 

 

This is to certify that the

thesis entitled

NURSES' EXPERIENCES OF MORAL DISTRESS .

presented by

LINDA DODSON HARRISON

has been accepted towards fulﬁllment 5
of the requirements for ‘

 

MASTEE' 5 degree in :

Interdisciplinary Programs in Health and Humanities

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NURSES’ EXPERIENCES
OF MORAL DISTRESS
by

Linda Dodson Harrison

A THESIS
Submitted to
Michigan State University
in partial fulﬁllment of the requirements
for the degree of
MASTER OF ARTS
Interdisciplinary Program in Health and Humanities

2000

NURSES’ EXPERIENCES OF MORAL DISTRESS
by
Linda Dodson Harrison

ABSTRACT

The purpose of this paper was to increase awareness about the existence of moral
distress. Nurses ﬁequently experience moral distress, yet may not recognize its presence and
the toll it takes. Moral distress occurs when a nurse believes she or he knows the right action
to take, but is prevented ﬁ'om carrying out that action. Initially distress creates ﬁ'ustration
and anger. Over time and with repeated incidences, moral distress creates bm'nout, job
dissatisfactions and results in nurses leaving the profession altogether.

To explore the causes of such distress, six hospital nurses were interviewed about
situations that created moral distress for them and each described how their situation affected
them. F romthese interviews two common themes were identiﬁed: all nurses were committed
personally and professionally to quality and compassionate care for their patients and each
identiﬁed the sense of powerlessness to act.

Moral distress is a common phenomenon and represents a unique experience for each
nurse. Satisfactory resolution of their distress lies in the understanding that nurses must
recognize the problem of moral distress, continue to talk about their experiences and consider
solutions to ameliorate the distress they feel. Through sharing experiences they can then

support and mentor each other and create innovative ways to lessen the sequella of morally

distressing events.

Dedicated
To my son Nathan.
You have shown me that
Quitters never win
and

Winners never quit.

Acknowledgments

I wish to thank all the nurses who took time to be interviewed and who shared
openly and honestly their stories. Without their participation, this project would not
be completed.

I would like to express my sincere gratitude to the members of my thesis
committee, Jacob Climo PhD, Judith Andre, PhD and Mary Jo Arndt, EdD. I thank
Patricia Jimenez and Kristin Mellon and Ruth Mendel for their editorial help.

I wish to thank my family and ﬁ'iends who have encouraged, supported, and

believed in me through this long ordeal.

iv

Table of Contents

Chapterl Introduction ............................................................................. l -4
Chapter 2 Literature Review .............................................................. 5-8
Chapter 3 Methodology ................................................................. 8-15
Chapter 4 Narratives ................................................................................. 15-50
Chapter 5 Discussion of Narratives .......................................................... 32-50
Chapter 6 Conclusions and Recommendations .......................................... 50-53
Appendix A. ............................................................................. 54

Appe nd ix B .............................................. 5 5

References Cited ............................................................. 56-60

LIST OF TABLES

Characteristics of Nurses Interviewed ................................................................. 10

Nurses Experiences of Moral Distress
Chapter 1
INTRODUCTION

I have been a nurse for twenty-ﬁve years. In that twenty ﬁve years there have been
clinical situations where I believed I knew the right thing to do, but felt ﬁ'ustrated and angry
because I was unable to act. Perhaps a patient needed a medication for pain in the middle of
the night and the doctor refused to order anything for pain because I woke him up or a patient
with terminal cancer continues to receive treatments that oﬂ‘er no beneﬁt yet leave him
vulnerable to infections that cause painful mouth sores, shaking chills and fevers that leave
himweakandexhaustedandsuﬂ'eringuntilhedies. Forthemostpartthese eventscreated
anger, ﬁ'ustration and sometimes guilt for not trying to make the situation ‘Tight”. I just put
the events out of my mind and tried to forget them. As time went on, those feelings of
distress did not subside. I began to wonder if I was suffering ﬁ'om burnout. I either needed
to explore the cause of my distress and change the way things were or leave nursing. I opted
to study this phenomenon further.

Ibeganto sharernyconcernswithmypeers, who admittedthat theyhadexperienced
similar incidences and felt the same ﬁ'ustration. They knew other nurses who left nursing
because they could not bear the sense of powerlessness to change the way things were.
Almost every nurse I talked with had experienced distressing circumstances accompanied by
feelings of powerlessness. I have heard stories ﬁ'om nurses in all areas of practice (obstetrics,
oncology, critical care, pediatrics). These are not isolated incidences; these events happen
regularly. Thesixstoriesreviewedinthispaperrepresentasmallsampling ofexperiences

nurses encounter every day. Nurses describe their experiences of seeing patients suﬁ'er

needlessly. They describe a sense of powerlessness to challenge physicians or supervisors
because they had too many patients or too much administrative paper work to safely care for
their patients.

The kind of distress nurses experience is a problem not only to nurses but to the health
care system. Corley (1994) writes “ineffective coping with moral distress included crying,
sarcastic retorts, withdrawing or going along with the situation, considering resignation” (p.
281). Anger ﬁ'ustration and guilt are not forgotten. The feelings accumulate. These
experienced and conscientious nurses are lost emotionally or literally ﬁom the health care
system

While nurses are aware of these negative feelings, most are not cognizant of the
concept of moral distress. They understand the negative feeling states of anger and
ﬁ'ustration, and can identify situations that cause emotional discomfort, but they do not think
about moral distress as an entity. They understand the emotion, but not the phenomenon.
They may lose satisfaction with their job and leave without ever understanding why, and of
course without ever seeking support to rectify the problem.

I would like to suggest that moral distress is part of a continuum of moral thinking.
On one end of the continuum there is guilt. Guilt is “a painful feeling of self-reproach
resulting from a belief that one has done something wrong or immo ” (Webster’s New
World Dictionary, 1984). One feels personally and solely responsible for an error in
judgement or wrongdoing. At the other end of the continuum is indignation which is “anger
or scorn resulting from injustice” (Webster’s New World Dictionary, 1984) where one
believes another is solely responsible for wrong judgement or wrong doing. I believe “moral

distress” falls somewhere between guilt and indignation. With moral distress, one feels a

certain account of moral complicity with the decision because of one’s social location. In this
study, the nurse is part of the implementation, yet does not agree with the decision. Moral
distress represents some guilt for not acting to rectify the situation and at the same time some
indigmtion towards the “other” ( physician, supervisor, administrative policy) for creating
such a situation.

It is important to increase awareness of the pitfalls of unresolved moral distress, its
etiology and essence, and to seek ways to understand why it exists and what can be done to
lessen its burdens. There are two deﬁnitions that describe the essence of moral distress.
Wilkinson (1989, p.16) deﬁned moral distress as “the psychological disequilibrium and
negative feeling state experienced when a person makes a moral decision, but does not follow
through by performing the moral behavior indicated by that decision.” The Wilkinson
deﬁnition suggests one feels guilty and assumes responsibility for not acting on a perceived
wrong. Jarneton (1984 in Wilkinson, 1994, p. 512) believes moral distress occurs when
“one knows the right thing to do, but institutioml constraints make it nearly impossible to
pursue the right course of action.” Jameton’s deﬁnition illuminates the morality of not
“doing the right thing,” but suggests the institutional constraints assumes some of the
responsibility for inaction. To those deﬁnitions, I would like to add another key factor in
moraldistress. Itistheincongruence betweenthehighstandardsnursesbelievetheymust
uphold (See Appendix A, Code for Nurses 1985) and the complexity of patient care in the
current health care environment. They have the responsibility for their patients, but do not
have the real power to be the advocate they believe they should be. The physician and the
hospital administration often take precedence.

Chapter 2 is the literature review. The review of the literature describes the history

of articles written on moral distress, oﬁ‘ering deﬁnitions and case studies that described the
existence of this phenomenon. It offers a description of the perceived barriers: powerlessness,
conﬂicting loyalties, close relationship and the strong commitment nurses have with their
patients. Finally it presents suggestions ﬁ-om the literature on ways that nurses can address
their distress.

Chapter 3 describes the narrative methodology using taped interviews to describe
morally distressing incidents and the participants’ emotional responses to those particular
situations. Those in depth interviews represent a richer description of the emotional toll
nurses experience in their clinical practice than has been described in the literature.

Chapter 4, Narratives, inchrdes a synopsis and interpretation of the six interviews and
reﬂects a diversity of situations, the resulting ﬁ'ustration and negative emotions that nurses
experience. This chapter is followed by Chapter 5, Discussion, which offers an in—depth
review of the narratives and recognition of common themes. Once these common themes are
recognized, it is possible oﬁ’er viable solutions. I offer conclusions and recommendations in
Chapter 6, Conclusions and Recormnendations. Chapter 6 also suggests ﬁrrther research on
moral distress.

I hope the ideas put forth in this paper capture the factors that contribute to moral
distress, advance dialog among nurses about this topic, and provide insight into ways that
resolve or abate such distress. Nurses remain an integral part of patient care, but must seek

ways to maintain job satisfaction and remain emotionally healthy.

Chapter 2
LITERATURE REVIEW

It is probably safe to say that moral distress has always been a part of nursing. It has
not been widely recognized or discussed as such. A search of the medical and nursing
literature since 1966 ﬁnds the earliest writings using the term “moral distress” were written
by Jameton in 1984. Wilkinson (1994) cites authors Hoﬂing, (1966) and Jacobson, (1973)
as describing stresses of nursing, but I did not ﬁnd the term “moral distress” used before
1984. In the 1990's.more authors Benoliel (1993), Corley and Raines (1993), Cunningham,
(1993), Daniel, (1998), Doka, (1994), Fowler ( 1993), Perkin, Young, Frier, Allen and Orr
(1997), and Taylor, (1993), wrote about moral distress and its effect on muses.

Corley and Raines (1993) reported that 55 percent of nurses, regarding decision
making, reported conﬂict between personal values and professional values. Moral distress
is the result of tension between what nurses are taught in nurses training about their
obligations to the profession of nursing and the realities of real clinical situations. “Although
nurses are socialized to perceive themselves as professionals with autonomy, full
accountability and decision nuking abilities, their actual work situation is a different picture”
(Corley & Raines, p. 614).

Corley, (1993) Raines, (1993), and Scanlon and Glover, (1995), believe the American
Nurses’ Association, Code for Nurses (1985) is the basis for the conscience of nursing. The
code addresses two facetsofnursing: ﬁrsttheconduct ofnursesintheircareofclients which
includes the ethical principles of autonomy, beneﬁcence, non maleﬁcence, veracity,
conﬁdentiality, ﬁdelity and justice. Second, it addresses maintaining the quality and

competence of nurses. “Professional nursing is regulated by standards that specify the

conduct of practitioners and hold them accountable for failure to uphold these standards”
(Raines, 1993, p. 614). However, the standards are lofty and “the applications of these
principles as absolutes is impossible. The practice of nursing involves people, human
relationships, and individual virtues, not abstractions” (Raines, p., 539).

