What is Moral Distress in Nursing? (With Examples, How to Address, & Negative Effects)
Written By:
Darby Faubion
Darby Faubion RN, BSN, MBA
Darby Faubion is a nurse and allied health instructor with over 20 years of clinical experience. Darby lives in Louisiana and loves exploring the state’s rich culture and history. Darby has a passion for caring for veterans and a special interest in those affected by post-traumatic stress disorder. In her quest to make a difference for veterans, she founded a non-profit called “Operation Battle Buddy.” Read Full Bio »» RN, BSN, MBA
Nursing is an amazing profession filled with endless opportunities for both personal and professional growth and development. In addition to the many benefits, nurses face challenges, as well. One thing nurses deal with more often than in years past is moral distress in nursing.
Perhaps you have heard the term moral distress but wonder, “What is moral distress in nursing?” In this article, I will explain moral distress in nursing and offer insight into its causes and ways to address it. Despite the challenges that come from moral distress, if you know the possible causes, it is possible to identify problems before they become overwhelming and have a satisfying career in nursing.
What Exactly Is Moral Distress In Nursing?
Moral distress in nursing is the emotional and cognitive response that arises when a nurse feels compelled to act against their own moral judgment or requirements. Moral distress is the result of the nurse's working conditions contradicting their beliefs, morals, or values or being forced to act against their values because of those working conditions.
How Often Do Nurses Face Moral Distress?
Moral distress occurs more commonly among nurses today than in years past. In fact, some sources indicate that up to
61% of nurses report experiencing “high moral distress.”
What Are The Most Common Examples Of Moral Distress In Nursing?
(The following are 10 examples of the most common causes of moral distress in nursing and how best to address them.)
Example #1: Giving False Hope to Patients or Family Members
About The Example:
A common cause of moral distress in nursing occurs when nurses feel they must give false hope to patients or family members. Some healthcare professionals argue that deceptive hope serves a positive purpose rather than a negative one, especially in cases when patients seem to have little time left and not much hope to cling to. However, the consequences of giving false hope can cause moral distress not only to nurses but it can cause harm to patients and their families in the end.
How Best To Address It:
According to the
False Hope Harms Argument, healthcare providers have a responsibility to avoid harm that could stem from offering false hope to patients. In short, the argument suggests that honesty is the best policy, creating an atmosphere of trust, even if the patient must face difficult truths about their health and prognosis. By being honest and forthcoming with patients, you do not have to deal with the moral distress in nursing that stems from untruths or false hope.
Example #2: Continuing Life Support, Although It Is Not Recommended or In the Patient's Best Interest
About The Example:
There are certainly times when continuing life support is justified, and our patient's health improves. However, when life support is not recommended or justified and only prolongs what nurses and healthcare providers realize is inevitable death, it becomes a source of great moral distress for nurses.
How Best To Address It:
One of the frustrating things about this example of moral distress in nursing is that decisions are left entirely up to the patient’s spouse or other legal representative. Even when nurses feel life support should be withdrawn, we are not to advise families or loved ones or to try and coerce them to do so. The decision to withdraw life support should be made by the family or authorized representative after being informed of the risks and benefits by the physician.
Example #3: Inadequate Nurse-Patient Ratios
About The Example:
A persistent
shortage of nurses nationwide creates many challenges for nurses and patients alike. One challenge, inadequate nurse-patient ratios, leads to other problems, such as safety risks, nurse burnout, and poor patient outcomes. For this reason, it is no wonder that inadequate nurse-patient ratios is one of the leading causes of moral distress in nursing.
How Best To Address It:
No single nurse can remedy the problems caused by inadequate nurse-patient ratios. However, you can do your part by working your scheduled shifts. When nurses reduce the number of sick calls or unnecessary absences, managers do not have to worry about the patient-to-nurse ratios being disproportionate. Nurses who work within the properly designated ratios find their jobs less stressful and feel less moral distress.
