Moral Distress: Are There Solutions?

By Georgia Gojmerac-Leiner

Much research has been done on moral distress and its effects on those who experience it. Epstein and Delgado credit Andrew Jameton for defining moral distress in 1984 “as a phenomenon in which one knows the right action to take, but is constrained from taking it.”¹ Moral distress has become prevalent in our medical settings to such a degree that we yearn to find some solutions to the dilemmas of caregivers. It can be experienced by a variety of caregivers and in a variety of circumstances. As a chaplain, I experienced some moral distress directly and some vicariously through nurses, aides, therapists, and physicians.

For instance, a case came to an ethics rounds with a question: “Should an ICU patient have CPR?” The particular case was of an 87-year-old woman who was a DNR resident at a long-term care facility. But the DNR order did not come with her to the hospital. The ICU attending physician wrote to have her resuscitated should she code. The nurse assigned to care for the patient became conflicted about calling code blue for the patient should it be necessary. Her moral distress arose from her belief that the resuscitation would harm the frail patient; her ribs would be broken in the process.

The members of the ethics rounds discussed the case in depth and provided emotional support to the nurse. The consensus was that the patient should not have CPR if she coded. But the physician was not present at the discussion, and the ethics team could do no more than make a recommendation. The case was complicated by the fact that the woman had no family, only a legal guardian who was not very involved in her care. Although the nurse felt supported by the ethics team she still faced having to follow doctor’s orders against her principle if the patient coded. The only other recourse would have been for the nurse to engage the physician in a discussion, along with the help of nursing administration and the hospital administration if needed.

Moral distress is an ethical concern, but some researchers have found that “traditional ethics education that focuses on ethical dilemmas and underlying principles is inadequate to address situations involving moral distress.”² Thus nursing professionals have proposed other means to help nurses deal with their moral distress.

While solving or eliminating moral distress may not be a realistic goal, some protocols and strategies can potentially ease it. A senior director of the American Association of Critical-Care Nurses, Ramon Lavandero, declared that “Our challenge isn’t to eliminate moral distress; it is becoming part of our new normal and not going away, so our new goals have become learning how to recognize and address it effectively.” He further explained that moral distress can be experienced not only at the end-of-life decision-making but also “in situations that involve workarounds, bullying and disasters.”

Lavandero and his colleagues offer the following 10 best practices for addressing ethical issues and moral distress. They say that organizations should:

1. Support the nursing code of ethics
2. Offer ongoing education
3. Create an environment where nurses can speak up
4. Bring different disciplines together
5. Provide ethics experts
6. Add unit-based ethics mentors
7. Hold a family conference
8. Sponsor ethics journal or book clubs
9. Reach out to professional associations
10. Offer employee counseling services.

Additionally, the Ethics Work Group of the AACN has developed a practical tool called “The 4A’s to Rise Above Moral Distress.” The four steps are Ask, Affirm, Assess, Act. This reflective document offers succinct definitions and can easily be adapted for professionals other than nurses, such as chaplains. The resource begins by answering questions, such as:

• What is moral distress?
• What are the sources of moral distress?
• What does moral distress feel like?
• What are the barriers to taking action?

The 4A’s guidelines begin with the person, asking her to self-reflect. The guidelines then lead the person through the process of self-affirming and self-assessing, and making the commitment to act. First, though, they need to “Contemplate (their) readiness to act.”

The resource usefully categorizes the common responses to suffering into four types: physical, emotional, behavioral, and spiritual. Under each of these categories are lists of examples of how suffering manifests itself in a person experiencing moral distress. The lists show how the experience of moral distress can be personally devastating and professionally detrimental. The 4A’s is an entirely practical resource for taking action, along with the 10 best practices discussed above.

In the case of “Should an ICU patent have CPR?” mentioned at the beginning of this article, the nurse would have benefited from reading the portion of 4A’s that deals with the 4R’s: Relevance, Risk, Rewards, Roadblocks. For a copy of the 4A’s brochure, click here.

These are some of the best practices found in the literature addressing moral distress. The next step for research might be to study the effectiveness of these practices.

Georgia Gojmerac-Leiner, D. Min., BCC, is a former chaplain at Emerson Hospital in Concord, MA.

¹ Epstein, Elizabeth G. and Sarah Delgado, Understanding and Addressing Moral Distress,” The Online Journal of Issues in Nursing, September 10, 2010, pg. 1
² Ibid, pg. 3