Moral Distress

Recently, moral distress has been a topic widely discussed in the literature as a serious problem for nurses.2–5 Nurses face multiple challenges on a daily basis: emergency situations, tension from conflict with others, complex clinical cases, new technologies, increasing regulatory requirements, acquisition of new skills/knowledge, staffing issues, financial constraints, workplace violence, to name a few. This care environment has led to increasingly complex moral and ethical dilemmas.⁵ In addition, they frequently may experience emotional outbursts from patients, families, co-workers, and feel a lack of control and “burnt out.”^2,5 Moral distress occurs when a person knows the ethically appropriate action to take but cannot act on it. It also manifests when a nurse acts in a manner contrary to personal and professional values. As a result, there can be significant emotional and physical stress that leads to feelings of loss of personal integrity and dissatisfaction with the work environment. Relationships with co-workers and patients are affected, and the quality of care can be negatively affected. There is also a great impact on personal relationships and family life; nurses experiencing moral distress may resign their position or leave the profession entirely.³

It is therefore important that nurses recognize moral distress and actively seek strategies to address the issue through institutional, personal, and professional organizational resources. Knowledge and application of ethical principles and guidelines can assist the nurse in daily practice when ethical dilemmas occur. Box 2-1 provides a position statement on moral distress, promulgated by the American Association of Critical-Care Nurses (AACN).⁶ The document is evidence-based, providing additional references for the reader. There is also a reference to ensuring that support to alleviate moral distress is present in a healthy work environment (see Chapter 1). Actions are listed for direct care staff nurses as well as employers.

The AACN has created a framework—The 4A’s to Rise Above Moral Distress—to support nurses who are experiencing moral distress (Figure 2-1). ASK, the first stage, is a self-awareness and reflection period in which one becomes more aware of the distress and its effects on oneself. Specific areas to address are physical, spiritual, emotional, and behavioral responses. During stage two, AFFIRM, one affirms the distress and makes a commitment to take care of oneself. In stage three, ASSESS, one needs to identify the timing and context of when the stressors occur; determine the severity of the distress; and examine one’s readiness to act. The final stage, ACT, consists of preparation, the action itself, and maintaining the desired change. Although the model was created by AACN, it is a framework that can be used in diverse settings and by various health care professionals.⁷ McCue⁸ reported using this model as a resource for resolving an issue between a chief nurse executive and chief executive officer. In this case, the impact of the outcome was at the organizational level.

Moral Courage

In order to avoid moral distress, nurses must feel free to advocate for themselves, their patients, co-workers, and a safe and effective work environment. Lachman and colleagues describes moral courage as “the willingness to stand up for and act according to one’s ethical beliefs when moral principles are threatened, regardless of the perceived or actual risks (such as stress, anxiety, isolation from colleagues, or threats to employment)”.^9,p24 They describe organizational cultures that support moral courage, the importance of peer support, education, and policies that can support moral courage of staff. Other authors have reported that moral courage is needed in everyday practice and that one must act ethically even in the presence of risk.^4,10

Autonomy

The concept of autonomy appears in all ancient writings and early Greek philosophy. In health care, autonomy can be defined as an agreement to respect another’s right to self-determine a course of action and the support of independent decision making¹¹ without coercion or interference from others. Autonomy is a freedom of choice or a self-determination that is a basic human right. It can be experienced in all human life events.

The critical care nurse is often “caught in the middle” in ethical situations, and promoting autonomous decision making is one of those situations. As the nurse works closely with patients and families to promote autonomous decision making, another crucial element becomes clear. Patients and families must have all of the information about a particular situation before they can make a decision that is best for them. They should be given all the pertinent information and facts, and they must have a clear understanding of what was presented. This is where the nurse is a most important member of the health care team—as patient advocate, the nurse provides more information as needed, clarifies points, reinforces information, and provides support during the decision-making process. Box 2-3 presents the Nursing Interventions Classification (NIC) feature on nursing intervention activities that facilitate decision making.

Beneficence

The concept of doing good and preventing harm to patients is the sine qua non for the nursing profession. However, the ethical principle of beneficence—which requires a nurse to promote the well-being of patients—points to the importance of this duty for the health care professional. The principle of beneficence presupposes compassion; taking positive action to help others; desire to do good. It is the core principle of patient advocacy.¹¹ Harms and benefits are balanced, leading to positive or beneficial outcomes. In approaching issues related to beneficence, conflict with another principle, that of autonomy, is common. Paternalism exists when the nurse or physician makes a decision for the patient without consulting the patient.

Traditional health care has been based on a paternalistic approach to patients. Many patients are still more comfortable in deferring all decisions about care and treatment to their health care provider. Active involvement by various organizations, agencies, and consumer groups in regard to health care has demonstrated a trend toward the public’s need and desire for more information about health care in general and more information about alternative treatments and providers. Paternalism may always be a possibility in the health care setting, but enlightened consumers are causing a change in this practice.

