By Marilyn Williams
Moral distress was first defined by Andrew Jameton in 1984 as a phenomenon that occurs when nurses believe they cannot act in ethically appropriate ways due to institutional constraints. Later researchers extended constraints to include internal constraints, including a sense of powerlessness and a lack of knowledge or understanding. (Jameton, 1984) Moral distress is characterized by psychological disequilibrium or painful feelings. (Kelly, 1998) Psychological characteristics of moral distress include frustration, anger, guilt, anxiety, depression, withdrawal, self-blame, and reduced self-worth. Furthermore, research has shown that nurses experiencing moral distress reported physical symptoms of headaches, back pain, and stomach pain. (Schluter et al, 2008)
Jameton theorized there are two components of moral distress: an initial distress of an acute nature that occurs as a situation evolves, and a reactive distress or moral residue that remains later when the initial distress is not addressed. Based on later research, Webster and Bayliss (2000) defined moral residue as “that which each of us carries with us from those times in our lives when in the face of moral distress we have seriously compromised ourselves or allowed ourselves to be compromised.” Moreover, Epstein and Hamric proposed in a 2009 research article a model they called the crescendo effect to describe the interrelationship between moral distress and moral residue based on an empirical study of NICU nurses and physicians. (Epstein and Hamric, 2009) Thus, when chaplains encounter initial moral distress, it is vital that they address it effectively in order to cope with future ethical situations.
Pastoral Response to Moral Distress
The research regarding moral distress is dominated by nursing; one of the few articles from a healthcare chaplain’s perspective is a 2014 article by Michael Guthrie, a chaplain at the Denver children’s hospital. (Guthrie, 2014) Although not based on quantitative or qualitative research, this article provides a nice review of the literature from a chaplain’s perspective as well as “food for thought and reflection” regarding the pastoral response to moral distress. Guthrie presents a theoretical case study involving a critical care nurse experiencing moral distress and her encounter with the chaplain. Building on the premise of Lutzen and Kuist (2012) that moral distress could actually strengthen an individual’s exercise of moral agency, Guthrie suggested that the chaplain can help facilitate the growth of character as well as healing of the one experiencing moral distress.
As such, he asserts that calling for an ethics consultation in the case presented would be a negative vs. a pastoral response. Instead, he says the initial goal should be encouraging the safe sharing of her story and emotional response. Then he outlines a pastoral response.
This article might be helpful to other chaplains in reflecting on their own pastoral practice when they encounter moral distress. Furthermore, it could help in formulating a model of pastoral intervention for a research study that would look at whether such an approach helps ameliorate moral distress in nurses or other healthcare professionals.
Nursing Research on Moral Distress
Reviewing the nursing research can help pastoral practice regarding moral distress. One of the earliest and foremost nursing researchers is Mary Corley; her first study of 111 members of the Association of Critical Care Nurses appeared in 1995. This study concluded that the three factors most associated with moral distress were aggressive care (unnecessary tests and treatments) at the end of life, lack of honesty with patients/families, and inadequate/incompetent treatment by physicians. This study also indicated that 12% had left a position due to moral distress. (Corley, 1995)
Then in 2001, Corley and her co-investigators published their landmark study of their moral distress scale, which is still being used with little modification. This instrument, initially 32 items and revised later to include 38, utilizes a 7-point Likert format — the higher the score, the higher the degree of moral distress. The scale has shown to be reliable and valid in measuring moral distress; mean scores of 3.9 to 5.5 indicate moderately high levels of moral distress. This scale has also been used with other healthcare professionals besides nursing.
Much of the nursing research has focused on the correlations between work constraints (e.g., policies and procedures, staffing level, leadership style and support, communication issues, lack of empowerment, ethical climate) and the degree or intensity of moral distress. Of course, correlation does not mean these factors cause moral distress. For example, Pauly et al (2009) showed an inverse correlation between ethical climate and moral distress.
Likewise, a 2012 Netherlands study of 365 nurses employed in different settings indicated that those with less job satisfaction also had higher moral distress scores. This same study showed that most moral distress occurred when nurses perceived a discrepancy between wishes of the patient and of the family, physician-nursing disagreement, and perceived unsafe staffing levels. (de Veer, et al, 2012) Interestingly, the Netherlands study also showed a higher level of moral distress for nursing home nurses than those in acute-care hospitals.
In other studies, however, especially in the U.S., the only subjects have been critical care nurses. There are significant differences in end-of-life care among countries that may impact the frequency and intensity of moral distress. Exploring this could make for worthwhile research. Of interest is a research protocol regarding moral distress in EOL care in the ICU published in 2013 for a study currently taking place in the United Kingdom. The results of the study could be thought-provoking to chaplains, since it uses a qualitative methodology of narrative inquiry for three categories of EOL situations occurring in intensive care and will look at moral distress in nurses, physicians, and relatives. (St. Ledger, et al, 2012)
Being familiar with the research on moral distress provides the chaplain with an additional context of how the work environment might contribute to moral distress beyond the specific situation, which could lead to more effective pastoral care. Future research could benefit from including chaplains on research teams. Research regarding the use and effectiveness of pastoral interventions could especially be helpful to those hurt by moral distress, as well as the institutions and ultimately the patients they serve. In addition, there appears to be no research yet regarding moral distress that chaplains may experience.
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