The Ethical Quandary of Moral Distress
When nurses cannot ‘do the right thing’
Imagine you are nurse treating a cancer patient.
You are aware that the patient is suffering and no longer wants to be treated, yet family members push for continuing chemotherapy in hope of a cure. The patient continues treatment to appease this aim, suffering personal misery and giving rise to what nursing researchers term “moral distress” in the caregiver.
This condition is distinct from other emotional states caused by the pressures and obstacles that make healthcare such difficult work, explains Cynda Hylton Rushton, PhD, RN, FAAN, who participated in a symposium on the topic and was the lead author of a resulting paper.1
“Although it has overlapping characteristics, it is often distinguished from other emotional states by its focus on the moral or ethical aspects of the situation,” says Rushton, a professor of clinical ethics in the Johns Hopkins Berman Institute of Bioethics and the School of Nursing.
Rushton and colleagues outline a path to “moral resilience” for nurses and other healthcare workers feeling conflicted about a given situation and the inner desire “to do the right thing.” Moral distress is more likely to occur as healthcare complexity increases, leading to ethically challenging scenarios that may contribute to burnout, they report.
Some of the building blocks for moral resilience cited in the paper include mindfulness meditation, ethics education, and organizational support. Thus, individual action within a broader framework of culture change is required.
“Addressing moral distress requires both individual and organizational strategies — neither is sufficient alone,” Rushton tells Hospital Employee Health. “A misconception about moral resilience is that it suggests that one is ignoring or being complacent about the real and complex ethical issues that are present in our workplaces. On the contrary, skills such as mindfulness offer the foundational mental and emotional stability that is needed for conscientious clinicians to recognize and respond to threats or violations of personal and professional integrity. Without such stability, clinicians risk causing harm to themselves and others.”
Clinicians also need to cultivate “moral efficacy” — the ability to recognize, deliberate, and act in ways that are aligned with their personal and professional ethical standards, Rushton notes.
“In order for moral distress to be addressed effectively, clinicians must practice in environments that support ethical practice [through] such structures as ethics committees, employee assistance programs, policies, and processes that support clinicians,” she says.
This will require moving beyond “either/or thinking” and realizing there is some interplay between individual moral beliefs and the ethical mindset of their place of employment, she notes.
- Ruston CH, Schoonover-Shoffner K, Kennedy MS. Executive Summary: Transforming Moral Distress into Moral Resilience in Nursing. American Jrl Nursing 2017;117(2)52–56.
Clinicians need to cultivate “moral efficacy” — the ability to recognize, deliberate, and act in ways that are aligned with their personal and professional ethical standards.
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