According to the American Association of Critical Care Nurses (AACN) “moral distress is experienced by one in three nurses and studies show that among 750 nurses, nearly 50% had acted against their consciences in providing care to terminally ill patients” 4. The effect of moral distress on nurses can be extensive. Nurses report experiencing the effects of moral distress ranging from physical and psychological symptoms such as depression, fear, and anger, to resignation from their positions and from the profession 5,6,3,7. Patients and their families may experience the impact of nurses’ moral distress through decreased quality of care, nursing ambivalence to meet patient care needs, delayed treatments, and prolonged hospitalization 8,3. Patient care situations that have been found to cause moral distress involve inadequate nurse-physician communications, continued life support even though it is not in the best interest of the patient, and false hope and prolonged treatments given to patients 9,10. Moral distress also influences the healthcare environment through financial losses as a result of decreased nurse staffing levels and recruitment efforts, poor retention of nurses, and patient safety issues 11. Work environment issues contributing to moral distress are inadequate staffing and training to provide care, and lack of autonomy in the work environment 9,10. The effects of moral distress seriously impact health care delivery and nurses, the direct providers of care.
While there is a plethora of research defining moral distress, how it occurs, and how it is measured, there is little evidence to support interventions that are effective in mitigating moral distress in nurses. Creating and implementing programs to identify and reduce moral distress are key actions to promoting a healthy work environment 12,13. Teaching the American Association of Critical Care Nurse’s (AACN) 4 A’s To Rise Above Moral Distress program is one approach to reduce moral distress, increase awareness, and manage morally distressing patient care situations in nursing.
The purpose of this quality improvement project is two fold: (1) evaluate CCU nurses’ acceptability of an online learning program on moral distress, and (2) evaluate a change in moral distress frequency and intensity experienced by direct care critical care nurses at one academic medical center one month after implementing an online continuing education program based on the AACN’s 4 A’s model. The plan for the project is to adapt the didactic portion of the AACN 4 A’s evidence based program into a narrated, online learning module. Modules will be uploaded into the Medical Center’s online learning management system (LMS). Modules posted in the LMS will help to ensure the CCU nurses’ ease of accessibility to the 4A’s educational program. Critical care nurses will be recruited to participate in the first session of the project which includes an online pre-test survey using the Moral Distress Scale-Revised (MDS-R) and viewing the onlne modules. This initial session of the project will provide data for establishing a baseline frequency and intensity of moral distress of the nurses who participate. One-month post intervention of viewing the 4A’s program, the second session of the project will be conducted. Participants will return to complete an online post-test using the MDS-R to re-measure moral distress and an Acceptability Questionnaire to evaluate the nurses’ acceptance of the online learning modules. If the results of this project indicate that a proactive intervention can reduce the impact of moral distress on this unit, then the 4A’s online continuing education module may be expanded to other hospital units as part of annual competency training, new orientation and nurse residency programs.