What Is Moral Distress in Nursing?

Have you ever felt that a treatment or intervention that you have to perform does more harm than good for your patient? Or, maybe you felt like family members made decisions because of finances that caused a patient more pain than necessary? Sometimes, as a nurse, you have to go against your own ethical judgments to do your job.

Situations like these can cause moral distress for clinicians, like nurses, nurse aides, nurse practitioners, and other team members. Over time, going against your own moral judgment can erode your sense of self, and compounding moral injury is closely related to nurse burnout and fatigue. It even contributes to post-traumatic stress disorder (PTSD), of which nearly 19% of nurses exhibit symptoms.

Conversations around moral injury amongst healthcare workers have exploded since COVID-19 began. Nurse moral distress can happen in nearly every clinical setting, and it results in feelings like guilt, shame, disgust, anger, and the inability to forgive yourself.

If you’re a nursing professional, chances are you’ve experienced this — more than 8 in 10 nurses have. Learning about this prevalent problem can help you understand your options and your resources so you can protect your mental health.

What Is Moral Distress in Healthcare?

When you know the right action to take, but institutional constraints make it next to impossible to pursue that course of action, you’re experiencing moral distress. At its root, it’s an ethical problem for you as a clinician when you have to deliver interventions that go against your own convictions.

This dilemma can feel like an individual problem, because it’s something you feel personally. But in reality, it’s usually created by the systems that clinicians work in. It happens when ethical problems aren’t being addressed adequately at the system level. External factors that contribute to moral conflict include:

• Financial considerations
• Power differentials amidst the healthcare team
• Inadequate staffing
• Inappropriate care plans
• Risk of litigation
• Lack of communication
• Inappropriate use of resources

Even though these problems exist at the system level, it often comes down to clinicians like nurses dealing with the ethical dilemmas they cause. And some specialties may increase your risk of specific types ethical dilemmas, like:

• Neonatal and pediatric intensive care (NICU and PICU) and clinicians may feel powerless when parents act against an infant’s or child’s best interest.
• Nurses who work in long-term care may deal with chronic understaffing, confused or combative patients, and facility decisions that are financially driven.
• Emergency department staff encounter situations where resuscitation efforts are futile, but family members demand extensive measures.
• Mental health nurses may experience ethical distress when discharging a patient, knowing that they don’t have the supportive community or financial resources they need.

It might look different in every specialty, but if you’ve experienced moral conflict, know that it’s not your fault. One of the more challenging aspects of this problem is that clinicians may not see it when it’s happening to them. How can you recognize it in yourself and your peers? Let’s take a look at two examples in nursing practice.

Moral Distress: 1

Andre, a dedicated neonatal intensive care unit (NICU) nurse, is caring for a premature baby born at just 24 weeks. The baby weighs only 600 grams and has a severe intraventricular hemorrhage, sepsis, and underdeveloped lungs. The medical team has conducted extensive assessments, indicating an extremely low chance of survival, and a high probability of severe neurological disabilities if the baby pulls through.

Andre is well-versed in NICU cases, and he comprehends the gravity of the situation. He witnesses the baby’s tiny body hooked up to whirring machines, the ventilator breathing for them, and monitors displaying alarming numbers. He recognizes the immense suffering the baby is enduring. Yet, the parents, driven by hope and love, express their desire for the medical team to do everything possible.

In this challenging context, Andre grapples with his knowledge of the baby’s critical condition. He knows the odds are overwhelmingly against a positive outcome. He is torn between the parents’ understandable desperation, and his part in the baby’s suffering. Andre’s expertise tells him that even if the baby survives, they will likely face a life of profound disability and pain. Yet he has to personally carry out a care plan that he does not believe in.

Moral Distress: Example 2

Candace works on a heart failure unit in a large medical center, and tonight she’s caring for Mr. Thompson, a 78-year-old man with advanced heart and liver disease.

On this particular night, Candace finds herself stretched thin, juggling seven patients with varying needs. Their unit doesn’t have the staff to supervise Mr. Thompson one on one, yet he is confused and doesn’t understand the bed alarm. Despite her best efforts to keep a close watch, Candance can’t be everywhere at once. In a moment of unfortunate timing, Mr. Thompson attempts to get out of bed without assistance, falls, and hits his head.

Candace rushes to the room at the sound of the bed alarm and finds Mr. Thompson on the ground. She calls the rounding team to evaluate him, and his blood pressure is dangerously low. The team rushes Mr. Thompson to the intensive care unit, where he later needs to be intubated after sustaining a cerebral hemorrhage during the fall.

Candace knows that this turn of events could likely have been prevented with proper nurse staffing — an extra pair of eyes could have ensured that Mr. Thompson didn’t attempt to move without assistance. It isn’t her fault that Mr. Thompson fell, yet she feels guilty that it happened on her watch.

Effects of Moral Distress in Nursing

This issue contributes to problems for individual nurses and whole healthcare systems. When situations like these happen over time, they can lead to moral injury in healthcare workers and problems with retention and short staffing at the system level. And these system-wide problems can further put more clinicians into ethical problems, worsening the cycle of moral discord. For individuals, the compounding effects may look like:

• The crescendo effect: Each distress situation intensifies the emotional response, leading to heightened reactions in similar circumstances.
• Burnout: Feelings of hopelessness and lack of motivation in the workplace.
• Cynicism: Growing skepticism and negative attitudes towards the healthcare system.
• Detachment: Emotional withdrawal from colleagues and patients, known as compassion fatigue.
• Reduced commitment and integrity: Decreased dedication to the profession.

Experiencing moral injury over time can make nurses lose their commitment to the job. And for healthcare systems, the consequences of moral injury impact patient care when staff leave the bedside and become less motivated in their roles.

How to Deal With Moral Distress in Nursing Practice

If you get into a situation where you have an ethical dilemma at work, consider following these steps to alleviate your distress:

1. Identify the source: This may be a specific treatment in the care plan, a policy problem, a communication issue with the team, or something else.

2. Do a self-assessment: The Moral Distress Thermometer is an assessment tool that you can use to gauge your distress and learn how urgently you need to act.

3. Develop a plan: Use the resources in your facility to address the problem. Resources that may be helpful include:

• Your charge nurse, a peer, or your unit manager
• The medical team
• Pastoral care
• The ethics committee

4. Communicate: Go to your charge nurse, nurse manager, or division supervisor, and describe the problem you’re having. Even if the issue you are having is with the medical team, escalate via the nursing chain of command.

5. Document: Make sure you have adequate documentation of the issue. This should not necessarily be in the patient’s chart, although that may be appropriate depending on the case. Document your conversations with family, staff members, and the patient.

In most facilities, anyone involved in a patient’s care can request a consultation with the ethics committee. If you feel that this problem needs supervision from the ethics team, don’t hesitate to reach out to them. But is it possible to stop these problems from happening in the first place?

How to Prevent Moral Distress in Nursing

Unfortunately, many of these ethical problems come from faults in the healthcare system at large. As an individual, it’s not up to you to shoulder the responsibility of solving such systemic problems. But there are things you can do to advocate for nurses and for better ethical practices in healthcare:

• Become an ethics champion on your unit.
• Join the ethics committee.
• Do debriefing sessions with your peers.
• Participate in shared governance.

Ready to Find a New Opportunity?

Moral distress is a challenging part of being a nurse, and if it’s affecting your mental health, it may be time to change specialties or roles. If you’re needing a job change, IntelyCare can help you find nursing jobs that better fit your life.