By Fr. Bryan Lamberson
Although the earliest discussion about moral distress in medical literature dates back to the early 20th century, philosopher Andrew Jameton is widely regarded as the first to offer a thorough treatment of the phenomenon in the modern era. In his 1984 book Nursing Practice: The Ethical Issues, Jameton described moral distress as psychological disequilibrium, 
painful feelings that result from recognizing an ethically appropriate action but failing to take that action. This inability to act can be the result of either internal (personal) or external (institutional) constraints on taking the “right” action (Fig. 1). Stated simply, moral distress occurs when one knows the ethically correct action to take but feels powerless to take that action.
| Fig. 1: Constraints Involved in Moral Distress | |
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Internal Constraints Lack of assertiveness Inadequate staffing Self-doubt Being socialized to follow orders Perceived powerlessness Incomplete understanding Of the situation |
External Constraints Hierarchies within the healthcare system Lack of collegial relationships Lack of administrative support Policies/priorities conflicting with care needs Fear of litigation |
A precise understanding of what constitutes moral distress is necessary, as the terminology can be confusing. For example, bioethics has long placed greater emphasis on ethical dilemmas than on moral distress. They are not the same thing. Ethical dilemmas speak to the ethical justifications when considering alternative courses of action (clinical, legal and spiritual components), whereas moral distress begins after the fact, and involves the social and organizational issues at play, along with a consideration of personal feelings and explorations of accountability and responsibility.
Moreover, moral distress is qualitatively different from emotional distress. Emotional distress is more common; it can be found in stressful work environments but not have an ethical element, which can be the source of an individual’s moral distress. Thus a moral element, not characteristic of emotional distress, is present. This moral element differentiates emotional distress from moral distress.
Long-term exposure to events causing moral distress can result in moral residue. Powerfully integrated into one’s thoughts and views of the self, it is this aspect of moral distress — the residue that remains — that can damage the self and one’s career, particularly when morally distressing episodes are repeated over time.
Among the most frequently cited causes of moral distress in the clinical realm are those identified as follows (Fig. 2).
| Fig. 2: Clinical Causes of Moral Distress | |
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Continuing life support when not in the patient’s best interest Initiating lifesaving actions that merely prolong dying Inappropriate use of resources (stewardship) Inadequate staffing or inadequately trained staff Inadequate communication about end-of-life care (especially with families) Following family’s wishes out of fear of litigation Providing inadequate pain relief Providing false hope to patients and families |
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Moral distress involves a threat to one’s moral integrity — that sense of wholeness and self-worth that comes from having clearly defined values that are congruent with one’s perceptions and actions.
Moral distress is clearly not just a nursing issue, but one that influences all healthcare professionals. It can be one of the key issues affecting the workplace environment. Moral distress causes existential suffering such as a sense of isolation, feeling unheard and devalued. It leads to compassion fatigue and may result in resignation if left unresolved. Groups of people who work together in situations that cause distress may experience poor communication, lack of trust, high turnover rates, defensiveness and a lack of collaboration across clinical disciplines
Most research and literature on the topic has focused on identifying the signs, inherent dynamics, and effects of moral distress. Methods focusing on how to alleviate it are less abundant. The following list (Fig. 3) incorporates a variety of agreed-upon strategies from the literature on how to achieve healthy resolutions.
| Fig. 3: Strategies to Address Moral Distress | |
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Speak up: recognize and name moral distress, dialogue with other parties involved Build support networks that empower speaking with one voice Focus on desired changes that preserve moral integrity Address causes in institutional culture that perpetuate distress and hinder collaboration among team members Develop policies that permit any provider to initiate ethics consultations |
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For a report on a promising pilot program addressing the issue, see “Schwartz Center Rounds Help Alleviate Moral Distress” by our colleague Karen Pugliese in the November-December 2015 issue of Vision.
Addressing moral distress and its causes should be part of any organization’s initiatives to create a healthy workplace environment. The benefits related to staff satisfaction, retention and productivity alone make support for such initiatives critically important to an organization’s leadership. If organizations are to remain true to stated core values such as compassion, respect, excellence, and integrity, finding solutions to moral distress is an ethical imperative. For chaplains and spiritual care providers, familiarity with and sensitivity to the signs of moral distress will provide opportunities to be of greater service to our colleagues.
Bryan Lamberson, BCC, is priest/chaplain at Sts. Mary & Elizabeth Hospital in Louisville, KY.