A key issue of moral distress identiﬁed in the literature is the sense of powerlessness
nurses feel (Erlen & Frost 1991). As a result of feelings of powerlessness nurses experienced
negative consequences such as anger, ﬁ'ustration, job dissatisfaction and even leaving nursing
altogether. Nurses may believe an action is morally wrong, yet feel powerless to act. The
perception of powerlessness originates ﬁom a variety of causes. Some acute care inpatient
situations create the sense of powerlessness that overwhelm nurses and inﬂuence their ability
to give care (Cunningham, 1993; Doka, Rushton & Thorstenson, 1994; Daniel, 1998).

Another common reason oﬁen cited is the physician/nurse relationship. Dalby related
a study by Haddad (1988) that found 75 percent of the nurses they studied had to
compromise ethical values, primarily due to physician requests. Benjamin and Curtis (1992)
wrote that physicians are at the center of decision making and the nurse acts as a “passive
recipient.” Medical care is under the direction of physicians; nurses follow the physician
orders and so traditionally physicians have more “power” over the management of patient
care.

Another issue that might be considered could be the traditional power imbalance
between men and women. Brody, (1992) suggests that the “relationship between men and
women is basically a disparity in power, with men having the social status and control
necessary to maintain their privileged power status”( p. 28). Medicine has traditionally been

a rmle dominated ﬁeld. Historically most physicians have been men and most nurses women.

At the same time, men continue to maintain most management positions in healthcare domains
(Sherwin, 1996a). Sargent and Brettell (1996, p. 189) write, “(w)omen as a group still have
relatively less public power than men do collectively...policies and practices of those
institutions ﬁ-equently favor men’s interests over women’s.”

The sense of powerlessness also may emanate ﬁom the institution that employs
nurses. Ray (1994) stated, “perception of powerlessness in the organizational work
environment was negatively related to ethical practice” (p.105). For fear of reprimand or
dismissal by the institution, nurses my believe they must follow physician orders, or care for
more patients than they feel is safe. Corley and Raines (1993, p. 612) related that, “(n)urses
often perceive thenmelves primarily responsible to the employing institutions and the
physician. ...The inﬂuence of the organization can be more powerful than the nurse’s
commitment to either the professional standard of practice or to the patient.”

The close connection to patients makes nurses more vuhrerable to moral distress.
Gadow (1980), LeVille Gaul (1995), Scanlon and Glover, (1995), Taylor, (1993), and
Wilkinson, (1994) identify the “hand on care” of nurses as an important factor in attachment
and connection to patients. Nurses care for patients by physical touch, visual observations
and hearing verbal and non verbal(e.g., breath or bowel sounds, equipment beeps and alarms).

They touch, see, and hear the patient and then assimilate the information in order to
understand the whole patient. Doka, Rushton and Thorstenson (1994) write about care giver
distress. Anguish is “experienced as a threat to our composure, to our integrity, to the
ﬁrlﬁllment of our intentions, and to who we are as nurses and as individuals. ...(S)uﬂeﬁng is
related to our competing obligations to the patient, the family, our colleagues, the institution,

and society in general” (p. 348).

Nurses need to understand the standards set forth by their profession (Raines, 1993;
Scanlon & Glover, 1995) because the standards provide a foundation to direct and guide
nursing practice. They must then, however, learn to balance competing obligations such as
to patients, physicians, the institution and their personal beliefs.

Jameton (1990), Le Ville Gaul, (1995), Doka, Rushton, Thorstenson, (1994), and
Raines, (1993), invite nurses to examine their values, both personal and professme to talk
about issues that create stress and to set priorities that will empower nurses to balance
personal, professional and institutional values for the beneﬁt of care givers and those who

receive care.

Chapter 3
METHODOLOGY

To gainadeeper understanding about moral distress, ﬁomthe viewpoint of mdrvrdual
nurses, I selected a narrative amlysis. Mishler (1986) writes that, “(t)elling stories is one of
the signiﬁcant ways individuals construct and express meaning”( p. 67), and that “narratives
are one of the natural cognitive and linguistic forms through which individuals attempt to
order, organize and express meaning” (p.106).

Narrative analysis requires close attention to what interviewers and respondents say
withlessemphasisonsyntaxandsemanticsthatonewouldﬁndusing statisticalanalysisof
codeddata. The intent ofthis studywasnot to analyzethe semanticsofmoraldistress, but
ratherthe essenceofmoral distress. Forexample, what situationscausedistressandwhether

there were common themes among the stories. Some narrative involved patient care, some

short staﬂing, and others administrative duties. The diversity of situations described in the
six narratives made it diﬁcult to use analytical comparisons.

The interviewing technique was unstructured, which Mishler (1984) identiﬁed as
most appropriate for preliminary research This was my ﬁrst attempt at nanative research and
no other research using moral distress as a topic was recorded in the literature. Participants
were told the purpose of the research and asked six open ended questions. The interviewer
allowed all questions to be answered with minimal interviewer input. A more structured
interview with extensive questions would have guided the responses too much. I was more
interested in responses that were not prompted and directed by the interviewer. A more
structured interview with speciﬁc questions about particular circumstances would have
aﬁ‘ected the spontaneity and purity of responses. Prompting would have the potential of
meahngwhattheinterviewerwamwtohearmtherthanmorecandidmsponses.

The analysis did not distance itself ﬁom the purity of the respondents by using
statisticalanalysisofthe syntaxandsemanticsasmiglrtberequiredinmoreepisternological,
temporal and objective content analysis. It sought to understand what nurses perceive as
morally distressing and how it affects them personally and professionally. The subjective very
personal expression that narratives reveal get at the heart of the matter in all the uniqueness
of each muse’s experience and perceptions of the situation. At the same time, the narrative
suggests that larger issues like moral distress are widespread.

Hearing and telling stories about moral issues is not new. Bioethical, medical and
nmsingjomnalsoﬂ‘eranumberofcase studiesthatreﬂect moraldistress(Perkin, etal,1997;
Corley, 1995; Wilkinson, 1988). The studies explore the situations within the medical ethical

framework of moral principles such as autonomy, beneﬁcence, non maleﬁcence, and justice.

The studies also explore the ﬁ'ustration and anger nurses feel when they are not able to
provide the care they believe the patients deserve. I believe there is more to understand about
these stories. Patient care management is a complex interplay of medical care (physical
healing), psychosocial (emotional and social inﬂuences), and political/legal factors
(reimbursement, health care regulations). This complexity may interfere with care that is in
the patient’s best interest and contribute to the distress nurses experience. Case studies ﬁ'om
the literature gave only limited details about morally distressing situations and none described
medical-surgical nursing perspectives. I believed in-depth interviews would reveal more
insight into the social sources and outcomes of moral distress.

Recruitmenttookplaceinavarietyofways. OnceIwasreadyto recruitparticipants,
I asked nurses I knew to suggest others that might be willing to participate. The unit manager
on a medical surgical unit referred three participants, the other three volunteered after I told
themaboutthe studyandlasked ifthey would participate. None weresupervisedbyor
worked directly with me. All participants in this study volunteered their time. All agreed to
participate because they believed their stories were important, and believed moral distress was
an important topic to explore.

I had originally planned four interviews, but ﬁve nurses volunteered. A sixth
interviewwasaddedto getasecondmale interview. Theﬁrstmale seemedsodistressedand
angry about his experience, I thought another male should be interviewed just to see if other
male nurses seemed to express such anger. The second male did express anger, but the
intensity was similar to the female interview participants.

Itoldeachonelwouldaskhim/herto relateadistressing situation; asituation

where they felt they knew the right thing to do, but were not able to carry out that action. All

10

were assured that their rmrrative and names would be kept conﬁdential. Aﬁer asking them
if they would be willing to participate, I then set up an appointment with them. We would
then meet at a place convenient for each one. I requested that it be a place that offered
privacy and no interruptions. Two interviews were conducted in the hospital, two in the
participant’s home, one in the interviewer’s home and one in an empty classroom on the
Michigan State University Campus. No other persons were present during the interviews.
Each participant signed a consent form (See Appendix B) and was asked the following
questions: (1) Can you tell me about a patient care related situation that upset, frustrated or
irritated you? Describe a situation where you knew the right thing to do but felt that
politically or socially you were not able to act. (2) How did you resolve the distress or
ﬁ'ustration? (3)What meaning did the situation have for you? (4) Do you feel these
experiences “spill over” into your personal life? If so how? (5) What barriers do you see that
prevent you ﬁom carrying out your responsibilities as a nurse? (6) What person, institutional
policy or other factor conﬂicted with your responsibility to the patient? Questions were not
necessarily asked in the same order, but each participant was asked the same questions. The
responses were in no way prompted. The interviews were taped and transcribed verbatim
which allowed careful review of content and lessened the possibility of inaccurate recall.
The interviews lasted ﬁfteen to twenty two minutes. All participants seemed relaxed
and cooperative. No limitations were placed on respondents regarding the type of event.
They were allowed to describe any situation. It did not nutter when the event occurred (one
participant related a story that happened twenty years earlier) or who was involved. Some

stories were patient care related, others concerned administrative duties that kept them from

accomplishing patient care.

11

Each interview was transcribed verbatim to allow a complete and thorough review.
I explained that the purpose of the study was to get a deeper understanding about situations
that distress them, to increase awareness about the existence of moral distress and to gain

insight into ways that might help nurses cope with the emotional fallout of such distress.

Characteristics of Nurses Interviewed Table 1

 

 

 

 

 

 

 

Participant Age Years Gender Degree in
Experience Nursing
#1 47 26 FEMALE Masters
#2 54 31 FEMALE Bachelors
#3 45 20 FEMALE Bachelors
#4 51 1% MALE Associates
#5 49 18 MALE Associates
#6 44 2 FEMALE Associates

 

 

 

 

 

 

 

All the nurses were between forty-four and ﬁfty-four years of age. A nurse who is
over forty would have more life experiences to draw from than would a twenty-year old nurse
ﬂesh out of nursing school. Their experience as a nurse ranged from eighteen months to
thirty one years. Three of the nurses held Associate’s Degrees in Nursing (a two-year
Community College preparation with both classroom and clinical experiences), two had
Bachelor’s Degrees in Nursing(a four-year college degree program with three years of clinical
experience and classroom preparation combined with an emphasis on nursing theories), and
one had a Master’s Degree in Nursing (a Baccalaureate degree in nursing and at least two
years of advanced nursing education for a Master’s degree). All participants were Caucasian

and employed full time in an acute care hospital in a mid western city, population over

12

600,000. (See Table 1).

Only one nurse was familiar with the term “moral distress,” so I shared one or two
examples from the literature or my own personal experience. For example, Ustal (1990)
wrote about Jason who was seventy-one and adamant about not being put on the ventilator,
yet his wife wanted everything done and the physician refused to write a Do Not Resuscitate
order or another situation where half the family wanted everything done and the other half
wanted treatment stopped. From my own personal experience I shared a story about a patient
who was forty-three with a terminal melanoma, which has no known effective treatment. He
was oﬂ'ered and given very toxic chemotherapy under the premise that it would prolong his
life. He died a week later after suffering from the severe side effects of his chemotherapy.