Example #4: Inadequate Training for Nurses on Quality Care Services
About The Example:
Quality healthcare services should be patient-centered, equitable, efficient, timely, and effective. When nurses are not adequately trained to provide quality care services, there seems to be an imbalance in the quality of services, which often leads to feelings of moral distress. For example, one nurse may be excellent at managing time wisely and working efficiently with the tools she is given but fails to make the care she provides patient-centered. Conversely, another nurse may provide patient-centered care that is slow, ineffective, and not mindful of the time and resources they expend. When the quality of care is off-balance, moral distress in nursing becomes an issue.
How Best To Address It:
The ideal way to address the problem of inadequate quality care training is for employers to improve employee training opportunities. However, it is subsequently each nurse's responsibility to pursue educational opportunities that improve performance, which impacts patient, professional, and organizational outcomes. When you take the initiative to grow and learn, you harness the power of knowledge, making it possible for you to influence patient care and improve patient care quality, which reduces the risk of moral distress in nursing caused by otherwise less competent care.
Example #5: Poor Patient Education Regarding Treatment Options
About The Example:
It is every patient's right to be informed about proposed treatment plans, including treatment options, expected outcomes, and possible adverse reactions to any treatment or procedure. Much of our role as nurses involves patient education. Even in cases where education is the responsibility of the physician, such as discussing options for cancer treatment, it is your responsibility to follow up with the patient and document their understanding. Unfortunately, when patients are poorly educated, it can lead to cases of moral distress in nursing. Moral distress in these cases often occurs because nurses feel a closer bond with patients than other healthcare providers, usually because we spend more one-on-one time with our patients.
How Best To Address It:
I cannot stress the importance of addressing this issue by doing your part to provide patient education within your scope of practice. When you educate patients within your scope of practice, you avoid overstepping boundaries that could lead to moral distress. If patient education beyond your scope of practice is required, assure your patient you will notify the doctor of their concern and follow through by doing so. Remember to document any communication between you, your patients, and any practitioner with whom you discuss educational needs.
Example #6: Poor Communication Among Interdisciplinary Team Members
About The Example:
One of the most important skills you can develop in nursing is the ability to communicate effectively. Effective communication helps interdisciplinary teams work together to achieve goals designed to meet patient needs and promote positive outcomes. When effective communication is lacking within the care team, it creates a breakdown in team dynamics, which often leads to moral distress in nursing.
How Best To Address It:
The best way to address poor communication among interdisciplinary team members is to learn ways to implement effective, therapeutic communication measures. Effective communication is one of the most powerful and essential skills nurses use. When you understand methods of
communication in nursing, why it is important, and learn measures to improve communication, you can bridge the gap often caused by lack of communication or ineffective communication, reducing the risk of moral distress.
Example #7: Fear of Lawsuits
About The Example:
If you have ever experienced an angry or dissatisfied patient or family member, you understand how quickly a situation can turn serious. In a society that is fraught with lawsuits at every turn, it is no wonder that nurses stay on high alert about potential accusations, even when they work with the best intentions. While nursing is a rewarding profession, it can also be a stressful job. When you add in the potential for legal issues when things go wrong, it is the perfect scenario for creating moral distress in nursing.
How Best To Address It:
While any conscientious nurse may worry over accusations related to poor or improper care and the possible legal ramifications that stem from them, the best way to address this cause of moral distress in nursing is to follow guidelines for best and safe practices in nursing. If you follow proper protocol and procedures and act within the scope of practice for your license, certification, and job, you reduce your chances of being involved in any type of lawsuit. Remember the old saying, “An ounce of prevention is worth a pound of cure?” That saying is certainly true when it comes to
protecting yourself from the risk of lawsuits and reducing moral distress.
Example #8: The “Domino Effect” of Poor Administrative or Leadership Support
About The Example:
I remember taking business and leadership classes and hearing one of my instructors tell the class that a team is only as strong as its leader. Although I have learned through the years that poor leadership does not always mean poor team performance, my experiences have proven that poor administrative or leadership behavior and support can impact the nursing team.
