ANSWER
Moral distress occurs when a person is aware of the ethically correct action to take but feels powerless to do so. According to research on moral distress among nurses, the sources of moral pain are numerous and diverse. The experience of moral distress leads some nurses to leave their jobs or the profession entirely. This article looks at moral distress and residue resulting from unresolved moral pain. First, we will provide a historical overview of the phenomenon of moral distress, identify familiar sources, and describe strategies for recognizing moral distress. Next, we will talk about moral residue and the crescendo effect that comes with it. We will wrap up by discussing how to deal with moral distress and the advantages of an honest distress consultation service.

Moral distress, ethics, decision-making, burnout, moral residue, and integrity are key terms.

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Ethical debate in clinical settings can be productive and positive, indicating that healthcare providers are working together and are concerned about the quality of care provided to their patients. The presence of moral distress, on the other hand, indicates an entirely different problem. Moral distress is a sign that ethical challenges are not being addressed adequately. What exactly is moral distress? Who is at risk? How is it identified? What are the options? This article begins to answer these questions to provide a more comprehensive understanding of this challenging but persistent, healthcare problem.

The Moral Distress Phenomenon
Andrew Jameton (1984) defined “moral distress” as a phenomenon in which one knows the correct action but cannot do so. Moral distress differs from the classical ethical dilemma in that one recognizes the existence of a problem and that two or more ethically justifiable but mutually opposing actions are possible. In many moral quandaries, each potential solution has significant drawbacks.

Consider the following situation:

Mr Anderson, a 92-year-old man living in a nursing home who has had Alzheimer’s disease for over ten years, has reached the point where he can no longer swallow food effectively. He has been hospitalized four times in the last year for aspiration pneumonia. The man’s eldest child, who lives in the same town, has a durable power of attorney, pays regular visits, and insists on inserting a feeding tube. His two siblings are behind him. The staff believes that the patient would be distressed by a feeding tube. “He swats away our hands when we try to hold him down to insert the tube, and he always pulls the tube out,” they claim.

…moral distress occurs when a person recognizes the ethically appropriate action but cannot carry it out.

The dilemma is that the family, legally authorized to make medical decisions for the patient, wants one thing (inserting the feeding tube). In contrast, the staff, who manage the patient daily and have clinical knowledge of the outcome, wants something else (not inserting the box, instead providing comfort care). As a result, there are two mutually exclusive options, both ethically justifiable and neither optimal. If the family’s wishes are followed, Mr Anderson will have a feeding tube inserted, and his life will be extended. However, one might wonder how useful a longer life is for Mr Anderson and what this action’s social, familial, and financial costs are.
On the other hand, if the staff’s wishes are followed, Mr Anderson will almost certainly die sooner. The family will almost certainly feel abandoned and angry—an end-of-life situation no one wants. Again, the action’s social, familial, and financial costs must be considered.

On the other hand, moral distress occurs when an individual recognizes the ethically appropriate action but feels unable to take that action. Consider the following scenario:

Mr Jones, an 82-year-old nursing home resident, suffers from several co-morbidities, including significant dementia. He is combative and frequently kicks or punches those who try to help him. Indeed, three members of the staff (two nurses and a nursing assistant) were treated in the emergency room for injuries sustained while caring for him. The man’s wife refuses sedative medications because she is concerned about the side effects. It is challenging to communicate the consistency and severity of the problem to the doctors, some of whom are there as consultants and all of whom only see Mr Jones at short intervals. While the nursing staff is unwilling to abandon Mr Jones, they are concerned for their safety. They are morally distressed because they feel compelled to endure physical violence while having no power to change the situation. They understand that giving Mr Jones medication is necessary for his safety. Still, they are limited by the fact that the doctors who must write the prescription do not understand the extent of the problem, and Mrs Jones, the patient’s power of attorney, is opposed to any form of sedation. They are entrapped.

There is no ethical difficulty in this situation; the nurses are confident that the ethically appropriate action is to give Mr Jones enough medication to allow safe care by the nursing staff, but not so much that he is obtunded and unable to respond to his surroundings. They are not conflicted between two actions. However, they may feel powerless to take the appropriate action and unable to effectively communicate with those with authority to carry out the ethically right course of action. This is a case of moral distress.

