My ethics paper for Nursing 110

Moral Distress: Causes, Effects, and Consequences for Nurses
by Juanita Heyerman
Antelope Valley College

A recent New York Times article titled "When Doctors and Nurses Can’t Do the Right Thing" (Chen, 2009) discussed how doctors and nurses, jammed between a rock and a hard place by the competing demands of hospital administrators, insurance companies, and patients' families, are sometimes forced to compromise on what they know to be right for their patients. The emotional and physical suffering this ethical conflict causes has come to be known as "moral distress." What is moral distress, what are some of its causes and consequences, and what might its impact be on a nursing student and beginning nurse?

The phrase was first defined by Andrew Jameton in his textbook Nursing Practice: The Ethical Issues in 1984. Jameton characterized moral distress as occurring when "one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action" (1984, p. 6).

In the years since Jameton first described it, moral distress has not gone unnoticed by the nursing community. In the last five years, dozens of articles on the topic have appeared in nursing journals; in 2001 nursing researchers developed the first moral distress scale (Corley, Elswick, Gorman, & Clor, 2001); and the American Association of Critical-Care Nurses recently published a position paper detailing its negative impacts on healthcare work environments (AACN, 2008).

Two of the most recent studies provided some answers about the experience of moral distress in nursing. "Critical Care Nurses' Perceptions of and Responses to Moral Distress" is the report of a qualitative study which collected an abundance of detailed data from just 12 critical care nurses in a Midwestern teaching hospital (Gutierrez, 2005). In contrast, the authors of "Registered Nurses' Perceptions of Moral Distress and Ethical Climate" used a quantitative cross-sectional survey to gather information from 374 registered nurses in acute care hospitals in British Columbia (Pauly, Varcoe, Storch, & Newton, 2009). These two research methods yielded extensive information on the causes and effects of moral distress.

Some of the causes described included: feelings of powerlessness; ineffective communication between nurse, patient and physician; and overly aggressive medical treatment (Gutierrez, 2005). Staffing levels, and competency of self and other health care providers were also factors (Pauly et al., 2009). One nurse expressed her feelings about powerlessness and overly aggressive medical treatment this way: "You don't feel you are doing any good. We can't make (the patient) better so we're already sort of failed there in a way, and now we can't even let her die well... We're not doing a good job." (Gutierrez, 2005, p. 236).

While the personal experience of the nurses was the focus of the qualitative study, organizational factors were stressed in the ethical climate study. It cited research which found that nurses' primary areas of concern included a lack of opportunity to be involved in ethical deliberations, a lack of practice support from administrators, and inconsistent policy and procedures in practice (Pauly, et al., 2009). Gutierrez also referenced institutional factors; some of the nurses she interviewed didn't believe management was aware of their moral dilemmas, and she was told that communication between nursing management and bedside nurses was all to frequently ineffective (2005).

Both articles agreed that the most damaging effect of moral distress is nurse burnout. As one nurse put it, "…it's hard to get up and go to work the next morning when you felt like you haven't really done your job the day before. It’s like 'Why go? What good do I do?'" (Gutierrez, 2005, p. 235). Both studies found evidence of the negative impact of moral distress on job satisfaction, and cited it as a factor leading to reluctance to come to work, nursing turnover, and ultimately to nurses leaving the profession. Other effects described were avoidance of or withdrawing from patients, sadness, anger, and hopelessness.

Even this brief survey of two articles on the topic makes it clear that it is impossible to completely avoid coming up against moral distress while working as a nurse. Ethical issues will almost certainly loom large in my future experience as a student nurse and as a nurse in the field. I plan to stay alert to the ethical climate of the places that I work, and to try and change it if it is hurting my ability and the ability of other nurses to do our jobs well.

I want to stay informed about continued research concerning moral distress. Both of the articles I read suggested areas for possible future research, including exploring the effects of moral distress on patient care (Pauly et al., 2009), and studying ways to increase nurses' job satisfaction and keep nurses at the bedside (Gutierrez, 2005). I will follow reports of this research with keen interest.


References

American Association of Critical-Care Nurses. (2008). AACN Position Statement on Moral Distress. Aliso Viejo, CA: AACN.

