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Beyond moral distress: Preserving the ethical integrity of nurses Martin Woods Nurs Ethics 2014 21: 127 DOI: 10.1177/0969733013512741 The online version of this article can be found at: http://nej.sagepub.com/content/21/2/127
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Guest editorial
Beyond moral distress: Preserving the ethical integrity of nurses
Nursing Ethics 2014, Vol. 21(2) 127–128 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733013512741 nej.sagepub.com
Martin Woods Massey University, NZ
Every year, I meet a new group of postgraduate nursing students who come together to study ethics at an advanced level. For some, it is the first time in their careers that they have been able to express their ethical concerns in such a forum, or in some cases, in any formal setting; for others, it is a confirmation that not all perceived failures relating to moral issues are necessarily of their or their nursing colleagues’ own making. For all, it is a bitter-sweet confirmation of the difficulties involved in dealing with those sometimes painful moral problems that they have encountered over what is often several years of practice. Indeed, it is as if through the exchange of narratives, each student feels not only marginally unburdened but free to finally state those things that really matter to them in a forum where others actually appreciate their opinions. But then at some point, we come to an examination of what is currently called nursing ‘moral distress’, and slowly but surely, a rising degree of exasperation and annoyance emerges around the room, as one by one the students all focus on the same question, namely, ‘What are we to do about moral distress?’ Moral distress is a phenomenon that is a reality in nursing however it is labelled or packaged, and whatever the experts say it is or it is not. Whenever a group of experienced nurses identify a collection of unresolved or poorly resolved ethical issues in their workplaces, it will exist in one form or another.1 It is moral distress (as opposed to other possibilities of nursing distress) when there exists a moral element or threat to a nurse’s moral integrity that causes feelings of disquiet, and yes, even distress. It is moral distress (and not an ethical dilemma) when nurses feel that they have no ethical choice to make in a given situation; when there is ample evidence that nurses often feel devalued and ignored when attempting to resolve an ethical issue; and when nurses in numerous countries all appear to be saying the same things about their difficulties and frustrations when attempting to effectively respond to ethical issues in their practices. For my own part, I discovered just how pertinent all of this was when analysing my own research results on this topic this very year when it became clear that 16% of nurses in New Zealand were presently considering leaving their positions, and 48% had at least considered leaving a given nursing position in the past because of moral distress.2 The causes of moral distress in nursing practice are clearly many and varied, although in recent times, they are largely described as being related to either ‘internal’ or ‘external’ constraints.3 Many nurses are no doubt familiar with the first kind; it is often difficult to know what the right thing to do is because there are always a number of conflicting interpretations and possibilities. Here, admittedly, the boundaries between a moral dilemma and moral distress may become blurred; such is the nature of the mental gymnastics so often associated with any significant ethical problem. But the second kind, the external constraints, is a different matter. Then, as is often argued, most nurses know what is the right thing to do, but cannot do so because of these constraints. It is not that there is even the illusion of choices in this instance because many of the constraints are related to factors outside the control of nurses. The list grows yearly, but lack of organisational Corresponding author: Martin Woods, School of Nursing, Massey University, Private Bag 11 222, Palmerston North 4442, New Zealand. Email: [email protected]
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support across all levels, indifferent and unsupportive organisational cultures, poor leadership, lack of adequate resources, recruitment and retention issues, government interference and dubious policies are but a few of the main ones.1,4 This then is not an argument about the lack of motivation to do the right thing, or a lack of moral ability or an adequate ethics education, but about the presence or otherwise of the best ethical climate in which to do the right thing, or as best we can under the circumstances. But how should nurses respond to moral distress? First, we must recognise and encourage debates about the problem in healthcare settings at all levels. The state of affairs concerning moral distress, or whatever it may eventually be called, cannot be allowed to continue forever, or to go unchallenged. Second, we need to understand the wider implications of the problem by remembering that moral distress is not just about nurses but about nurses and everyone else involved in healthcare, that is, patients, families, other healthcare workers, managers, administrators, advisors and more. Subsequently, nurses should be involved in interdisciplinary group discussions, ethics committees, and in