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Caught in Conflict

Moral distress can plague nurses who work with life-or-death scenarios

Monday October 19, 2009
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You know it’s time to withdraw ventilator support from your unresponsive patient.

That’s just one possible That’s just one possible source of moral distress — when healthcare professionals feel their core personal values and ethical obligations are in conflict.

“Moral distress is characterized by situations where you can’t do what you believe you should morally do,” says Ann Hamric, RN, PhD, FAAN, associate professor at the University of Virginia School of Nursing, who is also faculty affiliate for the Center for Biomedical Ethics and Humanities and a researcher in moral distress. “It’s nurses perceiving they’re powerless.”

Moral distress jumped into public view when The New York Times published “When Doctors and Nurse Can’t Do the Right Thing” on Feb. 5, 2009. The article generated nearly 300 online comments from readers, many of them healthcare professionals.

The ICU is ground zero for moral distress. “Nurses by far have the most intense and frequent experiences of moral distress,” says Ellen Elpern, RN, APN, who works in critical care at Rush University Medical Center in Chicago. “They spend 12 hours with the patient. They give the blood that’s not going to help, deliver the drugs that aren’t going to help.”

First described in 1984, moral distress is now recognized as a serious workforce issue. A study from the University of Pennsylvania School of Nursing and published in Social Science and Medicine (2007) found 25% of the 1,215 nurses surveyed said moral distress made them want to leave their positions. Another study in the Journal of Advanced Nursing (2008) reported 15% of nurses had left their jobs due to moral distress.

Anxiety, Guilt, and Discomfort
The most common source of moral distress is dealing with end-of-life situations, particularly where there is disagreement about treatment. Other issues include the fair distribution of resources and protecting patients’ rights.

Elpern says a major consequence of moral distress is suffering. She was the co-author of a survey related to moral distress, which was published in the American Journal of Critical Care (2005). “The information that came pouring forth [from the study participants] was wrenching,” she says. Anxiety, guilt, and discomfort all came into play. Nurses reported that moral distress adversely affected job satisfaction, retention, psychological and physical well-being, self-image, and spirituality. Experience of moral distress also influenced nurses’ attitudes toward advance directives (they were more likely to have one) and participation in blood donation and organ donation (they were more likely not to donate because of concerns the donation would be “wasted,” in other words, not used appropriately).

Unfortunately, too often nurses suffer in silence. “Sometimes nurses don’t even realize what the problem is,” says Laura McNamara, RN, MS, CCNS, CCRN, a clinical practice specialist at the American Association of Critical-Care Nurses. “They may feel a general dissatisfaction at work but don’t have a name for it. It can affect interactions with team workers, patients, and even bleed into personal interactions.”

“Merely acknowledging it, naming it, and giving people the opportunity to talk about it is huge,” adds Elpern. Nurses then understand they aren’t alone in what they’re feeling.

Moral distress doesn’t go away. “You don’t get desensitized to moral distress. It’s not that as you work longer in ICU you’re less sensitive to it,” says Elpern.

Communication and Collaboration
“Keeping moral distress to a minimum goes hand-in-hand with the culture of safety and a healthy work environment,” says Maureen Madden, RN, MSN, PNP-AC, CCRN, FCCM, a pediatric critical care nurse practitioner at Bristol Myers Squibb Children’s Hospital at Robert Wood Johnson University Hospital in New Brunswick, N.J. ICUs can create a culture that reduces moral distress by providing an environment rich in communication and collaboration.

The ICU where Madden works holds weekly meetings that include a representative from the physician group (an MD or nurse practitioner), nursing, and ancillary healthcare professionals. “It’s provides the opportunity for an open forum,” she says.

Daily multidisciplinary patient rounds by a team of nurses, physicians, pharmacists, nutritionists, and any other key members is another effective strategy.

“The team focuses on the big picture,” Elpern says. “Do we have a surrogate if the patients can’t speak for themselves? What are the goals of treatment?”

That fits well with a recommendation by Kathleen Dracup, RN, DNSc, dean and professor for the University of California, San Francisco School of Nursing. In an editorial in the American Journal of Critical Care, Dracup and Christopher Bryan-Brown, MD, wrote, “Care plans must contain clear criteria for success or failure so that patient response can be reviewed and communicated each day.”

