The plethora of literature on moral distress has substantiated and refined the concept, provided data about clinicians’ (especially nurses’) experiences, and offered advice for coping. Fewer scholars have explored what makes moral distress moral. If we acknowledge that patient care can be distressing in the best of ethical circumstances, then differentiating distress and moral distress may refine the array of actions that are likely to ameliorate it. This article builds upon scholarship exploring the normative and conceptual dimensions of moral distress and introduces a new tool to map moral distress from emotional source to corrective actions. The Moral Distress Map has proven useful in clinical teaching and ethics-related debriefings.
- Education for Health Care Professionals
- End of Life Care
- Interests of Health Personnel/Institutions
- Professional - Professional Relationship
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- Education for Health Care Professionals
- End of Life Care
- Interests of Health Personnel/Institutions
- Professional - Professional Relationship
Meaning and description of moral distress
The meaning of moral distress is famously nebulous. McCarthy and Gastmans compiled definitions. Several are highlighted in table 1. McCarthy and Deady characterise it as an ‘umbrella’ term, and rightly ask, “Is moral distress a situation? A set of beliefs or attitudes? A range of emotions? A group of symptoms?”1 It might be reasonable to call it a moral emotion, insofar as it is founded in moral angst or conflict. It seems to involve a crisis of conscience, leaving the clinician feeling powerless, threatened, confused or guilty. ‘For moral distress to occur, a case must arise in which [the nurse] recognizes a moral issue and believes she or he is responsible for her or his own actions in the situation’.2 In addition, the clinician perceives an obstacle to acting on his deeply held beliefs or professional obligations.
Normalising moral distress
We begin our exploration of moral distress by acknowledging that it is not always a sign of an ethical problem, but can signal the clinician's deep sense of moral responsibility. Being constrained in making moral choices is fairly normal. We expect reasonable, competent, caring clinicians to disagree sometimes about important aspects of patient care. Sometimes, we agree with the final decisions; sometimes, we do not. A realistic expectation is that stakeholders be heard, their experiences, expertise and insights thoughtfully considered—not that moral angst or suffering be altogether prevented.
Special features of moral distress
If we concede that patient care can be stressful in the best of circumstances, a critical task is to differentiate distress and moral distress. There are several distinguishing features of moral distress.
First, the person who experiences moral distress also feels heightened moral responsibility
McCarthy and Deady1 describe a situation in which a nurse experiences moral distress when restraining a patient. Restraining a patient is frequently distressing; it is morally distressing only when the nurse believes it is wrong to do so and she believes she bears moral responsibility. ‘The depth of nurses’ feelings is influenced by…the degree to which they feel responsible for what happens to their patients and the degree they are able to say, “It is not my decision to make.”’2 So the proclivity to experience moral distress reflects positive moral attributes, including clarity about the clinician's own values. He knows the right thing to do.
The sufferer feels sure but may not be correct. Moral intuitions should not be ignored, nor are they definitive. They must still bear the weight of ethical scrutiny. The potential for professional disagreements is a ubiquitous characteristic of clinical practice. Clarifying the ethical issues helps those involved ascertain what they are and are not responsible for.
Second, the experience of moral distress is directly related to the well-being of a patient
Moral distress is not a self-centred experience. A nurse who does not agree with the attending physician's plan of care will experience moral distress only if she thinks the plan jeopardises patient care or well-being. The moral compromise could harm both the clinician and the patient, but the harm to clinician comes by way of perceived harm to the patient. Even when clinicians experience moral residue, the lingering distress and discouragement that endures after episodes of moral distress, the memories and regrets related to a former or current patient are at the centre, resulting in feelings of discouragement and powerlessness.12
Third, moral distress is often caused or accompanied by a perception of powerlessness
Let us consider nurses. Nurses bear a lot of responsibility but often lack sufficient institutional or professional authority to change a clinical course. They cannot simply override the physician's orders, but they remain deeply responsible for the patient's well-being. Helping nurses find ways to act within their professional scope—to employ their moral agency—is the salve for the sense of powerlessness that feeds moral distress. Generally, the less one acts, the more moral distress one feels.
