but because of perceived barriers--personal, professional, organizational, or societal--is unable to do it. One's integrity and sense of authenticity are undermined with such choices. Nursing practice centers on the welfare of others. An inability to focus on that core obligation leads to moral distress, which can be expressed in different ways. Burn Out: is the most common name and officially recognized as a psychological syndrome where one becomes exhausted from the pressures of work. Burn out is often attributed to long hours with little down time; jobs with continual peer, customer, and superior interaction--all too common for nurses. Grief Out: is my own twist on this where in addition to the factors in burn out, there is also repeated grief and loss. Also very common for nurses and other health care professionals. Jading: is also the result of over work where one becomes apathetic to the point of appearing uncaring or actually being that way. Jaded people are negative, often cynical and sarcastic in an effort to avoid caring and closeness with anyone. They might even appear mean. They are the ones you say to yourself, "I don't know why she's a nurse, she is so negative about the work and mean to the patients." Compassion Fatigue: is probably the most descriptive of the problem. It is seen in both professional and family care givers. Nurses, in addition to dealing with job stress, face complex, heart wrenching and emotional challenges because of the nature of the work. With repeated episodes, repeated loss, general work and home stress, their compassion fatigues, and they find themselves drained of the ability to care. Secondary Traumatic Stress: often described with compassion fatigue, is common in trauma victims and those that care for them like nurses. Feelings of hopelessness and apathy are common and some even show signs of posttraumatic stress disorder (PTSD). This can occur outside trauma care as well. All of these are different ways to describe the problem and what happens when it's not dealt with. These phenomena are related and exist as something of a continuum, in that they are all caused by unrelieved stress and how people cope or don't. A person could be described as having one or all of them depending on the situation.
Professional and Personal Causes
Identifying the cause is essential to help and prevent moral distress. Job-related causes include the general stress of health care with its rapid pace and constant change. Societal causes include changes in reimbursement and increased numbers of patients without coverage for quality care. Patients are also sicker, putting their health needs aside until they are too sick to ignore them. Shortages in people and other resources further impact the quality of care. Team dysfunction contributes as does leadership where it's more about power plays than collaboration, both within and outside of nursing. Issues related to end of life care are frequently identified as major contributors to moral distress, particularly multiple deaths in close succession, or unexpected deaths. Nurses also find stressors in their role and relevance. Being in close proximity to the patient for hours, yet having a limited role in decision making is a stressor. In addition, nurses are with the patient continuously--8, 10, 12 hours--while others can walk away from the situation. There may be factors unique to a given patient and their family like those that are overly assertive, aggressive or outright abusive. In these tough economic times the social situations of patients is also adding to moral distress, when resources aren't there to support them outside the health care environment.
Personal factors that contribute to moral distress include the simple fact that each of us is a unique human being, and unique clinician with different personal and professional values. What is perceived as stressful to one person might not be to another. In addition, nurses like anyone else, have their own psychological or emotional situations that impact their work. Some may have difficulties with personal and professional boundaries. Nursing work leads to closeness with the patient and family, and often nurses over identify with them as well. Feeling that you can't help that patient, guilty that you can't help, or that you have compromised your standards all increase moral distress. It's hard to check your personal life at the hospital door, so stressors from home come in to the bedside along with everything else. Grief and loss are often repeated for nurses and can accumulate when there is lack of time to process and lack of closure.
Signs and Symptoms
Moral distress isn't usually the complaint made by the person experiencing it. Usually they are the last to know. It can appear as physical complaints like fatigue and other aches and pains. Psychologically they may complain of anxiety, frustration, blame others. They may become irritable, angry, depressed. Often I hear something like, "He just bit my head off," or "It's so out of character for her to behave that way." There might be increased absenteeism or tardiness. Negativity, gossip and horizontal violence may increase between nurses and others. Poor or inappropriate care may be a sign, or distancing from patients and peers, or avoiding work activities. Some may find that their work has no meaning and they question themselves, their beliefs and commitments to nursing. It can also be a real crisis of faith if one feels they cannot care for patients in a way consistent with their faith tradition. All of these things further exacerbate the distress and worsen the causes themselves, as well as the ability to cope. Any coping skills available can be made worse. More stress, worse team function, worse care, more grief, bad coping, etc., etc.
What To Do About Moral Distress
The American Association of Critical Care Nurses (AACN) model, AACN's 4 A's Model to Rise Above Moral Distress, offers a process to identify moral distress and opportunities for action. While the model speaks to individuals, nurse leaders and organizations can use it to help all members of the health care team identify and address moral distress situations. It can be used anywhere, not just in critical care areas and not just with nurses.
The first step is Ask. Ask yourself or ask another if they are feeling distress. Often those closest to us see our suffering when we don't. The goal is to become aware that moral distress exists. The next step is to Affirm the distress and commit to self care. It's an opportunity to validate feelings and perceptions with others as well, and to have them affirm and assist with your commitment to self care. As nurses it's also a time to recommit to the values and ethical commitments of the profession such as those contained in the American Nurses Association (ANA) Code of Ethics For Nurses. Remembering what we are here for can be a helpful, caring step. Just talking with a trusted colleague can be a great help as well. Next Assess the sources and severity of distress: personal, professional, environmental. Also determine the capacity to act to change. There may be ambivalence to act or the person is simply too stressed. A trusted colleague or mentor may be essential to assess the strengths, weaknesses, causes and barriers. The assessment may also reveal the need for other skills, which might include consultation with a therapist or other counselor, especially for severe psychological or emotional distress. Chaplains or spiritual care providers may help with identified spiritual distress. Help might also be found in the ethics committee, consultants, or ethics- focused conversations, like case studies or journal club. Such mechanisms are especially helpful for recurrent issues. Connecting with the ethics committee may help identify recurrent system issues or conflicts and help point the way to educational, policy or other solutions. Just simply talking about it can help a great deal. The final step is to Act. Action is both personal and professional and includes a plan to act, how to manage setbacks and how to maintain change. Committing to talk regularly about such cases, facilitated by a chaplain, hospital ethicist, or anyone with good group skills might be a simple thing to start with. The 4 A's Model is cyclical and it can be used as a way to keep asking those questions, reaffirming commitments, assessing causes, strengths, weaknesses and barriers.
Taking action to resolve moral distress restores integrity and authenticity. Resolving moral distress is about healing individuals, teams, and organizations. As nurses we know that health care is the human being business so it can be messy, and we are not good at self care. Some stress is part of the job, but addressing the moral distress can help turn the negative effects around. Dealing with moral distress is part of ethics capacity. Knowing its going to happen and being able to deal with it, to do the right thing is ethics empowerment.
* References available upon request to email@example.com.
by Kate Payne, JD, RN