An Overview of the Past
Jameson noted in his early work defining moral distress that the field of bioethics has placed a greater emphasis on ethical quandaries than on moral distress (Jameton, 1993). Because dilemmas require weighing the ethical justification for various courses of action, they are excellent teaching tools for encouraging the identification and discussion of ethical principles. The ethically appropriate action is likely to have been identified in situations that cause moral distress. As a result, discussing the ethical aspects is less critical. Addressing moral distress, on the other hand, necessitates the identification of social and organizational issues and questions of accountability and responsibility.

Traditional ethics education, which focuses on ethical quandaries and underlying principles, must be revised to deal with moral distress situations.

Nurses were the first to recognize moral distress, and most studies have focused on this population. Although this article focuses on moral distress in nurses, it is essential to note that it is not limited to nurses. It has been identified in nearly all healthcare professionals, including physicians (Austin, Kagan, Rankel, & Bergum, 2008; Chen, 2009; Forde & Aasland, 2008; Hamric & Blackhall, 2007; Lee & Dupree, 2008; Lomis, Carpenter, & Miller, 2009), respiratory therapists (Schwenzer & Wang, 2006), pharmacists (Sporrong, Hoglund, Hansson, Westerholm, & (Chen, 2009). There appear to be differences in what causes moral distress and how it manifests itself across professions (Austin, Rankel et al., 2005; Austin et al., 2008; Forde & Aasland, 2008; Hamric, Davis, & Childress, 2006; Hamric & Blackhall, 2007; Lee & Dupree, 2008; Lomis et al., 2009; Schwenzer & Wang, 2006; Sporrong et al., 2005). These distinctions are beyond the scope of this article, but nurses must recognize that this is a multidisciplinary issue.

According to Corley (2002), moral distress in nurses occurs when the nurse knows what is best for the patient. However, that action conflicts with what is best for the organization, other providers, patients, the family, or society. Thus, moral distress occurs when nurses’ internal environments — their values and perceived obligations — are incompatible with the external work environment’s needs and dominant views. Traditional ethics education, which focuses on ethical quandaries and underlying principles, is insufficient for dealing with moral distress situations. Clarifying values, communication skills, and understanding the healthcare delivery system are the tools required to address conflicts between the internal and external environments. According to Corley (2002), while moral distress can be devastating, leading nurses to consider leaving the profession, it can also be beneficial by raising nurses’ awareness of ethical issues.

In recent years, there has been some broadening of the definition of moral distress. For example, Hanna’s (2004) analysis of small qualitative studies of moral distress revealed that, while nurses do not consistently identify constraints on their behaviour or conflicts with the work environment, they do describe symptoms of emotional distress and a sense of isolation because others do not understand the moral elements they see. McCarthy and Deady (2008) cautioned researchers and authors to distinguish moral distress from emotional distress, which can occur in a stressful work environment but does not necessarily have an ethical component. Nurses are emotionally distressed in the case of Mr Jones, as they experience fear, frustration, and anger while attempting to manage his care appropriately. However, this case involves more than just emotional distress. The nurses believe they are undervalued and unheard of. As a result, a moral component, which is not typical of emotional distress, is present. This moral component distinguishes emotional distress from moral distress….moral distress is characterized by a threat to one’s moral integrity.

As implied but not explicitly stated in the preceding definition, moral distress involves a threat to one’s moral integrity. Moral integrity is the sense of wholeness and self-worth resulting from clearly defined values that align with one’s actions and perceptions (Hardingham, 2004). Entering Mr Jones’s room despite concerns for their safety jeopardizes not only their physical integrity but also their moral integrity.

Moral Distress Sources
Situations that cause moral distress differ between providers, just as values and obligations are interpreted differently. While nursing research has identified familiar sources of moral distress, not every nurse will experience distress in these situations, and some nurses will experience distress due to other factors. According to Corley (2002), the following are frequently cited sources of moral distress among nurses:

Life support should be maintained even if it is not in the patient’s best interests.
Inadequate end-of-life communication between providers, patients, and families
Inappropriate utilization of healthcare resources
Inadequate staffing or employees who are not adequately trained to provide the necessary care
Patients receive insufficient pain relief.
Patients and families are given false hope.
According to Jameson (1993) and Corley, Elswick, Gorman, and Clor (2001), a key component of moral distress is the individual’s sense of powerlessness or the inability to carry out the action perceived to be ethically appropriate. Jameson (1993) states that this occurs due to nursing behaviour constraints. Internal constraints can include fear of losing one’s job, self-doubt, anxiety about causing conflict, or a lack of confidence (Hamric, Davis, & Childress, 2006). Power imbalances among healthcare team members, poor communication among team members, cost-cutting pressures, fear of legal action, a lack of administrative support, and hospital policies that conflict with patient care needs are all external constraints that contribute to moral distress (Jameton, 1993). In the preceding case, the nurses caring for Mr Jones faced an external constraint in that the documentation system failed to effectively communicate the severity of Mr Jones’s behaviour to medical providers.