Fourth, blame often underlies moral distress
When the constraints to enacting one's moral conviction are external or environmental, then someone else chose wrongly and that person's choice is constraining the clinician. Often a person (eg, the attending physician) or entity (eg, administration) is blamed and cast as wrong-headed, insensitive or unethical. When the constraints are internal, such as a lack of courage or experience, the blame is self-directed, leading to remorse and guilt. Underlying the feeling of moral distress is the belief that the course of action can and should be rectified—the sense that the wrong or harm could be prevented but it is not. Ethical analysis tends to correct the oversimplification of pitting ‘the blameworthy’ against ‘the victims’, thereby encouraging creative and responsible action.
Fifth, at least two obligations or responsibilities are in conflict, at least one of which is a professional responsibility
A nurse wants his terminally ill patient to be as comfortable as possible in the dying process but worries that administering the analgesia orders as written will hasten the patient's death. This scenario will cause moral distress because his obligation to comfort conflicts with his obligation not to hasten death. The former obligation is professional. The latter is professional and may also be personal. Professional action is warranted and could include calling the doctor to request a change in orders. It is essential to help clinicians articulate conflicting professional and ethical obligations, as this is what distinguishes distress from moral distress.
Sixth, ameliorating moral distress may involve personal risk, and avoiding risk can threaten integrity
Moral distress and integrity are linked by the real possibility of risk. People with integrity act consistently; their actions are coherent with their beliefs; and they take risks to stand up for their values.1 ,13 ,14 Standing up for something can be personally and professionally costly. Even when clinicians take action to overcome internal and external constraints, they might resist risky action. When we are reluctant to take necessary risks, we may feel weak or worry we are failing, our integrity is threatened. Risks include speaking up, speaking out, enlisting managers or other actions that expose professionals to public scrutiny and anger. These kinds of risks are part and parcel to the moral life. If there are ethical obligations in our work, we expect to sometimes respectfully assert our position in the face of opposition, disagreement or adversity.
When the same sources of moral distress continually arise, resulting in frequent risks and confrontations, this becomes worrisome either because there are divergent values and cultures creating workplace tension or because the clinicians’ expectations need adjustment (or both).
For example, the first few times family members demand non-beneficial (medically futile) life-sustaining treatment for a dying patient and the attending physician acquiesces over her better judgement, we would expect distress from some of the treating clinicians. If there is persistent inconsistency in how this issue is handled, moral distress becomes more problematic because it is not episodic but endemic to the clinician's work day. It becomes an organisational ethics issue. It is this persistent moral distress that leads to burn-out and staff turnover.7
Seventh, when determining the best course of action, we should distinguish between actions that ease the nurse's moral distress and actions that improve the care or experience of the patient
Going for a run after work might ease the nurse's stress, but it is unlikely to alleviate tomorrow's moral distress. The clinician has to identify actions that could help the patient. Until these corrective actions are identified and executed, moral distress will continue.
Eighth, the primary moral goal is not to alleviate moral distress
Moral distress may prompt an ethics consultation, but the goal of the consultation should not be to alleviate moral distress, but to identify and address the moral issue(s) that cause it. If the clinician disagrees with an ethically appropriate course of action—the young, decisional patient should be permitted to refuse life-sustaining treatment even though there is evidence the treatment will be effective—he will experience moral distress but the plan of care is still ethically sound. Moral distress can linger precisely because of an ethical dilemma, defined as a situation in which more than one course of action is ethically justified. The symptom of moral distress should not be confused with the source.
