When ICU nurses at the University of Virginia Health System were experiencing a serious issue with moral distress, they asked Ann B. Hamric, PhD, RN, for help.

“We had tried a number of strategies to help staff with moral distress, most involving a lunchtime discussion,” says Hamric. But staff had a hard time getting off their units to attend.

Hamric, former associate dean of academic programs at Virginia Commonwealth School of Nursing and co-chair of the American Academy of Nursing’s Bioethics Expert Panel, is part of a research team studying moral distress in ICUs in Vancouver, British Columbia, Canada.

“It was evident that moral distress was continuing in some areas,” says Hamric. “I realized that a consultation model might be helpful in targeting our efforts.”

There were many challenges in creating the moral distress consultation service. First, interested clinicians had to be identified. “Our early moral distress consultants were not necessarily on the ethics committee,” notes Hamric. “I just approached people who I thought would be good for this, and willing to learn.”

The service started with about seven consultants, who worked in pairs. “Then, we had to teach ourselves how to do consults for this problem,” says Hamric. “The classic ethics consultation process did not really ‘fit’ moral distress.”

Next, it was necessary to publicize the service throughout the organization. “Nurses were the first discipline to raise the issue of moral distress and ask for help. So, we started with them,” says Hamric. “But even that was challenging.” It required ongoing communication to units.

Another challenge was educating administrators and clinicians about the sensitive nature of the morally distressing issues that were uncovered, and the need for system support. For instance, if the issue was the structure of a medical service, then support from the medical director of the service and the system administrator would be necessary.

“The goal is to address moral distress when it occurs, and intervene effectively,” says Hamric.

Part of the process entailed educating staff about how to minimize moral distress on their units and teams. Data is gathered after each consult.

“We think the data show that the moral distress consultation service can be a useful intervention in helping create a more ethical practice environment,” says Hamric.

The Moral Distress Consultation Service is now a part of the Ethics Consultation Service. Consultants are trained in both types of consults. “This merger was very important in the sustainability of the service,” says Hamric.


  1. Hamric AB, Epstein EG. Health system-wide moral distress consultation service: Development and evaluation. HEC Forum 2017; 29(2):127-143.


  • Ann B. Hamric, PhD, RN, Professor Emeritus, School of Nursing, Virginia Commonwealth University, Richmond. Email: abhamric@vcu.edu.