Recognizing Moral Difficulties
Moral distress is frequently accompanied by frustration and anger (Elpern, Covert, & Kleinpell, 2005; Wilkinson, 1988). Under the surface, and more challenging to identify, are feelings that threaten one’s moral integrity—feelings of being belittled, insignificant, or unintelligent. Unfortunately, these feelings are frequently carried alone because professionals often hesitate to discuss their impotence openly. As a result, morally distressed people may feel isolated, posing an additional threat to their integrity.

…Not everyone will be morally distressed in any given situation.

One complicating factor that adds to the sense of isolation is that not everyone in any situation will be morally distressed. Because different healthcare team members perceive values and obligations differently, moral distress is an individual experience rather than a situation experience. In the case of Mr Jones, for example, there are likely to be nurses who are deeply troubled morally. There are likely to be nurses who are not morally troubled. Nurses who do not experience moral distress are not morally deficient or insensitive. In other cases, they may suffer from severe moral distress.

So far, we have discussed how moral distress is defined, when it occurs, and how to recognize it. Many argue that moral distress ‘comes with the territory’ in healthcare. While some moral distress is unavoidable, it must be addressed, or the consequences will be disastrous. Indeed, there is mounting evidence that repeated exposure to moral distress can wreak havoc on one’s moral sensitivity to problematic clinical situations and careers. The damage occurs as moral residue levels rise, as described below.

Moral Remainder
Jameson observed that moral distress lingered and dubbed this lingering moral distress “reactive distress” (1993). Today, this lingering distress is recognized as a distinct but related concept to moral distress. It has known as “moral residue.” Webster and Bayliss defined moral residue as “that which each of us carries with us from those times in our lives when, in the face of moral distress, we have seriously compromised ourselves or allowed ourselves to be compromised” (2000, p. 208). Moral values have been violated in situations of moral distress due to constraints beyond one’s control. The moral wound of having to act against one’s values remains after these morally distressing situations. The moral residue is long-lasting and deeply ingrained in one’s thoughts and self-perceptions. This aspect of moral distress—the residue that remains—can harm oneself and one’s career, mainly when morally distressing episodes occur repeatedly.

Concerns about the Crescendo Effect
Moral distress and moral residue are related concepts, but each has distinct characteristics. Epstein and Hamric (2009) describe a preliminary model for interacting with these concepts, the crescendo effect (See Figure). The model includes two crescendo effects: moral distress and moral residue.

Figure 1: The Crescendo Effect (solid lines indicate moral distress, dotted lines indicate moral residue). The Journal of Clinical Ethics has granted permission to use this Figure.

The Effect of the Crescendo
Residual moral distress rises each time a morally distressing situation occurs and resolves.
As a clinical situation unfolds, moral distress reaches a peak. Nurses caring for Mr Jones may have noticed moral distress within a few days of his admission to the nursing home. These nurses understand that medicating him, even temporarily, will keep him from hurting the staff or himself, especially given his fragile neurologic and physical state. As time passes, the nurses notice that no one seems to understand the gravity of the situation. They believe they are compelled to put themselves and the patient in danger of physical harm. They are not being heard, and their moral distress is increasing. Despite repeated requests, the administration does nothing to assist. The doctors downplay the issue, saying, “He does not bother us when we examine him.” Assume Mr Jones has a stroke and is taken to a local hospital for further evaluation. Although some nurses may be distressed because they know the hospital nurses are about to face what they have been dealing with for several weeks, the level of moral distress drops precipitously because the situation is, in effect, resolved. The level of moral distress, however, does not fall to zero. Instead, there is some residual moral distress. These nurses reflect on the lack of priority given to this issue and their feelings of being powerless and voiceless despite their expertise and experiences with the patient. The moral residue is the ongoing realization that one’s moral concerns were not acknowledged, and thus right action was not taken.