They were asked to identify a situation that had occurred where they felt they knew
therightthingto do,butfelttheycouldnotact. Allsixnursessharedtheirpowerﬁrland
compelling stories. I did not judge whether the situation described was actually a moral issue
or not. It would be inappropriate to pre-judge a particular narrative’s content as to its moral
relevance, only the teller needed to decide. Each participant spoke about an issue they
believed was morally wrong and caused them distress.

Once the idea was explained, all participants were able to relate an incident. My
emphasiswasnottofocusontheactualincidentbuttheeﬁ‘ectithadonthenursesand
perhaps discern why it distressed him/her. The incidents and interpretations are discussed in
detail in Chapter 5, Discussion of Narratives. It was noteworthy that the term “moral
distress” was not a term they recognized, but all knew the experience. They all were grateful
for the opportunity to share these troublesome stories and hoped that nurses would beneﬁt

ﬁom the information they shared.

13

The interview process was an enlightening experience. Nurses talked openly about
a subject they seldom talked about, they all had different experiences, and they shared
situations I had not thought of as morally distressing until hearing their stories. I hope the
analysis contributes to a better understanding about the painﬁrl issues nurses face every
day. My intent is to explore the common themes in each story, consider why they might be
there and thus gain insight into possible resolution of the distress.

The interviews were compelling. The ﬁ'ustration, anger, disillusionment was genuine
as was also the overt sense of duty and commitment to the profession. Those in depth
interviews represent a rich description of the emotional toll nurses experience in their clinical
practice. Unfortunately, time limits precluded me ﬁom doing more interviews, but it was
evident many more stories could be told.

Using the methodology of narrative analysis lends its self to this topic. The
descriptions, the essence of moral distress, are a result of open ended inquiry into what causes
them moral distress. I reviewed the narrative as objectively as possible, and tried to see
the world through the eyes of the subject. I allowed them to describe any situation they
chose. The ﬁrst and sixth example were about clinical situations where patients were in
severe pain and were terminal yet the doctor would not respond to the nurses pleas to help
the patient be more comfortable and allowed to die without suffering. Narratives three, four,
and ﬁve described examples of nurses who were overwhelmed by the demands of their job.
Those demands kept them ﬁom delivering quality care they believed they should.

This study’s value rested in the exploration of the important, difﬁcult and interesting
aspectsofmoraldistressanditspossibleoriginsandtheinﬂuencesuchdistresshasonnursing

practice. The value lies in its capacity to identify and articulate the themes of moral distress

14

that are common to the nurses in this study.

Chapter 4
DISCUSSION OF NARRATIVES

The following are descriptive summaries of the six interviews.
Situation 1

A forty-seven-year-old female nurse with twenty-ﬁve years of experience related a
story that happened twenty-ﬁve years before. Briana was caring for a young male patient
with burns over 90% ofhis body. Three areas ofconcem for burn patients include: loss of
skin integrity, electrolyte imbalance including great problems with swelling and pain ﬁ'om
exposednervesandcontractures. Theskinisthe body’sbest defenseagainstinfection. Once
the integrity is lost, the riskofinfectionis great. Also once the skin is lost, body ﬂuids escape
the vascular system creating a tremendous problem with edenm (swelling) and ﬂuid
imbalance. Whenthe skinisburned, thefascia, whichareﬁbrousmembranesthatunitethe
skin with underlying tissue, contract and become rigid. This impedes circulation and in areas
such as the chest, prevents expmsion and leads to suffocation if the stricture is not relieved.
Fasciotomies (longitudinal cuts) relieve the stricture but also expose nerve endings which
increases pain. It is not possible to completely anesthetize a patient ﬁ'om the severe pain of
bums,to do sowouldkillhirn.

This particular patient lmd no chance of survival and although severely burned was
alert and coherent. The physician decided to treat this patient. This patient required one or
two nurses twenty four hours a day to care for him. Each day meant hours ofpainful

debriding (cutting away dead tissue) inch by inch and fasciotomies (cutting the fascia to

15

relieve contracting scar tissue). Third degree burns means the nerve endings of the skin are
destroyed, and therefore do not cause pain, but any areas with ﬁrst and second degree burns
are very painful. The patient was given pain medication that helped relieve some discomfort,
but certainly not all.

When asked, “Did it add to his suffering?” She replied, “Yes, because the longer he
was alive and the more ﬁnsciotomies you have to do because the eschar (dead tissue) gets so
tight. You know it would have suffocated him. ...Then you opened nerve endings to be
available for pain so I think he was nnore uncomfortable.”

later, I asked, “Was that part of your frustration?” Briana expresses empathy for the
physician in that “dealing with the physician, who I think at the time was probably unable to
deal with it himself. ...It was probably very diﬂicult to think about it, for the physician, to
know when to say stop. ...I think it was diﬁcult for him to say stop when we all knew
somebody needed to say stop and it was basically his call. ...The doctor was just not
comfortable with ‘do not resuscitate’ and I believed that the situation could have been
remedied fairly quickly without a lot of suffering on his (the doctor’s) part.” It was very
painful “watching someone suﬂ'er when there was no gain in it. ...We (the nurses) all knew
somebody needed to say ‘stop’ and it was basically his call. ...We had approached the
physicianto allowthispatient to die, but “Ijustthinkhewasnot inapositionpersomllyto
say stop.”

Thenursebelievedsheknewwhatwasbestforthepatientandthatwasto allowhirn
to die comfortably and with dignity. She did talk with the physician about allowing the
patient to die, howeverhewasunable to let that happen. Althoughhedid not withdraw life

support as she believed he should, she expressed empathy for the discomfort the physician had

16

watching the patient suffer and yet having diﬂiculty stopping life support. Briana expressed
distress about the patient’s continued suffering and felt powerless to change the circumstance
because the physician was in charge.

When asked what meaning this had for her, she admitted the event created some
sadness, but did not adversely affect her personal life. She was able to detach the events irn
her professional life ﬁ'om the events in her personal life.

When asked, “Do you tlnink you would handle it differently today?” Briana replied
“Yeah,...I would be more comfortable talking with a patient. ...I think the whole attitude in
healthcareisnowdiﬂ‘erent so that people are alot more comfortable sayirngthisisasfaras
we can go. ...My place as a nurse is to support them in whatever decision they (the patients)
make. So if they make a decision to go the long, hard way...I, as a professional have to
support that.” She believes it may be diﬂicult to watch a patient suﬂ‘er, but she would
support the patient’s decision.

“Nursing as a profession has gown and changed and there is much more ability to
have a collegial kind of relationship rather than physician-handmaiden. ...I thirnk it still
happens to some extent, but certainly happens to a lesser extent now. ...I thirnk they know
that patients have the right to make decisions.”

Thediﬂ‘erencesheperceivestwentyyearslateristhattlnepatienthasmoreto sayin
the decision making process about continuing treatment or not. She would share her
thoughts with the physician, if she disageed with his management, but would support the
patient if he/she chose to continue treatment. The patient’s input would make the difference

to Briana whether the treatment continues or not.

17

Situation two

A ﬁfty-four-year-old nurse with 31 years of experience related a story that happened
about two years ago. Mary was the IV (intravenous therapy) nurse who administered
chemotherapy for Mr. B. when he was admitted for treatment related to his lymphoma. He
had received several drugs, but one irn particular, Vincristine, has the risk ofbowel obstruction
secondary to its neurotoxic effect on the bowels. This patient had completed his
chemotherapy and was ready for discharge. As oﬁen happens aﬂer chemotherapy, his white
blood cells that provide immunity were quite low, but not low enough to warrant keeping him
the hospital.

Mary became concerned about the patient’s bowel status. He had not had a bowel
movement in several days, but was not uncomfortable. There were no signs of impendirng
bowel obstruction. He had complained of some nausea, but this was common with
chemotherapy administration. The patient wanted to go home. Since there were no obvious
reasons to keep the patient in the hospital, the physician planned to discharge him.

Mary stated she “intuitively” believed the patient would have serious bowel problems
after his discharge. He had not had a bowel movement and his nausea concermd her. She
tried to convince the Physician Assistant to keep him in the hospital until he had a bowel
movement, but there was no justiﬁcation for keeping this patient in the hospital.
Consequently he was sent home only to return two days later with a perforated bowel which
required surgery. His post operative conn'se was complicated by his low white blood count
and resultant infections.

Sine stated, “I felt we did a poor job caring for this patient, I feel like every nursing

judgementwehad,justinthisareaasanIVnursewas,wefellshort,wayshort. ...(I)twas

18

not really my job,...I was sick (pause in dialog)...l was devastated. It was like all I could
think of was this poor man carrne into our care expecting that we would act responsibly and
that we would do the things that were necessary for his outcome and we fell short of that.”

She felt the Physician’s Assistant or the other nurses should have intervened to insure
the patient had a bowel movement before discharge. Mary desperately tried to have the
patient’s discharge canceled. However, to have held up a discharge for lack of a bowel
movement in an otherwise stable patient would be unusual.

For whatever reason, Mary deﬁnitely felt responsnhle for what happened to the
patient. This narrative reﬂects this nurse’s strong sense of responsibility to the patient, but
alsonnyleadustoashhowfarshouldthatresponsibilityextend? Harmcanresultanda
nurse is responsible for that when nurses fall short in patient care, but in this instance there
wasno irnmediatedangertothepatient. Allmighthavegone well, butthepotentialwasthere
for problems and in this case the patient developed complications. As a result of the patient’s
outcome the nurse arranged an inservice to teach her peers about the potential side eﬂ‘ects of
Vincristine. This seemed to be a positive response to an unfortunate event and served to
ameliorate some of her guilt.

“...(W)ith the advent of shorter hospital days with my change irn roles, there has to be
a more creative way of accomplishing patients’ needs. ...There has to be an assertiveness on
the part of the nurses who intuitively know something isn’t right...and if necessary go the step
furtherand go tothechargenurseoreventhedepartmentmanager.” Maryappeared
distraught as she described these events. Her voice sounded emotional and shaky while
describing these events.

When asked how this situation affected her, she related that, “now I don’t care

19

anymore. I don’t think the quality of care is adequate to be able to pick up things like that.
If my family is in the hospital, you best believe I will be there probably 24 hours a day. I just
think people are not cared for in a way that when they leave you know for sure their care was
adequate. ...I think the pressure to transfer out of the hospital somewhere else is present, for
whatever reason either the hospital or the insurance companies pressure. I think it has
interfered with good judgement.”

Unfortunately, this incident created a serious mistrust of the patient care system where
Mary worked. Her distrust of the competency of the nursing care spilled over into a concern
for her own family members. She believed it was not safe to leave them alone in the hospital.
Her distress over this particular situation truly colored her perceptions about patient safety.

Patients such as Mr. B are at risk for a variety of complications, but it is not
reasonable to keeptheminthehospitalwithout medicalevidence ofsuchaproblem, suchas
a bowel obstruction. That would be an unnecessary use ofhospital resources and a continued
isolation of the patient ﬁom his home life.

The interview continued, “In terms of the way that your handle situations like this, can
you see a change from 25 years ago to now?” Mary replied, “I’m a lot more mature in the
way I deal with it. ...I incorporate other people. I think there is a geat deal of stress.” It
seems as ifshe feels some support by involving others in patient care situations, yet in this
particular incident, she took considerable responsibility for an outcome (a perforated bowel),
no one could have predicted. This incident reﬂects the enormous responsibility muses feel

for their patient’s welfare, even irn instance where they have no control over the outcome.