developing organisational policies and guidelines. Third, we must respond in an organised and appropriate manner. Worksite interventional programmes could be targeted at those employees identified most prone to experience the effects of moral distress. Nurse managers and other senior nurses should recognise the moral burden carried by those practitioners who deal regularly with major moral issues. Fourth, we must find ways to educate ourselves and others about the issue – by sharing our stories, by placing a greater emphasis on the problem at all levels of nursing education and by ensuring that the general public is fully aware of the issue. Finally, we really must find ways to support each other. Certain nurses could act as ethics counsellors or mentors on the unit level to help nurses identify and control sources of moral stress, and Charge Nurses should find time to discuss morally distressing patient care situations with their nursing staff. All of the above will require a certain kind of moral courage,5 but unless a series of concerted and systematic challenges are made, nurses are likely to continue to face a wide range of ethical situations leading to the experience of moral distress, and subsequent loss of moral integrity. Mindful of this, and whatever we may call the phenomenon that is moral distress, and whatever the arguments for and against the varied conceptualisations of moral distress, what is really important is that something should be done about this serious and demoralising problem now rather than later. References 1. Royal College of Nursing. Defending dignity: challenges and opportunities for nursing. London: Royal College of Nursing, 2008. 2. Woods M, Towers AJ, Rodgers VK, et al. Moral distress – the results and recommendations of a national survey amongst New Zealand nurses. Paper presented at the International Council of Nurses 25th Quadrennial Congress, Melbourne Convention Centre, Melbourne, VIC, Australia, 18–23 May 2013, p. 35 (in book of abstracts). Available at: https://b-com.mci-group.com/Abstract/Statistics/AbstractStatisticsViewPage.aspx?AbstractID=133250 3. Corley MC. Nurse moral distress: a proposed theory and research agenda. Nurs Ethics 2002; 9(6): 636–650. 4. Pauly B, Varcoe C, Storch J, et al. Registered nurses’ perceptions of moral distress and ethical climate. Nurs Ethics 2009; 16(5): 561–573. 5. Gallagher A. Moral distress and moral courage in everyday nursing practice. Online J Issues Nurs 2011; 16(2): 1–7.
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Beyond moral distress: Preserving the ethical integrity of nurses Martin Woods Nurs Ethics 2014 21: 127 DOI: 10.1177/0969733013512741 The online version of this article can be found at: http://nej.sagepub.com/content/21/2/127
Published by: http://www.sagepublications.com
Additional services and information for Nursing Ethics can be found at: Email Alerts: http://nej.sagepub.com/cgi/alerts Subscriptions: http://nej.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Citations: http://nej.sagepub.com/content/21/2/127.refs.html
>> Version of Record - Mar 12, 2014 What is This?
Downloaded from nej.sagepub.com at GEORGIAN COURT UNIV on October 2, 2014
Guest editorial
Beyond moral distress: Preserving the ethical integrity of nurses
Nursing Ethics 2014, Vol. 21(2) 127–128 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733013512741 nej.sagepub.com
Martin Woods Massey University, NZ
Every year, I meet a new group of postgraduate nursing students who come together to study ethics at an advanced level. For some, it is the first time in their careers that they have been able to express their ethical concerns in such a forum, or in some cases, in any formal setting; for others, it is a confirmation that not all perceived failures relating to moral issues are necessarily of their or their nursing colleagues’ own making. For all, it is a bitter-sweet confirmation of the difficulties involved in dealing with those sometimes painful moral problems that they have encountered over what is often several years of practice. Indeed, it is as if through the exchange of narratives, each student feels not only marginally unburdened but free to finally state those things that really matter to them in a forum where others actually appreciate their opinions. But then at some point, we come to an examination of what is currently called nursing ‘moral distress’, and slowly but surely, a rising degree of exasperation and annoyance emerges around the room, as one by one the students all focus on the same question, namely, ‘What are we to do about moral distress?’ Moral distress is a phenomenon that is a reality in nursing however it is labelled or packaged, and whatever the experts say it is or it is not. Whenever a group of experienced nurses identify a collection of unresolved or poorly resolved ethical issues in their workplaces, it will exist in one form or another.1 It is moral distress (as opposed to other possibilities of nursing distress) when there exists a moral element or threat to a nurse’s moral integrity that causes feelings of disquiet, and yes, even distress. It is moral distress (and not an ethical dilemma) when nurses feel that they have no ethical choice to make in a given situation; when there is ample evidence that nurses often feel devalued and ignored when attempting to resolve an ethical issue; and when nurses in numerous countries all appear to be saying the same things about their