EXECUTIVE SUMMARY

Moral distress causes some ICU nurses to consider leaving their positions — and negatively affects patient care. To mitigate this, organizations can:

• improve communication between nurses and physicians;

• track well-being of healthcare providers;

• address systemic issues causing moral distress


A group of researchers set out to learn the most effective ways to decrease moral distress in healthcare. In the process, they discovered the toll it was taking was greater than expected.

“I was stunned to discover that a significant number of ICU nurses have considered leaving their positions because of moral distress,” says Marianne C. Chiafery, DNP, PNP-BC, a clinical ethicist at University of Rochester (NY) Medical Center and an assistant professor of clinical nursing at University of Rochester.

Over a two-month period, 32 nurses from three ICU settings in an 800-bed tertiary academic medical center participated in six “ethics huddles.”1 A nurse ethicist led the discussions. Nurses appreciated the chance to analyze situations that troubled them deeply, says Chiafery, the study’s lead author. “The depth of moral distress ran deeper than I expected.”

The nursing ethics huddles were associated with higher quality of work life, improved patient care, and increased clinical ethics knowledge. Many nurses reported improved communication skills as well. “This was not an intentional goal, but a nice bonus for all involved,” says Chiafery.

Developing solutions to address ethical dilemmas was helpful in decreasing distress. Especially important, says Chiafery, is that someone with ethics expertise is available to:

• help nurses work through difficult situations;

• listen with an empathic ear;

• facilitate conversation and discussion;

• provide ethics education.

“It is vitally important that ethicists, or facilitators with a strong background in ethics and ethical reasoning, meet with staff on a routine basis,” says Chiafery.

Moral distress is nothing new, although there’s much greater awareness of it. “It has been around for a long time,” says Lucia D. Wocial, PhD, RN, FAAN, a nurse ethicist at Fairbanks Center for Medical Ethics at Indiana University Health in Indianapolis.

The fact that people are recognizing that moral distress is a significant concern for all clinical care providers is a “hopeful sign,” says Wocial. “Individual providers as well as organizations are beginning to recognize that it is not just an issue for nurses.”

The National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience, launched in 2017, is one example. It is not enough, though, says Wocial: “Addressing moral distress also depends on a recognition that the culture of healthcare at the unit, organization, and industry level must change.”

Nurse-Physician Communication

As an ICU nurse, Natalie S. McAndrew, PhD, RN, ACNS-BC, CCRN, experienced moral distress many times. Mostly, it involved decisions made by family or providers about life-sustaining interventions at the end of a patient’s life. “Healthcare organizations have to start taking this issue seriously. Otherwise, we will continue to keep losing nurses,” says McAndrew, an assistant professor in the College of Nursing at University of Wisconsin-Milwaukee.

McAndrew conducted several recent studies on moral distress. One explored the relationship between moral distress and the professional practice environment. That study identified communication between nurses and physicians as an important factor.2 “The more we have a good relationship, the more moral distress is going to tend to go down,” says McAndrew.

For example, simply understanding why a provider wants to try one more intervention can decrease moral distress. “That is how you grow as a clinician and do the kind of self-reflective practice that can help you with the next moral distress and the next one after that,” says McAndrew.

Another study explored the differing perspectives of nurses and physicians on end-of-life decision-making in the ICU.3 “Nurses and physicians experience moral distress,” says McAndrew. “The ability to resolve the distress is closely tied to one’s ability to share their moral perspective.”

When team members feel their perspectives about care are not heard, says McAndrew, “it becomes difficult to provide support to patients and families.”

The overall impact of moral distress and effective interventions remained unclear. “We needed a good idea of, ‘What is the state of the science?’” says McAndrew. This led to an analysis of 42 studies from 2009 to 2015 that suggested that moral distress has negative effects on the quality of care.4

“More data on how ethical conflicts and moral distress affects patients and families is needed,” says McAndrew. However, few effective approaches were identified in the literature. “We need to develop more effective interventions to improve patient, family, and provider outcomes,” says McAndrew. Putting metrics in place to assess the well-being of healthcare providers is an important step.

The growing focus on burnout among healthcare professionals has called attention to the problem of moral distress. “I think the burnout that we are experiencing is a manifestation of the ethical conflict that we feel, typically with end-of-life decisions,” says McAndrew.

Unresolved moral distress may be an antecedent to burnout. “Many health professionals will share that they get to a point where they have simply had enough and leave their clinical practice setting, or even the profession,” says McAndrew. Working with symptoms of burnout is a concern too, says McAndrew: “This can negatively impact patient and family care.”

While there’s greater awareness of moral distress, hospital administrators tend to see it as something an individual nurse experiences. Too much emphasis on coping skills can obscure the fact that systemic problems are involved, says McAndrew.

For instance, there may be a policy in place that prevents a family member from remaining at the bedside continuously, for instance. “We want to be careful that we don’t just say, ‘It’s just your problem as an individual and you need to go fix yourself,’” says McAndrew.

Also largely unrecognized: that physicians and other disciplines are adversely affected by moral distress. Often, it’s viewed as purely a nursing issue.

“Physicians’ voices are heard over the nurses’ voices, and the nurse gets caught up in the middle of the physician and family,” says McAndrew. “We need to work together in this.”

REFERENCES

1. Chiafery MC, Hopkins P, Norton SA, et al. Nursing ethics huddles to decrease moral distress among nurses in the intensive care unit. J Clin Ethics 2018; 29(3):217-226.

2. McAndrew NS, Leske JS, Garcia A. Influence of moral distress on the professional practice environment during prognostic conflict in critical care. J Trauma Nurs 2011; 18(4), 221-230.

3. McAndrew NS, Leske JS. A balancing act: Experiences of nurses and physicians when making end-of-life decisions in intensive care units. 
Clin Nurs Res 2015; 24(5), 357-374.

4. McAndrew NS. Nurses and physicians bring different perspectives to end-of-life decisions in intensive care units. Evid Based Nurs 2018; 21(3):85.

SOURCES

• Marianne C. Chiafery, DNP, PNP-BC, Assistant Professor of Clinical Nursing, School of Nursing, University of Rochester (NY). Phone: (585) 276-5184. Email: marianne_chiafery@urmc.rochester.edu.

• Natalie S. McAndrew, PhD, RN, ACNS-BC, CCRN, Assistant Professor, College of Nursing, University of Wisconsin-Milwaukee. Phone: (414) 229-5701. Email: mcandre3@uwm.edu.

• Lucia D. Wocial, PhD, RN, FAAN, Nurse Ethicist, Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis. Phone: (317) 962-2161. Email: lwocial@iuhealth.org.