20

Situation three
This story was related by a forty-ﬁve-year-old female nurse with twenty years

experience. Ellen was working irn an intensive care unit caring for two very critical and
unstable patients. One patient was an old man on a ventilator who was “ﬁightened and
scared,” the other was an elderly woman with severe liver disease who was “obtunded and
stuporous.” (Obtunded means no sensitivity to pain or verbal stimulus, comatose.) The unit
was short staﬁ‘ed, meaning there were too few nurses to adequately care for the patients.

Ellen, relates, “I’m running ﬁom room to room. When I approach the bedside of the man,
hekeepsgrabbingmyhandandhehasjustthisawfullook ofterroronhisface,heisso
ﬁ'ightenedandsoscared.Andofcoursehecan’ttalkbecausehehasatubeinhisthroat.
And, I keeptryingtoreassurehimbutlkeep feeling likeI’mrushing. ...WhatIought to be
able to do I can’t do because I have this other patient and I shouldn’t have this other patient.”
Ellen is concerned about the other patient as well, “I’m giving this lady enemas, she’s laying
in poop, ya know. ...What about this woman’s dignity?” Her concerns are not just for the
physical needs ofher patients, but their needs for compassion and respect for them as a human
being.

Ellen then receives a call ﬁ'om the supervisor who wants to send another patient. She
tells the supervisor she cannot possibly take another patient. The supervisor relates they must
takethispatientbecausetheyhavetlneonlycriticalcarebedopen. “WhileI’mtalkingto her
on the phone the alarms are going oﬂ'in the two rooms ofmy patients. ...We’re supposed to
have eight nurses and we have ﬁve...and I’m telling her to send the patient to somewhere else,
ya know, to another hospital, I don’t care where. But, I’m going to hurt somebody, ya know,

Somebody is going to get hurt up here, ya know.” “Having the one patient is more than

21

enough work for one nurse to do. In addition, I am in charge . . . and all the other nurses are
inasbadashapeaslam.” Andthisisthetypicalkindofstory. Weenduphavingto take
this other patient, now I have three patients who are getting ‘shitty’ nursing care.” Ellen with
a tense voice expresses her ﬁ'ustration and anger. “It is immoral to care for patients like that.”
She believes she cannot refuse to take the patient. Not only will she he “wrote up”
Monday morning for refusing the patient, but also for not providing adequate care for the
three patients she is assigned. “1 fear getting ﬁred because I didn’t take the patient. I felt like
my recourse was to go home, abandon the patients and that is not a real reconnse.” She
admits that abandonment of the patients was neither morally or professionally an option, but
those comments reﬂecttheintensityofher frustrationand senseofpowerlessnessoverthe
situation in that moment. Legally nurses cannot abandon their patients, but she must consider
documernting the irncidence and presenting her concerns to her manager, the nursing executive
and the CEO ofthe institution ifnecessary.
Atthetirnethesupervisorcalls,Ellendidnothavethetimeto“standthereandargue
about it. ...I might have been able to argue...but while I’m on the phone trying to argue... the
patients...need my attention right now. She agrees to take the patient because she did not
have the time or energy to plead her case further. The supervisor, Ellen’s superior, needed
a bed for a patient and pressured Ellen to comply even as she protested. Ellen felt powerless,
at that moment, to reﬁise the patient. Ellen struggled for several reasons: 1) there was
insubordination if she reﬁrsed the patient, including a reprimand ﬁ'om her manager and “black
mark” on her personnel record, 2) she was jeopardizing the care of those patients already
underhercare, 3)shewasalso increasingherprofessionalliabilitybycaringformorepatients

than was safe and if an injury resulted, it would be her own professional license at risk.

22

These thoughts go tlnrough her mind within moments. The ﬁ'ustration and anger must be
subjugated quickly so she can focus on the critical care needs of her patients.

When asked if there were things she could have done, she states, ‘you could demand
the administrator on call be called... You could tell your department rmnager on Mornday.
...But this is a common occurrence that is happening to nurses over and over again. And then
it’s like, they’ve heard that before.” Ellen realizes there are ways to express her concerns, but
believes those options will not provide relief for her situation.

Ellen goes on, “yes, I mean, I didn’t kill anybody, but it’s like awonder that eitherI
didn’t make a mistake...not to mention the emotional needs of this old man, and then, you go
home and I am tossing and turning, I can’t sleep, I’m angy. I’m angy about the whole
situation. Frustrated, I don’t want to go back to work. ...accepting the care of the patient
you don’t have staff to provide for is immoral, that is wrong.” She struggles with these care
issues in her private life. Ellen suffers ﬁ'om insomnia now and stated, she had done
“unhealthythingsto copeanditiswhatlthinkalotofnursesdo.” Unfortunatelythe
emotion does not dissipate. Insomnia and job dissatisfaction are the result of the inability to
channel her emotions in a healthy way.

Ellen has concerns for the other nurses she works with as well. “I see more and more
young nurses really detaching themselves and trying to become more technical and rmking
that their focus, because if you for one minute have to think of tlnese people as human beings,
then you can’t do it without it crushing you emotionally. ...They pretend they (the
patients)are not people, they are not human, they are a blob of protoplasm lying there and
they (the nurses)are like a gloriﬁed auto-mechanic, ya know. And that’s how they cope,

unfortunately.”

23

When faced with administrative obstacles she pursued further education in hopes of
using that education to make a difference. Now she has begun to invest more energy irnto
pursuing a Master’s degree. “I’m trying to help them. ...I went back to gaduate school...to
read, study and learn...to urnderstand the experience of illness, to ‘one on one’ help people,
other nurses . Well you know you are not going to change the world, but you are
hoping... this will give me ...more opportnmities.” It seems she has found one healthier way
to make a diﬂerence. Although there were times she considered leaving nursing, she chose
the path of investing time, energy and focus to make a difference for her patients, herself; and

her nursing colleagues.

Situation four

Situation four is told by a ﬁfty-one-year-old male with one and a halfyears experience.
Although David did not describe a particular Situation, the distress and ﬁ'ustration he
described were noteworthy. The circumstances involved being overwhelmed by all the
responsibilities surrounding “paper work.” So for the purposes of this discussion, excessive
“paper work” will represent the situation of moral distress.

David seemed burdened by the tremendous responsibility nurses have in caring for
patients. He states “what we are doing really can aﬂ‘ect people’s health and well-being and
itisnottobetakenlightly. Peopletellmethatlneedto lightenupaboutit . . . ,butlam
always reminded of the indoctrination that I’ve had in nursing school and from many sources
. . . Ifyoumakethewrong decision, it’s not thepersongivingyouthe advicewho isgoing
to be responsible, it’s you. So everything ﬁlls back on that individual nurse . . . ” The

responsibility of paperwork in addition to patient care is overwhelming him. “This is all very

24

personal to me, but it is still just a general systemic situation that I am reacting to, I think.
I am starting to question my own suitability for the given ﬂoor I’m on. It feels as though
everybody has been in my position and they have come to some kind of terms with it. They
have either gotten out or they have gotten beyond it through just sheer perseverance or what
ever it might be. They are sympathetic in a way, but they have concluded there really is no
needto solvethisproblemandifl stickwithitlwillget over it. Thisistheattitudel’m
hearing.”

“I feel in general nursing expects more of individuals than is reasonable. I found that
to be true as an employee of a nursing home, before I worked lnere, that the amount of work
expectedandthetimeallotted foranewnursejustseemsinsurmountable. Thekindof
advice that you get, even ﬁom people who are supportive is ‘just do it’, ‘do the best you can’.
Atthatpoint,myown imecuritiesmove me into anemotional statethat isveryhardto get
out of and for me manifests as anger.”

“Most ofthetirnelamworking inanangryﬁ'ame ofmirnd. Asfaraslcantell, other
people don’t react that way. ...I tend to think a lot of it’s (the)culture of nursing, that nurses
feel ‘called’ to the profession, many of them do and I don’t feel a ‘calling’ in that way. So
forme it isn’t amatter of‘let’s make this sacriﬁce oftrying to do morethanyouareprepared
to do’...or ‘I have always wanted to be anurse’. ...I have heard thistype of explanation ﬁom
people; ‘that is what nursing is, you have to expect it’, and ‘if you are called to do it, you just
doitandyougettlnroughit’. Andtheﬁrstyeargoesbyandthenthesecondyeargoesby
and things get a little easier. ...Certairn skills are becoming a little more...I’m becoming a little
more adept at them. But the emotional state hasn’t clnanged.”

David struggleswithbothhislackofexperienceandhismindsetaboutwhatanurse

25

ought to be. He does not feel a “calling”. He feels like an outsider in a culture that expects
nurses to perform under unrealistic expectations and yet do not challenge the system. He
struggles with inexperience and the burdensome responsibility that a license to practice
nursing carries with it. His coworkers disconﬁrm his struggles as a novice nurse who is
overwhelmed by the work load and the gavity of responsibility nurses carry. Mentoring by
his co-workers would help him as a nurse and as a person who needs support and comfort.

David believes the ancillary staﬂing levels have been decreased at night which adds
to his work load. When he complairns, the complaints ﬁll on “deaf ears”. “They’ve heard
it all before.” He has not tried to conﬁ'ont marnagement as “it has been done many times
before.”

When asked whether his anger and ﬁ'ustration transfer into his personal life David
answers aﬂirmatively. “My work situation really aﬁects my outlook on everything and this
past year, I think I have become rather reclusive and that has a lot to do with working the
nightshiﬁ. But moretlmnthatJthinkithasaﬂ‘ectedmyoptimism. Iusedto considermyself
a pretty optimistic person, but having this continual sort of low grade anger when I think
about work, even when I’m not at work, that has aﬂ'ected the rest of my personal life. He
believes the feeling as “low grade anger” and the loss of optimism are a direct consequence
of his overwhelming responsibility at work He believes the bothersome smoldering anger

will at some point cause him to leave his present job.

Situation five
A forty-nine-year-old male with eighteen years of experience tells of his distressing

situation. Currently Michael is a charge nurse on nnidnights on a 40+ bed medical unit. It

26

seems his main concern is stafﬁng problems and its subsequent effect on patient care. His
struggle surrounds the number of nurses who leave because they are “too stressed”. “New
staﬂ‘ are beirng inundated with so much that I’m really aﬁaid that we are going to start losing
sonne of them again before we even get them seasoned.” He states that eight nurses out of
sixteen have recently left to ﬁnd work in other areas of the hospital. With the inﬂux of so
manyadmissionsandthenumberofdiscussionsthathehasunththeDeparmrem Managerhe
wonders why nothing changes. Care of patients is ‘Vvhat we’re all about”. After eight
admissions in one night, Michael describes the ﬁ'ustrations nurses feel. “Dealing with the
ﬁ'ustrations of the individual, getting the tears, the ‘I’m going to quit’ syndrome... all that
plays a part when people don’t feel adequate in the situation.” I asked about the feelings of
inadequacy and he goes on, ‘yes, inadequacy, intimidation, to the point where I can’t do this
kindofthing. ...And evenaperson who has beenhere along, long, longtimewho wasjust
irn tears with me the other night , stated, ‘it’s time to get out’.”