Using the moral distress map
In order to uncover the ethical attributes of moral distress, we must become familiar with the terrain. The moral distress map (figure 1) was designed to be used along with active listening and empathy in moral distress trainings and case debriefings. Each component is outlined below. We always start with a case, either an active or former case. In a teaching context where there is not a single case common to everyone, the Moral Distress Survey can be used to elicit distressing cases first.15 Then, a case that resonates with the group can be used for the moral distress map exercise. Numbered below are explanations for each of the questions on the moral distress map.
Emotions: what emotions are you experiencing?
It is quite common for people to ‘talk around’ moral issues, circuitously describing their angst, frustration and guilt. Wilkinson writes, ‘nurses tend to identify as moral distress any painful feelings they have in patient-care situations’.2 Before we ask ‘what makes moral distress moral?’, we have to ask ‘what makes moral distress distressing?’ There are practical reasons for beginning with feelings. First, it honours the suffering of the clinicians and demonstrates concern for their well-being. Second, the goal of these sessions is to relieve current suffering or teach strategies for doing so in the future. Clinicians are more likely to achieve this goal if they can talk about their feelings. Third, a more structured analysis will likely be resisted without a preliminary invitation for personal, sometimes confessional, reflection.
Source: what precisely is the source of the moral distress?
The moral source of distress is also essential for determining appropriate next steps. For example, if the distress arises from an internal constraint like a lack of courage, demanding institutional ‘backing’ for the practitioner's position is inappropriate. Rather, mentorship by colleagues will be more helpful. Here, the experience of moral distress is an opportunity for moral growth.16
In contrast, if a nurse witnesses disrespectful treatment of a patient, he might experience moral distress temporarily—until he devises a plan to ensure it does not happen again. Here, institutional action might well be appropriate, and the nurse's action will quell the moral distress.
Constraints: name the internal and external constraints to taking action.
Real and perceived constraints placed on clinicians serve as obstacles to executing professional obligations and as root causes of moral distress.4 ,10 ,17 ,18 Internal constraints include feeling powerless and lack of information. External factors include inadequate staffing, lack of experience or competency and poor policy or administrative support.19 For internal constraints, emotional support from colleagues, reflecting on similarly challenging cases and information gathering are helpful. For external constraints, systematic and collective action is often required. The facilitator's job is to help the group refine and specify the sources of internal and external constraints, as these will inform possible courses of action.
Conflicting Responsibilities: Obligation X conflicts with responsibility Y.
As Wilkinson points out, moral distress requires the recognition of a moral issue; however, many clinicians simply experience a sense of ‘wrong’ or a troubled conscience.20 They often need help identifying the moral core. As discussed above, naming conflicting responsibilities is essential.
Possible Actions: what actions could you take: (1) to improve outcomes for the patient and family in the case; (2) to cope with your own moral distress?
Moral distress arises out of concern for the patient, so our first task is to figure out how to help him. Recognising that moral distress might endure even after an ethically appropriate care plan is developed, we also need to take care of and support the clinicians. It is important that these two actions be distinguished, otherwise we come to the mistaken conclusion that alleviating the clinician's moral distress has solved the underlying ethical problem.
Final action: what action should you take?
Acting to uphold a responsibility is an exercise of moral agency, and is likely the reason that doing so diminishes moral distress.20 This final step includes an examination of why the chosen action is best from both ethical and professional standpoints. Consider a case in which a dying patient's husband is reticent to consent to adequate analgesia. The nurse observes his patient's discomfort and feels moral distress when his gentle attempts to convince the husband are rejected. What options does he have? How can he best exercise his moral agency? He could educate the husband, propose a small increase in morphine and ask the husband to identify signs that trouble him (eg, somnolence). By taking action—even small incremental action—moral distress is likely to be reduced.
In this paper, I argue that clinicians benefit by distinguishing between distress and moral distress and offer a moral distress map to assist clinicians in identifying the precise moral sources of distress. The moral sources, once articulated, define and refine the array of appropriate actions. Without mapping the ethical dimensions of the distress, clinicians are left with gnawing, nebulous distress without adequate ways to root out and rectify its causes.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.