Considering Care

A Descriptive Study of Moral Distress

Elizabeth Smith, MS, RN, PMHCNS-BC, CHPN

Toby Bressler, PhD, RN, OCN

What is Moral Distress?

• Initial Definition: “occurring when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (Jameton, 1984).

• Later Definition: includes “psychological disequilibrium and negative feeling state” thus acknowledging it to be an emotional response (Wilkinson, 1988).

• Expanded Definition: “a psychological response to morally challenging situations such as those of moral constraint or moral conflict or both” (Fourie, 2013).

Consequences of Moral Distress

• Psychological and physical exhaustion

• Frustration, anger, depression, guilt, powerlessness

• Avoidance behaviors

• Decreased job satisfaction

• Negative impact on

– quality of care

– patient/family experience

Description of Study Unit

• 28 bed Respiratory Care Unit

• Patient characteristics:

- Average age 82 years old

- Majority identify as Jewish, most are Orthodox Jews

- Many with advanced dementia, serious neurological injury, anoxic encephalopathy

- Being sustained on artificial life support

(ventilators, artificial feedings, dialysis, vasopressors)

Medical Decision-Makingof Orthodox Jews

• Halachah – Collective body of Jewish law which guides all aspects of daily life, religious practices, rituals and customs, and medical decisions

• Supreme sanctity of life; religious obligation to

preserve life

• Central role of Rabbi

Study Questions

What is the experience of nursing staff?

Do they experience moral distress?

Study Design

• Exploratory descriptive qualitative study

• Protection of human subjects: IRB

• Eleven focus groups with semi-structured interview format

• Anonymous demographic form

• Purposive selection of transcripts

• Content analysis to identify themes

Demographics of Study Sample

n=27 (71%) participation

Days Nights

< 40 yrs of age 38% 84%

At least BS-BSN 54% 85%

Certification 40% 8%

Av. yrs experience 13 4.5

Av. yrs in current position 6.4 3.5

Study Findings

Contributors to moral distress in common with other studies:

• Medical treatment perceived to cause pain and prolonged suffering

• Providing unrealistic hope to patients and families

• Workload/overload

Unique Themes of This Study

• Nurses’ expectations not fully realized

• Significance of teamwork

• Cultural mismatch

Limitations

• Nurses only

– Recommendation for interdisciplinary research

• Focus group

– Group think

• Crosspollination

– Information sharing

Implications/Conclusions

• Further research warranted

– Other disciplines

– Family perspective

– Evaluation of interventions

– Valuing Nurses

Interventions

• Education

• Support

• Building Resilience

• Enhancing Work Environment

“As a nurse, we have the opportunity to heal the heart, mind, soul and body of our patients, their families and ourselves. They may forget your name, but they will never forget how you made them feel”

– Maya Angelou

Acknowledgements

The participants of this study

Nursing Team on Gellman 7 West!

Lisa Segreto, RN Nurse Manager Gellman 7 West

Dorothy Jean Graham-Hanna, RN Vice President Nursing; Department of Medicine

Tom Smith, RN: Chief Nursing Officer

Dr. Debra Hanna, PhD, RN: Key Personnel

Selected References1. American Nurses Association (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD.2. Burston AS, Tuckett AG. Moral distress in nursing: contributing factors, outcomes and interventions. Nurs Ethics 2012; 20(3): 312-324.3. Ferrell B. Understanding the moral distress of nurses witnessing medically futile care. Oncol Nurs Forum 2006; 33(5): 922-930.4. Fourie C. Moral distress and moral conflict in clinical ethics. Bioethics 2013; 1-7.

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

6. Kompanje EJ, Piers RD, Benoit, DD. Causes and consequences of disproportionate care in intensive care medicine. Curr Opin Crit Care 2013; 19(6): 630-635.7. Rushton CH: defining and addressing moral distress: Tools for critical care leaders. AACN Advanced Critical Care 2006; 17(2): 161-168.8. Schluter J, Winch S, Holzhauser K, Henderson A. Nurses’ moral sensitivity and hospital ethical climate: a literature review. Nurs Ethics 2008; 15(3): 304-321.9. Varcoe C, Pauly B, Storch J, Newton L, Makaroff K. Nurses’ perceptions of and responses to morally distressing situations. Nurs Ethics 2012; 19(4): 488-500.10. Wilkinson JM. Moral distress in nursing practice: experience and effect. NursForum 1987-1988; 23(1): 16-29.