Within the workplace, nurses operate under a code of ethics (Winland-Brown, 2015). They work with compassion and respect, having a commitment to the patient to help improve their health and advocating for their rights while remaining accountable for their practice.
Moral distress results when nurses are directed to actions they believe are not ethically appropriate and feel a sense of powerlessness to challenge these directives (Epstein, Delgado, 2010). Other factors such as poor communication, pressure to reduce costs or lack of administrative support may lead to moral distress as well. According to Epstein and Delgado (2010), two main sources of moral distress are inadequate communication of end of life care/goals of care between providers and patients and when healthcare providers give a false sense of hope to patients and families.
According to Hamric, Borcher and Epstein (2012), moral distress can be measured using a scale that identifies the root cause. The moral distress scale (MDS) has been validated using several types of healthcare workers, including physicians and nurses and identifies three root causes of moral distress; clinical situations, internal constraints and external constraints. The 4 point scale addresses each area not only identifying the level of distress a situation causes, but the frequency with which the provider experiences the situation. It is also important to note that different areas of healthcare and different roles may identify different causes of moral distress so it is critical the leader utilize the scale to measure the distress of their staff.
Once moral distress and its root cause is identified, action needs to be taken. Lievrouw et al (2016) lists four ways for individuals to cope. Using thoroughness or compromise means everyone on the team is included and accountable, while autonomy and intuition excludes the physician from the interventions. In different work environments different approaches may be necessary. Epstein (2010) identifies the need to speak up when faced with morally distressing situations. This will help to build support networks among the disciplines. Along with speaking up there should be education on moral distress and a workshop on dealing with moral distress.
Critical reflective practice, or CRP was developed by Lawrence (2011) as a way to use reflective practices to enhance self-awareness, self-esteem and sense of empowerment. CRP involves being mindful of one’s self within their professional practice and processing situations as a way to continually grow and develop as a professional.
Resiliency has been a focus to help alleviate moral distress as well (Rushton, Batcheller, Schroeder, Donohue, 2015). Resiliency is viewed as using spirituality and hope when faced with distress and suffering. While this provides insight into moral distress, more actions may be needed to alleviate moral distress.
Mindfulness based stress reduction, or MBSR is an effective intervention in coping with moral distress (Smith, 2014). Kabat-Zin (2011) describes the impact of being in the moment, ever mindful of where you are at the moment and accepting whatever situation you are in. While the official MBSR training involves an intensive eight week course, Smith (2014) found a four week course was also effective, with a focus on meditation, journaling and reflection. Horner, Piercy, Eure and Woodard, (2014) describe a study using mindfulness training to impact compassion, satisfaction, burnout and stress which resulted in increased patient and nurse satisfaction.
In one particular academic medical center, nurses on an oncology unit completed a satisfaction survey identifying only 9% of the staff were satisfied. Following a descriptive analysis using focus groups and support groups, staff identified hopelessness, sadness, and sense of futility and powerlessness; all symptoms of moral distress. The moral distress scale (MDS) was used to identify any root causes of moral distress. The main cause of moral distress among staff was observing other healthcare providers giving patients a false sense of hope. Over 80% of respondents not only listed false hope as being very distressing, but also happening with great frequency.
A personalized program was developed that included critical debrief sessions following events on the unit as well as support sessions following a death for reflection. In addition, Code Lavender Bags were made including tissues, a gift card for a cup of coffee, chocolate, lavender sachet, and a card with a personalized message from the unit leader. Yoga was started for both shifts, and bedside rounding with the interdisciplinary team was encouraged and supported by leadership. An eight week mindfulness program was also implemented to a core group of staff. Communication was enhanced among nurses and physicians during support debriefs.
Several months after full implementation of the interventions a staff satisfaction survey was again sent out. Satisfaction scores were at the national benchmark of 36%. The moral distress scale (MDS) was again administered and no significant moral distress was noted among the nursing staff. Patient satisfaction scores are also among the highest within the organization.
Creating a healthy work environment is critical among healthcare organizations to successfully provide quality patient care with improved outcomes. Each leader must focus on their staff to identify the aspects of their environment that lead to moral distress and take action to minimize those effects. We may not be able to change other’s practices, but we can learn how to perceive others practices and reflect on our own practices and the meaning of the practice.