Nursing supervisors and administrators whose autonomy is limited often feel moral distress because of the restrictions placed on them, despite their knowledge, skills, or experience. Subsequently, nurses who work under the leadership of managers and administrators who are passive, demonstrate incivility or are experiencing moral distress themselves tend to report higher rates of moral distress in nursing.
How Best To Address It:
Depending on your job title and role at work, your ability to address administrative issues may be limited. One thing you can do, however, is to be supportive of administrative staff by showing up for work, performing your job to the best of your ability, and promoting positive patient and team experiences. While you may not remove every source of moral distress, your encouragement, hard work, and willingness to be a productive team member can have a significantly positive impact.
Example #9: Pressure to Reduce Healthcare Costs
About The Example:
The American Nurses Association
Code of Ethics requires nurses to provide patient care based on individual needs, not financial ability to pay. In the United States, however, many patients go without necessary healthcare services because of the inflated cost of care. Nurses who work in facilities that disallow services if the patient is unable to pay face issues of moral distress in nursing because, in these situations, they are forced to practice in a context that goes against the nurse’s professional ethical code.
How Best To Address It:
As a nurse with many years of experience in both clinical and management positions, I understand the pressure that comes with needing to provide quality patient care while trying to keep an organization's costs at a minimum. Although many factors come into play when there is increased pressure to reduce healthcare costs, your main priority as a clinical nurse is to provide necessary services to patients in your care. If your facility has protocol regarding payment arrangements or policies that impact whether services are provided or withheld, those issues are typically referred to social workers who help patients apply for appropriate payment resources.
Example #10: Inappropriate Use of Healthcare Resources
About The Example:
Something that troubles me and many other nurses, often leading to moral distress in nursing, is the extent to which some nurses and other healthcare providers inappropriately utilize healthcare resources. Unfortunately, misuse or misappropriation of resources affects people at many levels. Patients, as consumers, are affected by increased healthcare costs, and healthcare organizations suffer financial losses because of waste. Additionally, when hospitals and other healthcare facilities are forced to tighten budgets due to overspending, payroll may suffer. One of the worst consequences of the inappropriate use of healthcare resources, and perhaps the main reason this leads to moral distress in nursing, is that patients in dire need of supplies or medications may do without because of overuse.
How Best To Address It:
While we cannot control everyone we work with, each of us can make a difference and help reduce moral distress by doing our part to encourage appropriate use of healthcare resources, including being frugal with resources. We can ensure resources are used appropriately and at appropriate times, which means supplies will be available when needed.
7 Main Negative Effects Of Moral Distress On Nurses And How To Cope With Them
Effect #1: Burnout
About The Effect:
The emotional, physical, and mental exhaustion caused by moral distress often leads to burnout. Nursing burnout is one of the main negative effects of moral distress in nursing.
How To Cope With It:
Burnout impacts nurses significantly, so much so that the World Health Organization has labeled it as an official medical diagnosis. If you begin to feel the effects of burnout due to moral distress, there are some steps you can take to help alleviate symptoms. Find a creative outlet, such as taking music or art lessons, find ways to create a healthy work/life balance, and
practice self-care.
Effect #2: Mental Health Issues
About The Effect:
According to the National Institutes of Health, morally distressing experiences can have a traumatic effect on the mental well-being of nurses. Examples of the psychological effects of moral distress in nursing include anger, guilt, frustration, and anxiety.
How To Cope With It:
The first step in coping with this negative effect of moral distress is to identify symptoms when they occur. If you feel anxious or frustrated, it may be necessary to take a break. Depending on the severity of your symptoms, you may need to ask for a sick day or extended leave from work. Something I have always told nursing students and peers is that it is impossible to provide safe, effective nursing care to patients if you do not first care for yourself. Make your mental health a priority so you can provide better patient care, as well.
Effect #3: Poor Interprofessional Relationships
About The Effect:
Another of the negative effects of moral distress in nursing that I have seen often is that poor interprofessional relationships often occur. Whether the moral distress is caused by a clash of personalities, workplace tensions, understaffing, or other issues, when the issues causing moral distress are not remedied, they can get out of hand and negatively impact relationships.