Chen, P. W. (2009). When doctors and nurses can't do the right thing. The New York Times. Retrieved from http://www.nytimes.com/2009/02/06/health/05chen.html

Corley, M. C., Elswick, R. K., Gorman, M., & Clor, T. (2001). Development and evaluation of a moral distress scale. Journal of Advanced Nursing, 33, 250-256.

Gutierrez, K. M. (2005). Critical care nurses' perceptions of and responses to moral distress. Dimensions of Critical Care Nursing, 24, 229-241.

Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice Hall.

Pauly, B., Varcoe, C., Storch, J., & Newton, L. (2009). Registered nurses' perceptions of moral distress and ethical climate. Nursing Ethics, 16, 561-573.

Reducing catheter-associated UTIs - the abstract

"Feedback to Nursing Staff as an Intervention to Reduce Catheter-associated Urinary Tract Infections," by Goetz AM, Kedzuf S, Wagener M, and Muder RR. In American Journal Of Infection Control [Am J Infect Control] 1999 Oct; Vol. 27 (5), pp. 402-4.

Abstract:
Because of high incidence of catheter-related urinary tract infections (UTIs) in our Veterans Affairs medical center, we began providing nursing staff with unit-specific UTI rates. In our preintervention period, the first quarter of 1995, 38 infections occurred in 1186 catheter-patient-days or 32/1000 catheter-patient-days (95% CI, 22.9-43.7). Thereafter, nursing staff members were provided with a quarterly report with catheter-related UTI rates depicted graphically by unit. In the 18 months after this intervention, the mean UTI rate decreased to 17.4/1000 catheter-patient-days (95% CI, 14.6-20.6, P =.002). We estimated a cost savings of $403,000. We conclude that unit-specific feedback of nosocomial UTI rates to nursing staff is a highly effective method of reducing infection rates and reducing costs associated with nosocomial UTI.

Wound care -- Irrigation and dry dressing

>BEFORE REMOVING BANDAGE:
1. Medicate for pain
2. Gather supplies
3. Wash hands
4. Ask patient/check chart and id bracelet for

--name
--medical record #
--date of birth
--allergies

5. Don clean gloves; wipe down table & rails w/disinfectant
6. Put supplies IN ORDER OF USE on table
7. Cut tape; write Date, Time, Initials

>REMOVE THE BANDAGE; TOSS IT, ALONG WITH YOUR GLOVES. DON'T FORGET:

--use sterile saline to loosen, if it sticks
--don't make patient see wound
--check for exudate

>DON CLEAN GLOVES; MEASURE WOUND; CHUCK GLOVES AGAIN

>GET READY TO IRRIGATE THE WOUND:
1. Cover the wound temporarily with a gauze pad or ABD
2. Get all your sterile stuff organized:

--open syringe box; use ring to lift up bottle; take out the syringe
--open saline, lip off & pour into syringe bottle
--don clean gloves
--open a gauze sponge or 2

>IRRIGATE THE WOUND:
1. only touch ring & top collar of syringe
2. cleanest to dirty
3. dry w/gauze
4. REMOVE GLOVES

>BANDAGE THE WOUND:
1. Open gauze (1), cover sponges (1), ABD (1)
2. Lastly, open sterile gloves and don
3. Put gauze, then cover sponges, then ABD on wound
4. Tape all 4 sides; make sure date, time and initials are easy to see

documenting refusal of treatment in a nutshell

(my thoughts after reading "Documenting Refusal of Treatment," by Linda Smith, in Nursing, Apr 2004, pg 79)

so as I see it, if a person refuses some treatment or other, you tell 'em:

1. what's wrong with 'em
2. what you want to do about it
3. how wonderful it might be for them if they let you (give 'em a pamphlet!)
4. how terrible it might be for them if they don't

also: ask 'em: why the hell they're saying no (maybe they're nuts?)

also you gotta:

1. make sure they're not nuts

2. write it all down

3. get 'em to sign it. you sign it. hell, get the doctor to sign it
4. if the patient won't sign it,
write that down too! sign it!