Whenaskedhowthese situationsaﬁ'ecthim, Michaelrelatestlntitmakeshimangry
and he struggles with outbursts of that anger. “So I get angy, then I’m afraid I will have my
little outbursts which aren’t appropriate.” He realizes he is the charge nurse and ought to
maintain his control. He does feel pressure to maintain emotional control to demonstrate a
positive role model believing he is also responsible for the welfare and contentnnent of his
staff. “I krnow what my job entails and I know what we are expected to do here. I know
whatweareallabout, butthere’sapart ofmethat says, ‘slowdown, thisboat isgoingalittle
too ﬁst for us and we need to be careful’.” He then struggles to regain emotional control so
hecanfocusonhisjob, whichincludespatient care andrmnagement ofhisnursingunit. “I

think concern for the individual nurse who’s trying to do a good job and really feels

27

ﬁ'ustrated. But the ﬂip side of that, (as an aside he goes on) and I will kind of tell on
myself—that is I’m in a crummy mood because of all of that, that does ﬁlter over and does
impact on them. So, irn that respect, not a real good example...because sooner or later they
are going to start feeling the same way you do.”

“I try to encourage them, even when I’m not encouraged. I just think I am trying to
aﬂ’ect change that I can’t aﬂ‘ect, that I really know tint I’m powerless to really do anything
about it. “You can’t give patients the kind of care you want to . . . you are just trying to get
the tasks done. ...At midnight you might be able to harndle ﬁve-six-seven patients, but if they
are all a lot of care, a lot of work that really weighs on. ...You can’t give that patient the kind
of care you want to, you can’t divide that much time between all those people who need,
because you are just trying to get the task done, let alone...talk with somebody, pat
somebody’s hand, tell them that you care about them. ...Certainly the climate has changed
a lot. People are sicker...we are ﬁll all the time. We don’t have breaks (i. 2. times of fewer
patients) like we used to have. ...So the only way they can get anywhere with that is that
if they ‘call in’ (call to say they are sick and cannot come to work) to get a day of reprieve.
Michaelbelieves“thestaﬂ'getsso stressedtheybecomephysicallyillorstayhomewith
‘mental health days’ because they are emotionally exhausted. That leaves everybody short.

...But, I can’t operate that way and there are a lot who can’t.”

However, being a patient advocate also carries with it the risk of a reprimand, which
he is willing to take ifit serves the patient’s best interest. He cites an example ofa patient
admittedwithsevere gall bladder painwho insistsonhavinghernew bombabystaywithher.
Hetriedreﬁrsingthepatient forthe safetyofthe newborn. Thebabywouldbeat adeﬁnite

risk ofacquiring an infection in a patient care area where people are ill with pneumonia and

28

other types of communicable diseases. Michael admitted he would ultimately take the patient
even though it was against his judgement.

He admits he has been “written up” with a reprimand that went into his personnel ﬁle.
He understands this may inﬂuence his opportunities for promotion or transfer. Even at that
he questions how much more he can take. He entertains leaving his present position, but
believes lne is limited by his Associates Degree in Nnnsing. Most management positions
require a Bachelor’s or Master’s Degree in Nursing.

Michael ends by saying, “I’m trying to affect change that I can’t affect, I really
know that I’m powerless to really do anything about it. I don’t know that anyone could do
anythingaboutthem.” Hebelievesheiscaught inthemiddle betweenmanagement andthe

nurses he works with.

Situation six

Celine, a forty-ﬁve-year-old female nurse with two years experience relates a story
about a situation in which an elderly female patient was transferred to her care. “They knew
she was going to die, it was just a matter of time. ...She came over with no pain meds
whatsoever at all, nothing. And, she was okay for a while, but then it was obvious that she

got in pain. I mean, she went from verbalizing to not being able to talk, to moaning, to

groaning,facialgimacing. Imean,everythingweknowthatwhenapatient can’tactually

say ‘I’minpain’. Youcantelltheyareinpain.” Theﬁmilyhadageednotto resuscitateher.
The plan was to “keep the patient comfortable” and allow her to die peacefully.

When Celine called Dr. Diamond to request pain medication, he refused to order

29

anything. “He was a jerk about it and he refused and hung up on me.” When Celine told the
ﬁmily there was nothing for pain, “they were very, very upset. So I called back and he (Dr.
Diamond) wouldn’t even talk with me. ..It was so ﬁ'ustrating, the family wanted me to
makehercomfortableandtheysaidthat iswhat Dr. Diamondagreedto whenhetransferred
this lady to our unit. ...I must have called back three or four times. ...(emphatically she
stated) and the answer was No, No, No.” This incident was still upsetting to her. Her voice
softened as she described the family’s appreciation for her attempts to get pain medication for
the patient. “the family,(our bond was really good), kept thanking me for trying and
reinforcing that this is what they wanted for her.”

She relatedthatthefamilywasquiteupset the patientwasnot being kept comfortable.
Inﬁct,thehusbandbecamesoupsethewassubsequentlyadmittedtothecardiaccareunit
for observation. Celine called Dr. Diamond at least three or four more times.

“She is not hurting... though he had not seen her in six hours.” (Evidently Dr.
Diamond believed the patient could not feel pain because she was in a coma.) Celirne
repeatedly requested pain medication. Frustrated, the family then called her ﬁmily physician,
Dr. Nathan for advice. She did not have privileges to write orders, but was supportive and
agreed the patient should be kept comfortable. Dr. Nathan spoke with Celine and reiterated
that she knew the patient did not want to be resuscitated, but would want to be kept
comfortable. The ﬁmily physician was supportive of the Celine’s actions.

At some point, later in the day, the attending physician, Dr. Diamond called the charge
nurse and requested Celine be taken off the case. “Oh he wanted me oﬂ‘ the case. My charge
nurse didn’t want me oﬂ’thecase and shegot onthephonewithhirnand stoodupforme.”

Eventually she assigned the patient to 30mm else. Although the charge nurse disagreed,

30

she did so to “keep peace”. “This guy, his ego was so huge, it was all about control, him
being in control of what this patient got or didn’t get.” The patient contirnued in pain. Celine
related that, “the family told me, after he left, they were so upset, I mean visnhly upset. They
saidthat hehadtheaudacityto tellthem,tothedad, ‘yourwifecan’t feelanypainbecause
she is not here in body anymore, she is up there looking down on you.’ So he’s imposing his
own weirdo personal beliefs.” Finally Celine told the patient’s ﬁmily, “ya know what, your
guys could ﬁre him. You don’t have to keep him. You can get somebody else as your
primary, get rid of him if you are not happy with the care. So they did.”

They got a new physician who asked Celine what she wanted for pain control that
would help this patient. She suggested a morphine drip which he did order. Subsequently,
the patient seemd to rest better, breathing easier and more comfortable. The patient died
within the next twenty four hours. “They (the family) thanked me and thanked me.” Celine
believed her interventions saved the patient undue pain and suﬂ‘ering. “Dealing with him was
areallynegativeexperience,butitendedupbeingpositive . . . I learnedﬁomthisexperience.
Ithinkifthatkindofthing happens again,Iwilltellthe family sooner ‘youcanﬁrehirn
(physician), you don’t have to keep him. ’ ...I was a patient advocate and I feel like tint is part
of my job and I won’t be intirrnidated by the doctors, or even if I am, I won’t let them know
it.”

As an epilog, Celine was unable to attend the funeral, but called the ﬁmily to oﬂ'er her
condolences. “It just made me feel good to know that someone is reinforcing that I did the
right thing too and they thanked are.”

This story represents a contrast to the ﬁve other previous stories. The ﬁrst ﬁve

described the sense of powerlessness the nurses felt and the resulting moral distress. Celine

31

 

however stepped forward and persevered, risking reprimand from the physician, challenging
his management of his patient, she ultimately did the right thing for her patient. Her actions
represented the recognition that physicians are not always in control over patient management
and care. Nurses have more opportunity to control the care patients receive than they choose

to do.

Chapter 5
DISCUSSION

Eachnarrative describedanactualexperiencethatparticipants identiﬁedasmorally
distressing and ﬁ'ustrating. Each nurse’s story reﬂected a strong sense of personal and
professional responsibility and commitment to their profession and their patients. Each
narrative described very different kinds of situations. All six took place in an acute care
setting.

When I interviewed the nurses, I expected stories about patients experiencing
needless pain and suffering or end-of-life issues such as physicians reﬁising to write “do not
resuscitate” orders, even though the patient asked not to be resuscitated. Interviews one and
six were the type of stories I expected. However, in three situations (narratives three, four
and ﬁve) the situations that created moral distress were problems with administrative details.
Ellenwasoverwhelmedwithtoo manypatientsandﬁ'ustratedbythe lackofsupport ﬁomher
supervisor, David was upset because he felt he was not supportive enough to his staff when
they were overwhelmed by admissions and Michael was overwhelmed by the excessive
responsibilities of paper work and documentation (which are an important and necessary part

of nursing responsibilities). These situations demonstrate that morally distressing events

32

 

occur in diverse situations and can be related to situations other than direct patient care
conﬂicts.

Each narrative represented two common themes. First, every nurse indicated a strong
sense of commitment to and responsnhility for her job, both personally and professionally.
The dedication to their patients was the underlying foundation of their moral distress. When
those nurses were not able to provide safe, quality, beneﬁcent care and comfort, it caused
moral distress. Second, each nurse identiﬁed a sense of powerlessness in the situation they
described and in some cases, they even felt responsible for events over which they had no
(Mary and the patient with the bowel obstruction and Michael with eight admissions in one
night). Their commitment to the ideals of nursing practice and their perceived powerlessness
to change the situation created their moral distress and resulted irn the emotional strain and
ﬁ'ustration they experienced.

Moral distress involves a variety of factors which include: conﬂicting loyalties and
obligations, conﬂicting personal values and beliefs, and feelings of powerlessness. Each
ﬁctor challenges the nurses sense of duty and responsibility about the care she gives and the
professionalism she represents.

Their stories were about the day to day challenges nurses face. They were not
sensational stories about moral dilemms. Nurses were distressed because they could not
render what they believed was appropriate care and felt responsible when that care was not
provided. They were conscientious and dedicated, and they worked hard to provide good
care and felt the negative consequences when they could not provide adequate care, even
when it was beyond their control.

The realities of the clinical situation are complex. Patients irn acute care hospitals are

33

ill and vulnerable. Even in non life threatening situations the patient is very dependent on the
skills of his or her health care providers and their hands-on care. Patients expect safe care,
kindness and concern.

The nurses believed it was their duty to live up to the standards set in the ANA Code
for Nurses (1985, Appendix A). They were taught in nursing school to uphold those
standards and the code represented the foundation for the care nurses believed they should
provide. Often, however, the reality of the clinical setting does not allow this to happen.
There existsatemionbetweenthesﬁndardsofthecodeandmerealhiesofthechmw
situation. Clinical situations arise without much time to reﬂect about the right thing to do at
that particular moment.

