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By Heather Stringer
Moral distress is a game changer
EDITOR'S NOTE: Heather Stringer is a freelance writer.
Catherine Hiler, DNP, RN, CCRN, had experienced the deleterious effects of moral distress for nine years during her career in critical care before she decided to leave the bedside and pursue a job in nursing education.
“I was in a constant state of anxiety, and it started to manifest as physical symptoms like shoulder pain, muscle tightness and fatigue,” said Hiler, DNP, RN, CCRN, now an assistant professor of nursing at the Jefferson College of Health Sciences in Roanoke, Va. One of the major stressors in her work as a cardiac intensive care nurse was providing treatment that conflicted with her moral beliefs and these situations often included requests from family members to continue life-sustaining medical interventions even when patients were not improving.  To better understand the causes of moral distress, Hiler conducted a national study of 328 nurses, and her findings were released in January in the American Journal of Critical Care. Responses from survey participants revealed the severity of moral distress was significantly associated with a nurse’s intention to leave his or her profession — 73% of the respondents had considered leaving their jobs in the last six months. Similar to her own experience as a nurse, Hiler also found moral distress occurred most frequently when the wishes of the patient’s family to continue life support were followed even though the nurse believed doing so was not in the best interest of the patient.
Multidisciplinary methods for mitigating stress
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Although the consequences of moral distress are sobering, Hiler’s study showed there are factors that decrease this form of stress among nurses, such as increased participation in hospital affairs like shared governance. Nurses who experienced support from nurse leadership and collegial relationships with physicians also reported less moral distress.

The data from the study also revealed nurses employed in a Beacon-recognized unit — an honor awarded by the American Association of Critical-Care Nurses to hospitals that have a positive and supportive work environment — experienced less moral distress. Although there are a variety of ways organizations can attempt to decrease moral distress, Rushton’s experience as an ethics consultant informed her decision to tackle the issue by developing a program that focused on building moral resilience in nurses. During six four-hour sessions taken over the course of three months, nurses from Johns Hopkins enrolled in the Mindful Ethical Practice and Resilience Academy learned self-regulation, moral discernment and how to take action by voicing concerns.  “One thing that is very different about this program is that it is experiential, not a passive didactic course in which an expert does most of the talking,” said Rushton, who launched the program in 2016. “The participants engage in reflective practice and discover their own solutions rather than being told what to do.” Nurses practice guided meditation every day and learn to pay attention to their minds and bodies throughout the day. In one of the sessions, participants spend time exploring their personal values and beliefs and learn how to recognize opportunities to bring their voices into an ethics conversation. They also practice communication strategies that will promote productive conversations about difficult topics and enhance their advocacy skills. “What we’ve noticed is that nurses often lose track of their sense of purpose and meaning, and then discount the value of their contribution,” Rushton said. “We invite them to recognize the incredible value they bring to patients and families, and how to see themselves as effective moral agents that belong in these difficult conversations.” Rushton also encourages nurses to avoid statements like “Why are we doing this?” when talking to physicians about interventions, and instead start with affirming their shared commitment to the patient. Then they can offer their perspective on the situation and suggest new questions or directions. More than 100 nurses have completed the program, with preliminary data showing participants trending toward improved work engagement, ethical confidence and competence. “The feedback from the participants has been overwhelmingly positive,” Rushton said. Nurses often enter the program depleted, discouraged and questioning their decision to become a nurse and they leave with renewed enthusiasm and connection to their work, she said.
“There has been a shift in many ICUs to having more patients who are chronically and critically ill,” said Cynda Rushton, PhD, RN, FAAN, the Anne and George L. Bunting Professor of Clinical Ethics in the Johns Hopkins Berman Institute of Bioethics and the School of Nursing. These patients may survive an initial episode of critical illness, but they remain dependent on intensive care treatment and may not recover. A study published in the American Journal of Respiratory and Critical Care Medicine estimates there are more than 100,000 such patients in the U.S. at any point in time. Rushton has seen nurses struggle when asked to continue using methods such as ECMO (extracorporeal membrane oxygenation) when patients are not improving and there is pressure to keep going. Nurses also express concern about whether patients and families understand the implications of agreeing to use certain therapies, such as a ventricular assistive device, Rushton said. “People don’t always understand how it will affect them functionally, socially and financially in the long run.” Studies have shown that moral distress not only increases the risk of turnover, but also impairs a nurse’s ability to provide proper patient care and perform expected job responsibilities.
Strategies to decrease distress
Debriefing meetings is another strategy that can help nurses cope with stress after difficult cases, especially because the discussion gives caregivers an opportunity to hear the perspectives of doctors, nurses or other specialists who were involved in the case, said Abigail Butts, MS, RN, CCNS, CCRN, a medical intensive care nurse at MedStar Georgetown University Hospital in Washington, D.C.

“Sometimes we discover that we may not have known the whole story as we learn about conversations others had with the family or patient,” she said. A physician and nurse on her unit also are pioneering a training that will help caregivers broach difficult topics with families around end-of-life care. The daylong training, called Integrating Multidisciplinary Palliative Care into the ICU, focuses on a clinician’s role in a family meeting and communication skills related to prognosis and goals of care.  The program, offered three times a year, has been popular among nurses and resulted in improved job satisfaction, Butts said. “As much as people hate role playing, it is helpful because the scenarios simulate these discussions accurately,” she said. “There are so many things that we can do in medicine now, but we need to get better at asking what should we be doing, and this helps us do that with families and doctors.”
Studies have shown that moral distress not only increases the risk of turnover, but also impairs a nurse’s ability to provide proper patient care and perform expected job responsibilities.
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Critical care nurses' inner turmoil over others' treatment decision can lead to higher turnover
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