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Recognizing and dealing with moral distress.

Have you ever been in a situation in which you knew the right thing to do, but couldn't or didn't do it? Or been caught between a patient's wishes and a provider or system that is not supportive of those wishes? If so, you've probably experienced moral distress. And you're not alone. Studies over the last decade have shown an increase in the frequency of moral distress experienced by nurses (Ulrich, Lavandero, Woods, & Early, 2014).

Moral Distress--What It Is

Moral distress is not a new concept. The term was first discussed by Jameton in 1984, who defined moral distress as "when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action" (p. 6).

The American Association of Critical-Care Nurses (2004) described moral distress as occurring "when you know the ethically appropriate action to take, but are unable to act upon it or you act in a manner contrary to your personal and professional values, which undermines your integrity and authenticity" (p. 1).

Recognizing Moral Distress

The first step in addressing the issue is to recognize that it exists. Moral distress often manifests as physical symptoms (e.g., insomnia, fatigue); emotions such as anger, anxiety, and apathy; and questioning one's own competency and confidence. Having open discussions with colleagues about potential moral distress issues can make them easier to recognize when they occur. Debriefing after actual moral distress incidents can also raise everyone's consciousness to recognize the symptoms earlier in the future.

Dealing with Moral Distress

Nurses and organizations both have roles in dealing with moral distress. Nurses are responsible for preparing themselves to deal with moral distress and the issues that can cause it. The best time to think about moral distress is before it happens. Role playing moral distress scenarios can be very helpful, especially for novice nephrology nurses.

Organizations are responsible for creating positive, supportive work environments, ensuring that their nurses and other caregivers are prepared to deal with morale distress issues, and providing processes that allow honest discus sions while maintaining respect for all participants. Managers and administrators also need to be aware of the symptoms of moral distress and be prepared to help their employees work through the issues.

Moral Distress in Nephrology Nursing

Nephrology nursing is ripe with opportunities for moral distress. When you combine the varying views and desires of patients, their families, nurses, physicians, and other healthcare providers with the life and death decisions made in nephrology settings every day, you have a myriad of opportunities for moral distress situations to occur. Who should be dialyzed? Who should receive organs for transplantation? When should a patient stop dialysis? What are a nurse's, a physician's, or an organization's responsibilities to patients who do not seem to be taking responsibility for themselves?

Nephrology nurses have a long history of dealing with issues that can result in moral distress, dating as far back as the selection committees of the 1960s. Despite our experience, we have not yet reached the consistent level of transparency, preparation, and support needed to successfully prevent and manage moral distress in all nephrology nurse practice settings. It is a need that should be addressed by nephrology nurses and nephrology organizations.

Beth Ulrich, EdD, RN, FACHE, FAAN



American Association of Critical-Care Nurses. (2004). Position statement: Moral distress. Aliso Viejo, CA: Author.

Jameton, A. (1984). Nursing practice: The ethical issues. Upper Saddle River, Nj: Prentice-Hall.

Ulrich, B.T., Lavandero, R., Woods, D., & Early, S. (2014). Critical care nurse work environments: A status report. Critical Care Nurse, 34(4), 54-79. doi:10.4037/ccn2014731. Retrieved from
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Author:Ulrich, Beth
Publication:Nephrology Nursing Journal
Article Type:Letter to the editor
Date:Jul 1, 2017
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