For example a patients is terminally ill and the physician refuses to write a “do not
resuscitate” order. The patient tells the nurse, “I’m ready to die when the time comes and I
don’t want to be put on “life support”. A short while later, the patient stops breathing. It is
the hospital’s policy and the doctor’s intent the patient be resuscitated. The nurse’s code
requires the nurse to protect the autonomy of the patient and to respect his human dignity.
Thenurse professionallyandpersonally wants to respecttlnepatient’s wishes. She knowsthat
resuscitation requires invasive procedures such as inserting a breathing tube, inserting
intravenous lines, CPR (cardiopulmonary resuscitation) and deﬁbrilation to restore a heart
beat. For a terminal patient, who is ready for death, this is not treating them with dignity, it
is cruel. A nurse has seconds to decide whether to follow the patient’s wishes and go against
the physician and hospital policy or to resuscitate the patient as required by the physician
orders and hospital policy.

Nurses rmnage many facets of a patient’s care. It is much more than just carryirng

34

out physician orders. Nurses are the coordinator of the care a patient receives. Nurses use
knowledge, skills and critical thinking to: l) assess the patient’s physical condition ( pulse,
blood pressnne, EKG monitoring, breath sounds), 2) evaluate laboratory tests and
communicate the results to the physician, 3) administer and evaluate the effect of medications,
4) delegate and supervise care responsibilities to unlicenced assistive personnel (orderlies,
nurse aids), 5) perform and evaluate the effects of treatments, 6) teach patients and families
how to care for themselves (e.g. teaching diabetics how to test blood sugar, what meal plan
to follow, how to administer insulin, how to recognize and treat insulin reactions), 7) provide
emotional support and caring, and 8) document the plan of care, observations and patient
outcomes on the patient’s record . The nurse develops an implements the plan of care for
the patient, while continually monitoring changes in patient condition and revising the care
based on her assessment and evaluation.

Nurses continually make complex decisions. Their decision making ranges ﬁom
helping a patient plan for care at home to nnking “split second”decisions during a crisis. The
burdennurse bearisnotjust “life anddeath”inthe “short run”, but quality oflife inthe“long
run”. Nursesviewpatientsasmorethananillness. Theyseeapatientasacomplexirnterplay
along a continuum of illness and wellness which is inﬂuenced by their gender, age, race,
religious beliefs, occupation and the personal relationships they maintain (ﬁmily, work,
comrmmity).

Wlmtanurse perceivesasmorallyrightorwrong inpatient care situationsdepends
ontheirpersonalvaluesandthe standardsinthe eleven statements oftheAmericanNnuses
Association Code for Nurses (1985) (See Appendix A). According to the code, duties

include patient advocacy (Statements 1 through 3), personal responsibility for competent

35

practice (Statements 4 through 6), commitment to continuing education (Statement 7), high
standards and integity of the nursing profession (Statements 8-10) arnd a commitment to
meeting the health care needs of the public (Statement 11). A nurse thus expects to be
committed to their profession, employer, patients, the other healthcare team members
(physicians, pharmacists, social workers, chaplains, dietitians, physical therapists), and the
entire commnmity. These are enormous expectations. Nurses protect patients’ autonomy by
advocating for the right to make their own choice about treatment. This requires the nurse
to betruthfulabout treatment and its expected eﬂ‘ect onthatparticularpatient. Thenurse is
loyal to the patient (although she must balance with her loyalty to the physician, the
employing institution and her peers). The nurse advocates for quality, caring patient care,
preventshmmandunnecessarysuﬁ‘ermgandmsmesﬁhueamemofpatientsbythe system
they have entrusted their care to.

Itisinherent irnnursingandmedicalcarethatonepracticeswithhonestyandintegity
inproviding appropriatecare to everyone. Moralityis inﬂuenced bypersonalvaluesandby
values learned ﬁ‘om formal education. Nurses incorporate the tenets of the “Code for
Nurses” (1985) which states that nurses must respect human dignity, protect privacy, protect
patients from incompetent, unethical practices, and be responsible for their own actions.
Nurses must also collaborate with other health professions to meet public health needs and
to maximize the quality of life.

Nursesmedto knowandunderstandthestandardssetforthbytheirprofession
(Raines, 1993; Scanlon & Glover, 1995). Understanding provides a foundation to direct and
guide their professional practice. Corley, (1993) Raines, (1993), and Scanlon and Glover,

(1995) noted that the American Nurses’ Association, Code for Nurses (1985) is the basis for

36

the conscience of nursing. They emphasize, ﬁrst the conduct of nurses in their care of clients
that irncludes, autonomy, beneﬁcence, non maleﬁcence, veracity, conﬁdentiality, ﬁdelity and
justice. Second they mention the competence of nurses. “Professional nursing is regulated
by standards that specify the conduct of practitioners and hold them accountable for ﬁilure
to uphold these standards (Raines, 1993, p. 614).” Raines emphasized that the standards are
loﬁy and “...the applications of these principles as absolutes is impossible. The practice of
nursing involves people, human relationships, and individual virtues, not abstractions ( p.,
539).”

I believe that all the nurses who were interviewed wished to uphold the standards of
nursing care. The standard for patient advocacy was particularly evident in narratives one,
two, three and six. Briana , Mary, and Ellen were advocates for the welﬁre of the client;
Briana to allow the patient to die peacefully and comfortably, Mary to intervene before the
patient suffered a bowel obstruction, and Ellen to have adequate staﬂ‘ for the patients she was
assigned. Alltried to intervene inbehalfofthe patient, but were overruled bysonneonewith
more authority. Celine persevered and succeeded irn getting pain medication for the patient.
She expressed positive feelings about her advocacy. It took a lot of phone calls, time, and
energy. She persevered. She followed through with what she believed was right and the
patient beneﬁtted as a result.

Others directly (physicians) or indirectly (third party payers) control care, but that
caremaynot appearto be inthe best interest ofthe patiernt. Attimes, physiciansmaydirect
care that seems to cause more harm than good. The physician expects the nurse to follow his
orders, the hospital usually supports the physician and the nurse perceives herself in a “one

down” power struggle. These power imbalances (physicians and administrators wield more

37

power than do nurses) and conﬂicting loyalties ( to the patient, the ﬁmily, the irnstitution,
the physician) create tension in the nurse’s professional practice. Nurses struggle between
responsrhle patient care, following physician orders, the policies of the institutions and the
law. Wilkinson (1989) suggests that conﬂicting loyalties can occur when nurses are close to
patients. A nurses primary responsibility is to her patient and yet she has responsibilities to
families, employers, and physicians. She needs to answer questions and concerns the ﬁmily
has, she must follow policies of the institution and follow the orders the physician may write.

Insurance companies deny payments for care that may be beneﬁciaL but are deemed
too costly, such as bone marrow transplants. In addition, insurance companies dictate care
through levels of reimbursement. They may require early patient discharge or refuse certain
treatments. Sometimes employers ask nurses to care for more patients than physically
possible and professionally safe. Often the nurse becomes angy and W and may
believe there is no one to support her.

As written in Cunningham, (1993), Doka, Rushton and Thorstenson, (1994), and
Daniel, (1998), state that powerlessness is created irn some acute care situations. Nurses feel
overwhelmed and it inﬂuences their ability to give care. The perception of powerlessness
originates form a variety or causes. Benjamin and Curtis (1992) identiﬁed that physicians are
at the center of decision making and that the nurse acts as a “passive recipient.” Patient care
is under the direction of physicians and nurses do follow their orders. Erlen and Frost (1991)
concluded that nurses saw themselves as powerless. Brody (1992) pointed out that gender
may be an issue when physician are men and the nurses are women. He wrote that the
“relationship between men and women is basically a disparity in power, with men having the

social status and control necessary to maintain their privileged power status” (p. 28). Two

38

of the narratives may have represented this gender issue. In Briana’s case (the burn patient)
and Celine’s case (the dying patient), the male physicians seenwd to hold some power over
each nurse that prevented her from doing what she believed was right. Briana could not
convince the physician to write a “Do not resuscitate” order. Celine went against Dr.
Diamond’s directive, but he succeeded in having her removed as the nurse caring for his
patient.

Other instances of powerlessness occurred when Mary attempted to get the physician
assistant to keep the patient in the hospital. Ellen and Michael tried to keep their supervisor
ﬁom admitting any more patents. Mary attempted to advocate for the patient, while Ellen
and Michael were advocating for patients and colleagues. All expressed anger and
frustration. They all felt morally responsible for the outcomes they had no control over.

Mary struggled with guilt because she believed she was responsible for letting the
patient go borne too soon and the patient subsequently developed a perforated bowel which
required weeks in tin hospital. I do not believe anyone blamed her for the patiernt’s outconne,
but she felt responsible for a situations she was powerless to prevent. Ellen believed she was
powerless to stop the patient’s admission to her already overwhelrnirng patient care situation.
Michael believed he was powerless to stop eight admissions in one night or to keep his staﬁ‘
from gettirng discouraged and quitting. David believed he was powerless to the stop the
necessary paperwork from erodirng his time away from his patients. He struggled with the
fear he would miss sonnething or make a mistake.

Powerlessness is an important component of moral distress, however it is not the only
component. The sense of duty and commitment to patients is woven into the foundations on

which nursing is based. A nurse’s personal and professional sense of duty and perception

39

about what they ought to be or do is also a key component which determines the situations
that create moral distress. The feeling of distress is magniﬁed by the sense of duty and
commitment nurses have to their patients and this may conﬂict with their sense of duty to the
institution that employs them, the physicians who write the orders, and their peers who
depend on their support and guidance.

Nurses do follow most physician orders and most would agree not to follow orders
that would harm the patient. For example, if there is a dosage error or the wrong medication
is ordered, nurses would never give the medication, she would call to clarify the order. There
are times when the determination of “rightness” in following physician orders is less clear.
For example, in Celine’s story the patient who is refused adequate pain medication. What if
a cancer cinemotherapy treatment is ordered for a patient and the nurse knows that it oﬂ‘ers
nobeneﬁttothepatientandthepatienthasnotbeeninformedabouttheseveresideeﬂ'ects
andnegligiblebeneﬁt? Thenurseknowsthatthetreatmentwillcausesuiferingandno
beneﬁt. Should the nurse follow the physician’s order or disobey it when she feels it is
morally wrong? She risks reprimand for not following the order, she risks watching the
patient suﬂer for following the order.

The complexity of moral issues in health care is mind boggling. Situations such as
those described above should not be conﬁrsed with other instances where nurses may still feel
powerless, but do not necessarily create moral distress. Nurses are ﬁced with life and death
situations. Theycannot preventaninevitabledeathorpreventthepainofwalkingagainaﬁer
pelvic ﬁacture in a car accident. Yes, they experience feedings of powerlessness in those
situations, but they do not suffer moral distress. In those situations nurses are able to accept

the inevitable. However, irn circumstances where they believe they could have or should have

40

made a diﬁ‘erence, they feel distress.