Communication must be both open and effective, and that depends on collaboration. “A collaborative practice that is communication rich, appropriate staffing, outlets for sharing feelings, respect for each individual, and valuing everyone for their knowledge will help address issues positively and lower moral distress,” says Madden.

Nurses sometimes find collaboration challenging. Hamric says they may feel no one is listening to information they have from their close contact with patients and families. She says nurses need to “insist on being part of the collaborative team and bringing your information into the decision-making process. If we want to be true collaborative partners, we have to speak up.”

If a nurse feels he or she isn’t being heard, Hamric suggests first approaching the physician and saying, “I need to share some information from the family. If that feels risky, work through your manager or advanced practice nurse to set up a meeting.” She adds, “Get support from other nurses so you don’t feel like you are climbing out on the limb by yourself while everyone else is on the trunk waiting for you to fall off.”

When Opinions Collide
“High technology and high invasive care is very appropriate for many ICU patients, but what happens when the quality of life is so diminished that it’s unlikely this patient will have a good quality of life again, or survival is so slim that what we are doing is prolonging pain?” asks Dracup.

When there is disagreement on the answer to that question, multidisciplinary care conferences can help. Another option is an ethics committee. “They evaluate the case and make recommendations,” says Madden. “They try to put more clarity to different viewpoints.”

However, these committees may deal with the ethical issue, but not address the moral distress associated with it, says Hamric. And they may not address moral distress from other sources than the immediate patient situation. That’s one reason the University of Virginia developed a moral distress consultation service. The education coordinator on the unit makes the request, and two facilitators who are part of the service meet with those involved and listen to everyone’s concerns.

“We try to tease out the patient issue, the team issue, the unit issue, and the organizational issue,” she says, adding that it’s important to move beyond a simple “debriefing” to address solutions. “Once the staff is heard and validated, they have many suggestions for solutions that can be pursued.”

“Moral distress is not just a nursing phenomenon,” adds Hamric. “We’re seeing it in all members of the healthcare team.” However, physicians and nurses may react very differently when there is an impasse. “Nurses’ dominant action is withdrawal, while physicians often react with anger,” Hamric says, although she adds there isn’t research data to support these anecdotal reports. Part of the reason for the difference is that nurses may feel they lack control.

When there is a difficult patient situation, the staff at Rush tries to ease the burden for each other by providing respite care for the nurse. The primary nurse is switched to a different patient for the day.

The Family’s Perspective
McNamara emphasizes that it’s important to assess what families really understand because “they are scared and frustrated.” She advises keeping the focus on the patient, perhaps asking the family what his or her loved one would want done. “It’s much easier to say don’t put the patient on the ventilator because there is no hope than to withdraw it,” Dracup syas.

Precise language is key. Nurses or physicians might say, “The labs look better today than yesterday,” even though the laboratory results are still dreadful. “Families will grasp onto words that are fuzzy and could be interpreted with hope,” Dracup says. “We have to be very clear.” She suggests frequent, carefully crafted communication that paints a realistic picture for the family. “We can use survival models such as the APACHE [Acute Physiology And Chronic Health Evaluation] score to help us predict how likely it is for patients to survive,” Dracup says, “And we need to share that information when it’s appropriate.”

Dracup understands the nurses’ challenge. “Patients or family members are sitting there tearfully, and you want to convey hope. But the kinder thing is to give them the real information.”

A Call to Action
“It’s the responsibility of every nurse and every employer to do something about moral distress,” says McNamara. For example, employers can develop code of conduct policies that are enforced. “If you have an administration that turns a blind eye to unprofessional behavior, it would be hard to implement change, but if you have an administration that understands moral distress, it can be so effective in managing it.” Several resources are available for nurses, including AACN’s “The 4A’s to Rise Above Moral Distress,” handbook so they don’t feel alone in dealing with moral distress.

“Find someone who is a source of support for you, you can bounce things off of, who can answer questions — a peer or someone else,” Madden says.

Of course, sometimes the problem requires a system change, which can be challenging. “Change takes time, especially in systems with as many moving parts as a hospital,” says McNamara. But nurses and employers must remember that each play a role in reducing moral distress.

“I don’t think we will ever eliminate it, but we can learn to manage it,” says Hamric.

Cynthia Saver, RN, MS, is president of CLS Development Inc Columbia, Md.


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