In the critical care setting, many instances of and possibilities for paternalistic actions by the nurse exist. Postoperative care, which is designed to assist the patient with achieving a quick recovery, is a good example. Encouraging the patient to turn, cough, and deep breathe and increasing the patient’s activity in the form of dangling, sitting in a chair, and ambulating are all paternalistic actions when the patient is experiencing pain and sleep deprivation and wanting to be left alone. However, the benefits and harms sometimes must be balanced. In these instances, the duty to do no harm—which is the next principle to be discussed—takes precedence over the need to avoid paternalistic actions. When ethical principles are in conflict, the nurse must weigh all the benefits and choose the best principle to follow.

Nonmaleficence

The ethical principle of nonmaleficence, which dictates that the nurse prevent harm and correct harmful situations, is a prima facie duty for the nurse. Thoughtfulness and care are necessary, as is balancing risks and benefits, which was discussed earlier. Beneficence and nonmaleficence are on two ends of a continuum and are often adhered to differently, depending on the views of the practitioner.

A practitioner may consider long-term consequences and the good to society as a whole, or the principle and its effect on the single individual in the situation. Such complex problems as quality of life versus sanctity of life are always difficult to analyze in the critical care setting, as well as in noncritical care settings.

Veracity

Veracity, or truth-telling, is an important ethical principle that underlies the nurse-patient relationship. Veracity is important when soliciting informed consent, because the patient needs to be aware of all potential risks and benefits to be derived from specific treatments or their alternatives. The critical care nurse can be in the middle of a situation in which all of the facts and information about a particular treatment option are not disclosed.

Sometimes, information has been given accurately to the patient and family but has been delivered with bias or in a way that is misleading. Veracity must guide all areas of practice for the nurse—that is, colleague relationships and employee relationships, as well as the nurse-patient relationship.

Fidelity

Another ethical principle that is closely related to autonomy and veracity is fidelity. Fidelity, or faithfulness and promise-keeping to patients, is an essential aspect of nursing. The American Nurses Association (ANA) states that this principle requires loyalty, fairness, truthfulness, advocacy, and dedication to our patients. It involves an agreement to keep our promises. Fidelity refers to the concept of keeping a commitment and is based on the virtue of caring.¹¹ It forms a bond between individuals and is the basis of all professional and personal relationships. Regardless of the amount of autonomy that patients have in critical care areas, they still depend on the nurse for many types of physical care and emotional support. A trusting relationship that establishes and maintains an open atmosphere is one that is positive for all involved.

Like all of the other principles, fidelity extends to the family of the critical care patient. When a promise is made to family members that they will be called if an emergency arises or that they will be informed of any other special events concerning the patient, the nurse must make every effort to follow through on the promise. Fidelity upholds the nurse-family relationship and reflects positively on the nursing profession as a whole and on the institution in which the nurse is employed.

Confidentiality is one element of fidelity that is based on traditional health care professional ethics. Confidentiality is described as a right whereby patient information may be shared only with those involved in the care of the patient. An exception to this guideline might occur if the welfare of others would be put at risk by keeping patient information confidential. In this situation, the nurse must balance ethical principles and weigh risks and benefits. Special circumstances, such as the existence of mandatory reporting laws, guide the nurse in certain situations.

Privacy also has been described as being inherent in the principle of fidelity. It may be closely aligned with confidentiality of patient information and a patient’s right to privacy of his or her person, as in maintaining privacy for the patient by pulling the curtains around the bed or making sure that he or she is adequately covered. The ANA summary and principle on privacy and confidentiality are found in Box 2-4.

Justice

The principle of justice is often used synonymously with the concept of allocation of scarce resources. According to the ANA, it is based on analysis of benefits and burdens of decisions. Justice implies that all have equal rights and that there be a fair and equal distribution of resources to all.¹¹ Contrary to the belief of many people, health care is not a right guaranteed by the Constitution of the United States. Rather, it is the access to health care that should be provided to all people. With escalating health care costs, expanded technologies, an aging population with its own special health care needs, and in some instances a scarcity of health care personnel, the question of how to allocate health care becomes even more complex.

Technologies and Treatments

Limitations of resources force society and critical care health professionals to reexamine the goals of critical care for patients. The application of new or experimental treatments and procedures needs to be carefully analyzed for each case, with particular attention paid to the expected outcome.

Quality of life is an issue that should be considered carefully when examining the use of technologies. This issue is personal and value laden; it is different for each individual involved and depends on the various aspects of the case. Quality of life has the dual dimensions of objectivity and subjectivity. Objectivity examines the person’s ability to function, whereas subjectivity analyzes his or her psychosocial state. Patients’ treatment preferences reflect the values they place on various health outcomes and may be very different from those of health care providers.

Health Care Personnel

Critical care nurses are faced with rationing of critical care beds and nursing staff on a daily basis. Strengths and weaknesses of the staff must be balanced with the needs of the patient. Orientation and other special circumstances—such as designation of a charge nurse, trauma nurse, or code nurse—must be considered when scheduling staff and making assignments. Any inexperienced staff, float staff, or registry staff must be given appropriate orientation and backup during the shift.