Nurses feel responsibility to patients, their profession, the agency they work for and
to the physician. As Doka, Rushton and Thorstenson (1994), noted, with a multitude of
loyalties, internal conﬂict can occur. It is the strong sense of duty and the high standard
nurses set for themselves that create a strong sense of obligation to those they serve. That
obligation is intensiﬁed because nurses deal with life and death situations on a daily basis and
the people they serve are vulnerable.

Sometimes principles conﬂict. A patient, for example, could ask a nurse to assist irn
a suicide. Should a patient’s autonomy be respected by the nurse in this situation? Nurses
cannot break the law to support patient desires. Apatients autonomyisnot absoluteand may
need to be overridden in some circumstances. Patients are customers who intrusted their
care to health care professionals. Professionals have an explicit moral obligation to their
patiems. The society they serve expects this obligation and this is conﬁrmd by the medical
arnd musing professional code of conduct. Professional nurses publically promise to care for
patients with competence and to protect them when they are ill and vulnerable.

It is the lack of resolution of issues and the feeling of powerlessness to change the
situation that ﬁ'ustrates the nurse. The energy it takes, the time (in an already busy day) and
thenmcertaintyofareprimandornegativeoutcomeleadsmost nursesto takethepathofleast
resistence arnd simply “forget it and move on.” Sometimes the feelings of distress remain
turbulentunderthecalmsurﬁceof“businessasusual”. Nursesneedaforumwheretheycan
discuss the moral principles or issues, explore their values and biases, vent their doubts and
frustrations, consider alternatives and seek problem solving opportunities. Understanding

irnterpersonal differences, learning nnoral principles, sharing experiences and successes may

41

 

empower people to follow their convictions and alleviate moral distress.

Benoliel (1993), Corley and Raines (1993), Cunnirngharn, (1993), Daniel, (1998),
Doka, (1994), Fowler ( 1993), Perkin, et a1 (1997), and Taylor, (1993) indicated that moral
distress was a common experience for nurses. What made it noteworthy was its negative
consequences such as anger, ﬁ'ustiation, feelings of powerlessness, job dissatisfaction and
even leaving nursing altogether. Corley (1998) wrote that “(t)he impact of nnoral distress on
nurses is responsible for 13% of those who have left nursing positions in the past and in 5%
of those who have left the profession” (p.325).

The sense ofcomrnitrnent to do what is right is an important part ofthe complete
package ascribed to nursing care. Society expects nurses to be devoted care givers and
protectors of the vulnerable patients in their care. I suspect society does not recognize the
moraldistressnurses experiencewiththeirjobs. CorleyandRaines(l993) reportedthat ﬁfty
ﬁve percent of nurses reported conﬂict between personal values and professional values.
There is little doubt that most nurses experience distress when they believe they have not
supported or protected their patients the way they believe they should. The emotional
connection nurses have with patients includes comforting patients and ﬁmilies who are often
fearful and apprehensive about beirng in the hospital. Patients often rely on the nurses for this
emotional support. A nurse may assume responsibility for her patient’s physical, emotional,
and spiritual well-being. When something irnterferes, such as lack of time secondary to work
load, unreasonable physician orders, or extensive paper work, nurses can experience moral
distress.

Moraldecisionmakingisinﬂuencedbytheheathcareproviderswishingto do what

they believe is the “right thing” for the patient. Winether the right thing is to implement all the

42

technology and nnedical knowledge to maximize the moments of physical being or to step
back and breath in the essence of the patient as an individual with desires and wishes about
quality and quantity of life.

Otiner professions such as airline pilots, school bus drivers, airplarne traﬂic controllers
all have tremendous responsibility for the people in their care, but I do not believe they
experience the day-to-day moral distress nurses experience. Nurses ﬁce life and death
situations regularly and lunve direct physical contact with the people they serve. Patients trust
that nurses will care for tinem. Such responsibility is expected by each nurse, by other nurses
in the profession and by society. Nurses realize that a mistake or miscalculation on their part
could (althoughseldomdoes) causegreatharmordeath. Medicineandmlrsingarenotan
exact sciences. Patient care and life and death situations are fraught with uncertainty. One
can practice good mdicine/nursing and have a bad outcome. For example, the young burn
patient received good care, but no one could prevent his inevitable death. Such situations
occur and we are powerless to change the outcome, but there can be room for self doubt. We
wonder if there was something nnore we could have done.

The nurses’ workload and the critically important care they provide often prevent time
for reﬂection on the distress they are experiencirng. Because of the nature of the job, the
nurse must continue to care for her multiple patients and merely “stuﬂ” the negative feelings.
The ﬁ'ustration builds, the nurse becomes disillusioned and changes jobs or leaves nursing.
Corley (1993) identiﬁes that “ineffective coping with moral distress included crying, sarcastic
retorts, withdrawing or going along with the situation, considering resignation”(p. 281).
Benoleil (1993), Fowler, (1993), Winters (1993), Wocial (1996), Corley (1995), Doka

(1994), Curtin (1994) claim that professional, personal and societal values set the stage for

43

moral distress and the power that prevents nurses from doing the right thing for the patients
they serve. The authors all express concern about the ﬁ'ustration that leads to dissatisfaction
and leaving nursing as a career.

The nurses in this study descrlhed the sequella of their moral distress. The distressing
events created anger and ﬁ'ustration at the time it occurred at work, but some noted the
lingering eﬁ‘ects that blended into their personal lives. David felt anger was becoming
problematic in his personal life. Ellen suffered from insomnia. Michael believed his anger and
ﬁ'ustration was a negative inﬂuence on other nurses be supervised. Moral distress is a
personal and private issue. Distress can be cumulative and it can leach into ones personal and
professional satisfaction with life. These issues are complicated by the lack of clarity about
what the moral issues are, our own sense of values, what the patient’s best interest is, how
ﬁr the professional duties or responsibilities go and how powerless the muse is (or believes
she is) to change or rectify the situation.

The hands-on care a nurse provides establishes an irntimate connection between the
nurse and the patient. When patients suffer, nurses see and hear the patient’s pain and
suﬂ'eringﬁrsthand. Itmakesitmorediﬂicuitwhenthenursesees carethatsheknowsis
adding more pain and suffering than therapeutic beneﬁt. It is one thing for physical therapy
tocausesomepainifitmeansthepatientwillregainuseoftheirlegsandresumenornnl
functioning, but it quite another for the muse to follow a physician’s order to continue
physical therapy on a patient who is irnminentiy termiml, extremely ﬁtigued and suﬂ‘ers
severe pain during therapy. In the latter case, the patient’s suﬁ‘ering serves no useful purpose.

Values and beliefs originate ﬁom teachings and experiences throughout a lifetime;

teaching from ﬁmily, religion, education, job experiences, peer group mentoring, as well as

44

ethnic and cultural factors. “We recognize that ethics are ﬁamed and rooted in political
values, laws, and a legal system; but ethics also are rooted in our own personal biographies
and values. As such, they are inﬂuenced by our culture and our religious values
(Doka,1994,p. 346). Beliefs and values are multi faceted. Values tend to remain stable over
time. Beliefs are inﬂuenced on a continuum over time arnd experience. As life experiences
occur they change the way one sees the world in which they live.

There are times, especially with inexperience when the nurse is uncomfortable with
morally relevant care issues. As the one mentioned above, the muse may be uncertain or
ambivalent about the situation and its outcome. It is critical for the nurse to explore her
values and beliefs and to seek support from colleagues and discuss these morally relevant
situations. There may be times when nurses experience uncertainty about patient care issues
aswellasmoralmrcertaintiesrelated to patientcare situations. Nursesinthesecircunutances
should seek mentoring ﬁom nurses who have more experience in these circumstances. These
mentors can offer guidance for those disconcerting situations.

Self awareness about one’s values and beliefs is important. One must integrate
experiences ﬁom social, ﬁmilial, spiritual, political, professional and educatioml inﬂuences.
What we know (or believe) to be true does not necessarily agee with what we feel or want
to believe. For example, what if Briana’s burn patient had been a “do not resuscitate”, but
she believed that patients should be kept alive at all costs. She knows that should the patient
stop breathing, she should not call a “Code Blue” to summon the resuscitation team. She
would feel moral distress because of her personal beliefs.

Orne cannot prevent moral conﬂict ﬁ'om occurring. Each event is perceived through

our own eyes. Each event may not be able to be remedied but it is important to hear the

45

voices of different nurses describing different events to acknowledge that moral distress is a
common occurrence in day to day musing care and that it is related to the timing of an event
and/or the context. Events causirng moral distress are not just sensational cases such as when
a seventy-nine year old man, fonuteen years beyond the accepted standard, is given a donor
heart transplant or end of life decisions where irndividuals such as forty-ﬁve year old with end
stage, terminal lung cancer is put on life support.

Distress can be related to the timing of an event and/or the context. One nurse
cannot change all the causes and effects of morally distressirng situations, but should be
encouraged to take some action, however small. She can tell the physician how she feels and
whyshebelievesitisnotinthepatient’sbest interest, shecandocument incidencesof“short
stafﬁng”andmeetwithhersupervisorstoletthemknowthe effect shortstaﬂinghason
patient care, or appeal to the insnuance company case managers when reimblusement is
denied for necessary treatments. She must choose her battles wisely. Barry Adanu a muse
from Massachusetts was ﬁred when he “raised concerns about his hospital’s deteriorating
conditions and reported dangerous staﬂing levels W p. 13).” He believed that
safe care for his patients was worth losing his job. Not every nurse would risk losing their
job. The nurse should know what values she is willirng to stand up for and “the price” she is
willing to pay. It may mean transferring to a different departnnent or leaving a particular
institution. If enough nurses take action, their voices will be heard. Saying “it’s no use” or
“why bother, it won’t make any difference,” will only serve to create burnout and ﬁuther
exodus of good nurses ﬁ'om the health care system that depends on their clinical expertise,
compassion and commitment to quality patient care.

As Whitbeck (1996, p.9) stated, “Moral problems are not multiple choice—problems.

46

One must devise possible courses of action.” Nurses can identify the problems and should
develop a system iii which they can problem solve or at least share experiences and receive
support and empathy ﬁom others. An example of such an opportunity was a program called
“Etinics Brown Bag” which is held at a local hospital. Ethics Brown Bags are one hour,
monthly presentations on a topic related to medical etlnics. Topics may include a discussion
about a clinical situation, a case presented to the ethics committee or informational
presentation on moral principles. Its focus is education and discussion of a timely topic on
ethicalissues. Thejuogramlamhighlightingwastitled “MoralDistress: AProblemﬁ'omthe
Inside Out or the Outside In”. There were twenty ﬁve participants ﬁ‘om a variety of health
care professions. Approximately half were nurses, the other half were social workers,
chaplains, physicians, a laboratory technologist and a sociologist. The facilitator ﬁrst offered
a deﬁnition of moral distress and a brief description of how she was inﬂuenced by moral
distress irn her own practice. The hour long discussion followed about whether people
experienced moral distress because of who they are and the values they have, or did they
experience distress simply because they worked in a healthcare environment that offered
opportunities for morally distressing events. The consensus was that both ﬁctors were
integal in developing and relieving moral distress.