difficulties and frustrations when attempting to effectively respond to ethical issues in their practices. For my own part, I discovered just how pertinent all of this was when analysing my own research results on this topic this very year when it became clear that 16% of nurses in New Zealand were presently considering leaving their positions, and 48% had at least considered leaving a given nursing position in the past because of moral distress.2 The causes of moral distress in nursing practice are clearly many and varied, although in recent times, they are largely described as being related to either ‘internal’ or ‘external’ constraints.3 Many nurses are no doubt familiar with the first kind; it is often difficult to know what the right thing to do is because there are always a number of conflicting interpretations and possibilities. Here, admittedly, the boundaries between a moral dilemma and moral distress may become blurred; such is the nature of the mental gymnastics so often associated with any significant ethical problem. But the second kind, the external constraints, is a different matter. Then, as is often argued, most nurses know what is the right thing to do, but cannot do so because of these constraints. It is not that there is even the illusion of choices in this instance because many of the constraints are related to factors outside the control of nurses. The list grows yearly, but lack of organisational Corresponding author: Martin Woods, School of Nursing, Massey University, Private Bag 11 222, Palmerston North 4442, New Zealand. Email: [email protected]
Downloaded from nej.sagepub.com at GEORGIAN COURT UNIV on October 2, 2014
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support across all levels, indifferent and unsupportive organisational cultures, poor leadership, lack of adequate resources, recruitment and retention issues, government interference and dubious policies are but a few of the main ones.1,4 This then is not an argument about the lack of motivation to do the right thing, or a lack of moral ability or an adequate ethics education, but about the presence or otherwise of the best ethical climate in which to do the right thing, or as best we can under the circumstances. But how should nurses respond to moral distress? First, we must recognise and encourage debates about the problem in healthcare settings at all levels. The state of affairs concerning moral distress, or whatever it may eventually be called, cannot be allowed to continue forever, or to go unchallenged. Second, we need to understand the wider implications of the problem by remembering that moral distress is not just about nurses but about nurses and everyone else involved in healthcare, that is, patients, families, other healthcare workers, managers, administrators, advisors and more. Subsequently, nurses should be involved in interdisciplinary group discussions, ethics committees, and in developing organisational policies and guidelines. Third, we must respond in an organised and appropriate manner. Worksite interventional programmes could be targeted at those employees identified most prone to experience the effects of moral distress. Nurse managers and other senior nurses should recognise the moral burden carried by those practitioners who deal regularly with major moral issues. Fourth, we must find ways to educate ourselves and others about the issue – by sharing our stories, by placing a greater emphasis on the problem at all levels of nursing education and by ensuring that the general public is fully aware of the issue. Finally, we really must find ways to support each other. Certain nurses could act as ethics counsellors or mentors on the unit level to help nurses identify and control sources of moral stress, and Charge Nurses should find time to discuss morally distressing patient care situations with their nursing staff. All of the above will require a certain kind of moral courage,5 but unless a series of concerted and systematic challenges are made, nurses are likely to continue to face a wide range of ethical situations leading to the experience of moral distress, and subsequent loss of moral integrity. Mindful of this, and whatever we may call the phenomenon that is moral distress, and whatever the arguments for and against the varied conceptualisations of moral distress, what is really important is that something should be done about this serious and demoralising problem now rather than later. References 1. Royal College of Nursing. Defending dignity: challenges and opportunities for nursing. London: Royal College of Nursing, 2008. 2. Woods M, Towers AJ, Rodgers VK, et al. Moral distress – the results and recommendations of a national survey amongst New Zealand nurses. Paper presented at the International Council of Nurses 25th Quadrennial Congress, Melbourne Convention Centre, Melbourne, VIC, Australia, 18–23 May 2013, p. 35 (in book of abstracts). Available at: https://b-com.mci-group.com/Abstract/Statistics/AbstractStatisticsViewPage.aspx?AbstractID=133250 3. Corley MC. Nurse moral distress: a proposed theory and research agenda. Nurs Ethics 2002; 9(6): 636–650. 4. Pauly B, Varcoe C, Storch J, et al. Registered nurses’ perceptions of moral distress and ethical climate. Nurs Ethics 2009; 16(5): 561–573. 5. Gallagher A. Moral distress and moral courage in everyday nursing practice. Online J Issues Nurs 2011; 16(2): 1–7.
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