Commonly, a triage system for critical care units is called on when there are more admissions than available beds. The critical care nurse is instrumental in assisting the medical director to determine patient selection for transfer, if appropriate. Hospitals establish a set of standards, criteria, or guidelines for determining patient admission and transfer to and from critical care areas.

Nursing Code of Ethics

The ANA Code of Ethics for Nurses²⁰ provides the major source of ethical guidance for the nursing profession. The nine statements of the code are found in Box 2-5. Further delineation of each of the provisions along with in-depth discussion and examples of application can be found on the ANA website, www.nursingworld.org.

The code was first adopted by the ANA in 1950 and has undergone revisions over the years. It provides a framework for the nurse to follow in ethical decision making and provides society with a set of expectations of the profession. When the requirements of the code are not in concert with the law, it is the nurse’s obligation to uphold the code because of the societal commitment inherent in nursing.

What Is an Ethical Dilemma?

In general, ethical cases are not always clear-cut. An ethical dilemma exists if there are two (or more) morally correct actions that cannot be followed. The result is that both something right and something wrong occur. In these situations, there are both ethical conflict and ethical conduct issues.²⁸ The most common ethical dilemmas encountered in critical care are forgoing treatment and allocating the scarce resource of critical care, but how does the health care worker know that a true ethical dilemma exists?

Before any decision model is applied, it must be determined whether a true ethical dilemma exists. Criteria for defining moral and ethical dilemmas in clinical practice are threefold: 1) an awareness of the various options; 2) an issue that has options; and 3) two or more options with true or “good” aspects, with the choice of one option compromising the option not chosen. One must pause, expand group consciousness about the issue, validate assumptions, look for patterns of thoughts or behaviors, and facilitate reflection and inquiry prior to making any decision.²⁹

Steps in Ethical Decision Making

To facilitate the ethical decision-making process, a model or framework must be used so that all involved will consistently and clearly examine the multiple ethical issues that arise in critical care. There are various ethical decision-making models in the literature.30–31 Box 2-11 lists steps in an ethical decision-making model that will be briefly discussed in this chapter.

Institutional Ethics Committees

Although they are not required by law, many health care facilities have developed institutional ethics committees (IECs) as a way to review ethical cases that are problematic for the practitioner. Major functions of IECs are education, consultation, and recommendation to policy-making bodies. An IEC may function in a variety of ways. The committee may serve as consultants and make recommendations that are not binding. In other situations, health care providers may be required to consult with the committee when there is an ethical problem, with recommendations again not being binding. The third approach requires that ethical dilemmas be presented to the committee and that the recommendations made by the committee must be followed. Regardless of the type of IEC, ethics consultations can help to resolve conflicts that may otherwise prolong unwanted or nonbeneficial treatments.

IECs very often comprise executive medical staff. Membership may include staff physicians, administrators, legal counsel, nurses, social workers, clergy, and community public volunteers. To fulfill its requirement for consultation, the committee must include members who not only have expertise but also are representative of various groups. Regardless of the type of committee model, the IEC provides consultation and support to the practitioners.

Inservice and Education Programs

Basic education about ethical principles and decision making is an important first step in facilitating ethical decision making among nursing staff in the critical care area.32–33 It is important for nurses to examine their own values, beliefs, and moral convictions. Nurses need to know and use the ANA Code for Nurses in their daily clinical practice. Treatment choices for patients and ethical issues involving patients, nurses, and medical colleagues must be explored and discussed in the classroom setting, where no time constraints or extraneous distractions exist to interrupt the decision-making process. Use of the nursing process as a framework can be a teaching strategy for understanding ethical issues¹ (Box 2-12).

Nursing Ethics Committees

Nursing ethics committees provide a forum in which nurses can discuss ethical issues that are pertinent to nurses at the individual, the unit, or the department level.32–33 Unlike the IEC, which involves treatment choices for patients, the nursing committee may or may not address a patient situation. Depending on the specific goals of the committee, it can also serve as a resource to nursing staff, make recommendations to a policy-making body about a variety of professional issues, or actually formulate policies. It also may serve to educate the department on ethical and professional issues. Membership usually comprises representatives from all major clinical areas or divisions, educators, clinical nurse specialists, administrators, and other specialty staff. Some departments, such as critical care, may have their own unit or division committee.

Ethics Rounds and Conferences

Ethics rounds at the unit level regarding patients in the unit can be done by nurses on a weekly or other established basis. Rounds educate the staff about problems and can have preventive effects when facilitated appropriately. During the discussion, potential problems may be identified early, and actions may be taken to decrease or prevent the incidence of a problem. An individual patient ethics conference may be scheduled to include only the nursing staff or to include a multidisciplinary group to discuss unit issues.32–33 A patient ethics conference may function as a liaison with the IEC or as an end in itself.