Participants were enconuaged to describe how moral distress inﬂuenced their practice.
The responses were touching and sincere. One man, a sociologist observed, “(w)hen we
have an identity (as a professional), taking away our decision making makes us ﬁ'ustrated; we
loose our autonomy.” When we watch a patient suffer because we have too many patients
underonucareandmust seeone, asEllendescribed, lying inherown“poop”,weexperience

moral distress. We know the patient deserves a clean bed, yet at that moment we cannot

47

 

provide what the patient needs.

Another nurse described the sadness she experiences when staﬂing on the night shift
forces a nurse to abandon an opportunity to sit with a patient, to hold a hand, to listen to a
patients’s fears about leaving three small children and a husband because she will soon die
from breast cancer. This nurse made the point that these opportunities often present
themselves in the middle of the night when all the visitors are gone and the patient has quiet
time to reﬂect.

Each participant had touching scenarios to share. As the honu came to an end,
everyone agreed they were gateful for the opportunity to share their morally distressing
experiences, to hear ways ofsuccessﬁilly handling such experiences, and to share how the
experiences helped them gow. The discussion was helpful in relieving some of their distress
andhelpedthem realizetheirexperienceswere not imique. Manyparticipantsthankedthe
facilitator for the opportunity to share their stories and suggested more metings such as this
one would be beneﬁcial.

I believe that institutions could easily implement discussion goups similar to the
Ethics Brown Bag forums. It should be a regular ongoing effort and it would cost very little
to implement. The institution could provide the space, recruit a goup discussion leader, and
offer the progam dluing lunch or break times so it would not be “paid time.” The ﬁcilitator
would help guide the discussion, allowing participants the opportunity to speak ﬁeely, yet to
be respectful of other’s viewpoints. Participants would also be assured that their comments
would be kept conﬁdential to allay fears of a reprimand. Concerns of the participants would

besummaﬁzedattheendofeachsessionandconcemsshmedwhhadmmisuationas

appropriate.

48

Brown Bag Discussions would provide an opporturnity for nurses to share their
morally distressing experiences. The goup would allow nurses the opportunity to vent their
ﬁ'ustrations and provide a therapeutic environment to relieve stress in the short term Many
times just talking about diﬂicult situations and receiving support ﬁ'om one’s peers can be
helpful.

Another option would be collaborative work goups that would be established to
make changes in policy or correct behaviors that are unacceptable. These groups might
include nurses, physicians, administrators, and/or ethicists who would met regularly to create
innovative solutions that serve to decrease the number of morally distressing situations. They
may focus on situations such as improved staﬂing ratios or establish mentoring/counseling
for care providers (physicians, nurses, administrators or other health care professionals) who
cause or potentially cause suffering to their patients (e. g. reﬁising adequate pain medication
for a dying patient). Hopefully such options would improve working relationships, reduce
morally distressing situations, improve job satisfaction and improve patient care.

Working within a hospital system, nurses might consider three ways of managing
moral distress. One (which I believe is nmacceptable) would be to lower the standards
expressed in the Code for Nurses. Lowerirng the standard would not only effect the quality
of care, but damage the trust and faith people have in the nursing profession. To lower the
standards of the nursing profession in order to lessen moral distress would not be
appropriate.

A more reasonable possibility might be for nurses to take more risks by conﬁ'onting
the situation or issues that create moral distress. An example of risk taking behavior was

modeled by Celine when she challenged the physician’s unwillingness to prescribe pain

49

medication for his dying patient. Nurses can make a conscious choice to challenge a
physician’s order or administrative policies when the welfare of the patient could be adversely
affected.

A third, but rather idealistic choice, would be to give muses the resources and
authority to perform their jobs at the same level of authority accorded physicians and
administrators. It should be a situation where nurses do not fear retribution for challenging
a physician’s order or a supervisor’s unreasonable request to take more patients. Care and
nunagement ofthatcarewouldbeprovidedinacollegialmilieuwherethejudgementsand

decisions of each discipline could be heard and considered equally.

Chapter 6
SUMMARY AND RECOMMENDATIONS

I have gained a better understanding about the moral distress of nnuses. Noteworthy
wasthe factthatmostnurseswerenotﬁmiliarwiththetermmoral distressandhadnotreally
explored solutions to relieve their distress. I realized that moral distress involves aspects of
nursing care other than end-of life moral dilemmas. Moral distress emanates from an intense
sense of duty and responsibility to the patients they serve and the profession they represent

The sense of duty and responsibility is very powerful and coupled with a belief of
powerlessness, nurses experience moral distress. David, Michael, and Ellen still felt the anger
from their past distressing events. Mary felt guilty about her patient’s suﬁermg. I believe we,
asaprofession, must help nnuses cope withtheirmoraldistressand supportthemwhenthey
are faced with situations where they have no control or perceive they have no control. When

theycannotachievethestandardsmtheCode,nursesmustrealizethattheCodeisnotthe

50

problem. It is the situations that requires the muse to perform contrary to or to a lesser
standard than the Code allows. Nurses must help each other cope with distress.

Moral distress causes people to suffer. They suﬁer ﬁ'om anger and ﬁ'ustration and
they suﬁer from job dissatisﬁction because they cannot do the job they believe they are
supposed to do. Sometimes the “right thing to do” is not clear, but intuitively the nurse
believes “the wrong” is being done. There can be many obstacles to doing the right thing.
The Code for Nurses serves as a guide to the kind of professional a nurse should be, but there
are limits to such standards. The standards are not absolutes; to accomplish all is often not
possible. Sometimes the autonomy of a patient, such as seeking a heart transplant at severity-
nine, shouldnotbesupported. Admittingathirdcriticallyillpatientmightbegoodforthe
one patient, but when it jeopardizes the care of two other patients, it should not be done.
Interpretation of the standards as absolutes ultimately sets the stage for moral distress.

A nurses responsibility to the Code for Nurses is complex. We want the muse to
upholdthestandardssetforthbytheCodefoanusestobeconﬁdentthattheyare
competent, caring, truthful, ﬁir and promote public health. In the hospital, the nurse spends
tinemostofthetimewiththepatientandlearnsﬁ'omthepatientwhatisimportanttothem,
administers the care, teaches him about the treatments and expected outcomes. The nurses
arethe ones closest tothepatient. Perhapsthisclosecontactwiththepatientmakesmuses
nnore vulnerable to moral distress.

Nurses will continue as patient advocates, but they must recognize the conﬂicts that
occru with that role and the emotional sequella If they recognize the phenomena of moral
distressinthemselvesandothers, theythencanestablishnnore dialogue abouttheparticular

situations and seek support and understandirng ﬁom each other. Nurses do not usually

51

 

recognize their own distress. They do not nurture themselves or their colleagues during
distressing events. David was told by his co-workers, “that is what nursing is, you have to
expect it and if you’re called to do it, you just do it and you get through it.” or “People tell
me to lighten up.” I believe these comments are common. Nurses are so often caught up iii
the hectic pace of patient care and we do not take time to hear the ﬁ'ustrations and support
each other enough.

It is important to see moral distress as commonly occurring and ongoing issue for
nurses and that the result can be disillusionment with nursing as a profession. Like the
metaphor, “It’s not the height of mountain we are climbing, but rather the grain of sand in our
shoethatwearsusdown.” It isthedayto daydistressthatcreatesthedisillusionment.

Nurses need to support each other when they advocate for their patients and/or their
peers. The voice of many, supporting the rights of others is always more powerful than a
single voice. Nurse should not feel alone when ﬁced with morally challenging situations.
Seeking support and understanding, nurses can work together to forge better solutions.
Better solutions would support better job satisfaction and create less burnout. Through
increased awareness of muses’ moral distress, disillusionment can become enlightenment.

I hope this paper has made more visible the morals distress nurses experience. This
research has merely scratched the surﬁce of the stories that nurses could tell. Future
research on moral distress could include nurses from other acute care areas (pediatrics, labor
and delivery, critical care) and explore whether they too experienced similar feelings of
powerlessness and professional responsibility. Nurses working in public health, home care,
long term care facilities (e.g., musing homes), or hospice should be interviewed to see what

issues create moral distress for them.

52

Another interesting prospect for further research would be to interview other health
care professionals and then compare similarities or differences among each discipline. It
would be interesting to learn about the moral distress physicians, medical social workers,
dietitians, or physical therapists. Perhaps this paper will encourage further research about

health care related moral distress.

53

Appendix A

American Nurses Association Code for Nurses
(1985)

1. The muse provides services with respect for human dignity and the uniqueness of the client,
unrestricted by considerations of social or economic status, personal attributes, or the natlue
of health problems.

2. The nurse safeguards the client’s right to privacy by judiciously protecting information of
a conﬁdential nature.

3.Thenurseactsto safeguardtheclientandthepublicwhenhealthcareandsafetyare
affected by the incompetent, unethical, or illegal practice of any person.

4. The nurse assumes responsibility and accountability for individual nursing judgements and
actions.

5. The muse maintains competence in nursing.
6. The nurse exercises informed judgnent and uses individual competence and qualiﬁcations

as criteria in seeking consultation, accepting responsibilities, and delegating musing activities
to others.

7. The nurse participates in activities that contribute to the ongoirng development of the
profession’s body of knowledge.

8. The nurse participates in the profession’s eﬂ‘orts to implement and improve standards of
musing.

9. The nurse participates in the profession’s efforts to establish and rmintain conditions of
employment conducive to high quality nursing care.

10. The nurse participates iii the profession’s effort to protect the public from misinformation
and misrepresentation and to maintain the integity of nursing.

11. The nurse collaborates with members of the health professions and other citizens in
promoting community and mtional efforts to meet the health needs of the public.

54

Appendix B
Consent Form

My name is Linda Harrison, 1 am working on a study that will be the basis of my Masters
Thesis in Interdisciplinary Progam in Health and Humanities. You have been asked to participate in
a study exploring the meaning of a situation related to patient care where you knew the right thing to
do, but felt that politically or socially you were not able to act titled “A Narrative Study About the
Effects of Moral Distress on Nurses Caring for Adult Patients.” You will be asked to brieﬂy describe
the situation and what this event meant to you, how it has affected you, and how the situation was
ultimately resolved. The first interview will take no more than forty-ﬁve minutes. A second, shorter
interview may be required within the next three to six months to clarify or enhance the information
revealed in the ﬁrst interview. This information will be interpreted by the researcher for purposes of
the study.

There are no risks or costs to you as an individual. All discussions and your identity will
remain conﬁdential. You may refuse to answer any questions or volunteer any information that makes
you uncomfortable. You may stop participation at any time in the interview process without any
penalty. After interpreted, the audio tapes will be erased. By voluntary participation in this study you
are consenting to the use of information from the interview to be used later as part of possible
published research. There is no risk to you whatsoever by participation in this study.

If you have any questions or concerm related to participating in this study you may contact; Principal
Investigator, Jacob Climo, PhD, Professor, Department of Anthropology at 517-355-0189,
Linda Harrison, RN, BSN, Investigator at 517-339-0591 or UCI-IRIS (University Committee on
Research Involving Human Subjects at Michigan State University) chair, David E. Wright at
517-355-2180.

Signature Date

Linda Harrison, BSN

Masters Candidate

Michigan State University

Interdisciplinary Program in Health and Humanities

55

 

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