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MORAL DISTRESS Nurses experience

MORAL DISTRESS Nurses experience stress in clinical practice settings as they are confronted with situations involving ethical dilemmas. Moral stress most often occurs when faced with situations in which two ethical principles compete, such as when the nurse is balancing the patient’s autonomy issues with attempting to do what the nurse knows is in the patient’s best interest. Though the dilemmas are stressful, nurses can and do make decisions and implement those decisions. Moral distress, first described within the discipline of nursing by Jameton (1984), is a negative state of painful psychological imbalance seen when nurses make moral decisions, but are unable to implement these decisions because of real or perceived institutional constraints. This author acknowledged that there are three categories in this phenomenon: moral uncertainty, moral dilemma, and moral distress. Moral uncertainty is characterized by an uneasy feeling wherein the individual questions the right course of action. Generally, this uncertainty is short lived. Moral dilemma, according to Jameton (1984), is characterized by conflicting but morally justifiable courses of action. In such a dilemma, the individual is uncertain about which course of action should be enacted. Moral distress involves the individual knowing the ethical course of action to take, but the individual cannot implement the action because of institutional obstacles. Seen as a major issue in nursing today, moral distress is experienced when nurses are unable to provide what they perceive to be best for a given patient. Examples of moral distress include constraints caused by financial pressures, limited patient care resources, disagreements among family members regarding appropriate patient interventions, and/or limitations imposed by primary health care providers. Moral distress may also be experienced when actions nurses perform violate their personal beliefs. A study by Zuzelo (2007) concluded that the primary sources of moral distress included the following: • Resenting physician reluctance to address death and dying • Feeling frustrated in a subordinate role • Confronting physicians • Ignoring patients’ wishes • Feeling frustrated with family members • Treating patients as experiments • Working with staff members perceived as inadequate (pp. 353 – 356). These themes were present in nurses practicing in multiple care settings who work with various populations of patients across the lifespan. A later study by Pauly and colleagues (2009) concluded that high levels of moral distress for nurses in clinical settings involved “nurses’ own feelings of competency and their confidence in the competence of registered nurses” (p. 569). Corley (2002) had found in an earlier study that lack of adequate education in nursing ethics, specifically in being able to apply ethical decision-making models, may also account for some of the moral distress experienced by nurses in clinical settings. He further noted that there is a relationship between moral distress, nurse satisfaction, and nurse attrition. Moral distress may be further subdivided into initial moral distress and reactive moral distress (Jameton, 1993). Nurses who are experiencing initial moral distress generally experience frustration, anger, and anxiety when confronted with value conflicts and institutional obstacles. This frustration, anger, and anxiety result from being prevented from doing what the nurse sees as the correct course of action. Reactive distress incorporates negative feelings when the nurse is unable to act on his or her initial distress. Reactive distress involves the inability to identify the ethical issues involved or may result from a lack of knowledge regarding possible alternative actions. Signs and symptoms of reactive moral distress include powerlessness, guilt, loss of self-worth, self-criticism, and low self-esteem and physiologic responses such as crying, depression, loss of sleep, nightmares, and loss of appetite. In extreme cases, moral distress may culminate in moral outrage, causing burnout and inability to effectively care for patients. The impact of moral distress among nurses can be quite serious. There is evidence that moral distress com-

promises patient care and that moral distress may be manifested in such behaviors as avoiding or withdrawing from patients (McAndrew, Leske, & Garcia, 2011). Their study noted that nurses who experienced moral distress may avoid aspects of patient care, decreasing the nurse’s role as patient advocate and further contributin