How To Cope With It:
If I could give you any advice to combat the potential for developing poor interprofessional relationships, it would be to keep the lines of communication open between yourself and your team members. Effective communication among team members reduces the risk of misunderstandings and omissions of vital information and reduces the risks of errors, all of which increase the risks of moral distress in nursing.
Effect #4: Negative Patient and Organizational Outcomes
About The Effect:
Moral distress in nursing has far-reaching impacts, which include more than nurse burnout, emotional stress, or physical side effects. When left unresolved, moral distress can lead to negative patient and organizational outcomes.
How To Cope With It:
Once negative outcomes occur, it takes sincere effort to turn the situation around. The ideal way to cope with this effect of moral distress is to identify the risks before they manifest as negative outcomes. In cases where patient and organizational outcomes are impacted, you can do your part to improve the situation by promoting positive communication, encouraging patients and coworkers, modeling good behavior, and fostering an atmosphere conducive to professional growth and development. While none of us can fix every problem alone, we each can do our part to add to the solution.
Effect #5: Decreased Job Satisfaction
About The Effect:
Another serious effect of moral distress in nursing is that nurses begin to feel less satisfied with their jobs. Decreased job satisfaction often leads to nurses leaving their jobs, and, in serious cases, some nurses leave the profession altogether.
How To Cope With It:
Many nurses who begin to experience moral distress at work feel stuck or at a standstill and wonder what they can do to help cope with it or make the situation better. Getting involved in facility-sponsored events like nurse roundtables or other sharing opportunities is an excellent way to share your thoughts and ideas to improve job satisfaction. Also, leading by positive example is a way to boost team morale and improve job satisfaction for yourself and your peers, which can help reduce moral distress in nursing.
Effect #6: Nurses Leaving Their Jobs or the Profession
About The Effect:
One of the most troubling effects of moral distress in nursing is that it often leads to nurses leaving their jobs or choosing to pursue a different career path. With a
nationwide shortage of nurses already impacting the healthcare industry and expected to continue, this effect of moral distress on the profession is quite profound.
How To Cope With It:
When problems of moral distress lead to nurses feeling they must leave their jobs or the profession to feel relief, it can have a devastating effect. Healthcare managers and administrators can implement strategies focused on career development, staff retention, and educational opportunities that make employees feel valued and teach ways of addressing and minimizing the effects of moral distress. In addition to working with your peers and leaders, practice self-care and mindfulness to decrease the effects of moral distress.
Effect #7: Poor Patient Satisfaction Rates
About The Effect:
Unfortunately, moral distress in nursing has effects that reach beyond nurses. The anxiety and dissatisfaction that we experience due to moral distress is often felt by our patients, which leads to poor patient satisfaction and often negative patient outcomes.
How To Cope With It:
Despite conflicting feelings related to moral distress, we can improve patient satisfaction by performing our jobs to the best of our abilities and maintaining a professional attitude. Discuss issues that cause moral distress with leaders and managers, not patients or their loved ones. Keeping conversations light and positive can ease the tension and anxiety patients have and improve patient satisfaction.
My Final Thoughts
As nurses, we work with diverse groups of patients and peers and have enormous responsibilities. Some situations and decisions we face lead to extreme cases of anxiety, frustration, and often anger, often referred to as moral distress in nursing. To gain a better understanding, in this article, I shared insight to answer the question, “What is moral distress in nursing?" By identifying potential causes of moral distress and working together with nursing teams, we can decrease the risks associated with moral distress in nursing and improve long-term outcomes for patients, ourselves, our organizations, and the profession.
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https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/
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https://www.ncsbn.org/news/ncsbn-research-projects-significant-nursing-workforce-shortages-and-crisis
Darby Faubion, RN, BSN, MBA
Darby Faubion is a nurse and Allied Health educator with over twenty years of experience. She has assisted in developing curriculum for nursing programs and has instructed students at both community college and university levels. Because of her love of nursing education, Darby became a test-taking strategist and NCLEX prep coach and assists nursing graduates across the United States who are preparing to take the National Council Licensure Examination (NCLEX).