The moral residue crescendo occurs after repeated moral distress situations. Residual moral distress rises each time a morally distressing situation occurs and resolves. As a result, moral residue accumulates gradually. The fact that morally distressing problems in a given clinical setting tend to be similar over time exacerbates moral residue. Furthermore, new situations remind providers of their powerlessness in previous situations, and the crescendo continues. For example, prolonged aggressive treatment with little chance of survival in the intensive care unit is a common and recurring source of moral distress (Corley, 1995; Epstein, 2008; Hamric & Blackhall, 2007). The resulting moral distress has less to do with the individual patient and more with the dreaded feeling of “here we go again.” As a result, the sheer repetition of similar clinical situations eliciting moral distress adds a sense of futility, increasing the moral residue.

The fear is that a tipping point will be reached as the moral residue crescendo rises over time due to repeated episodes of moral distress.

According to Epstein and Hamric (Epstein & Hamric, 2009), moral distress and moral residue can have three outcomes. The first implication is that providers may become morally numb to ethically tricky situations. They may no longer recognize or participate in clinical situations that necessitate moral sensitivity. Second, providers may engage in various conscientious objections to the situation’s trajectory (Catlin et al., 2008). Conscientious objection makes an opinion known more forcefully in order to overcome constraints. Some methods of objection may be more productive than others (for example, calling an ethics consult) (for example, documenting dissent in a patient’s chart). Burnout is the final and most damaging consequence. Recent research indicates a link between moral distress and burnout symptoms (Meltzer & Huckabay, 2004). Several studies have found that nurses have considered leaving their jobs or even their profession due to moral distress (Corley, 1995; Hamric & Blackhall, 2007). The fear is that a tipping point will be reached as the moral residue crescendo rises over time due to repeated episodes of moral distress. Two studies found that years of experience are related to levels of moral distress (Elpern et al., 2005; Hamric & Blackhall, unpublished data), but this finding is inconsistent (Corley et al., 2001). Nowadays, the healthcare system must maintain valuable and morally invested clinicians.

Managing Moral Anxiety
Nursing must change the work environment. To improve a system, multiple perspectives and collaboration are required. Several methods have recently been published or reduce moral distress (and moral residue). Although more research is needed to determine the extent to which these approaches are practical, their foundations are solid, and they are, at least in part, helpful to nurses at the bedside. The strategies described below can be tailored to an individual, unit, or organizational setting as needed by nurses.

4 A’s of the American Association of Critical Care Nurses

Moral distress has been identified as a priority area by the American Association of Critical Care Nurses (AACN, 2005). The 4 A’s approach to addressing and reducing moral distress has been developed (AACN, n.d.; Rushton, 2006). Although designed for critical care, the 4 A’s are adaptable and applicable in various non-critical care settings. ASK, AFFIRM, ASSESS, and ACT are the four A’s. They are outlined below. Readers are encouraged to consult AACN (n.d.) to describe the four A’s comprehensively.

ASK: Review the definition and symptoms of moral distress and consider whether you are experiencing moral distress. Are your coworkers showing signs of moral distress as well?

AFFIRM: State your feelings about the situation. What aspect of your moral integrity is jeopardized? What role could (or should) you play?

ASSESS: Begin assembling some facts. What is causing your moral distress? What do you believe is the “right” action to take, and why? What is being done now, and why? Who are the people involved in this situation? Are you prepared to take action?

ACT: Make a plan of action and carry it out. Consider potential pitfalls and strategies for avoiding them.
QUESTION
Many nurses are very concerned about what lies in the future of their careers. Each generation has their challenges, but this generation will probably always remember COVID-19. As nurses, we had to reflect on what happened during those days and we needed to soul search because of what we had to confront as nurses. Some of you are on the front lines of this pandemic taking care of patients that are affected.

Instructions:

Go to the American Association of Critical-Care Nurses (AACN) website and read about moral distress.
Please share a couple of experiences that you may have had or that you may imagine that you would have caring for a patient with COVID-19
Example: It really disturbs me that a person that is dying cannot communicate with their family. As a proponent of palliative care and hospice and all the ideas connected to this I am adamantly against any person going through the dying process without family present. This has really disturbed me to the point that I am personally dealing with feelings of distress that I cannot come up with an answer.
Distinguish between moral distress, burnout and compassion fatigue. Classify the example that is given above.
Read the AACN Position Statement: Moral Distress in Times of Crisis. Comment on the AACN Position Statement. Do you believe the same things about moral distress. What do you believe?

https://www.aacn.org/clinical-resources/moral-distress

https://www.aacn.org/policy-and-advocacy/aacn-position-statement-moral-distress-in-times-of-crisis