Moral Distress


Moral Distress
NANDA-I
Definition
Response to the inability to carry out one’s chosen ethical/moral decision/action
Defining Characteristics
Expresses anguish (e.g., powerlessness, guilt, frustration, anxiety, self-doubt, fear) over difficulty acting on one’s moral choice
Related Factors (r/t)
Conflict among decision makers; conflicting information guiding ethical decision-making; conflicting information guiding moral decision-making; cultural conflicts; end-of-life decisions; loss of autonomy; physical distance of decision maker; time constraints for decision-making; treatment decisions
Nursing Outcomes Classification (NOC) OutcomesPersonal Autonomy, Patient Satisfaction: Protection of Rights
NOC Outcomes with Indicators
Patient Satisfaction: Protection of Rights as evidenced by: Requests respected/Included in decisions about care/Care consistent with religious and spiritual needs. (Rate Protection of Rights: 1 = not at all satisfied, 5 = completely satisfied.)
Patient Outcomes
The patient will:
Be able to act in accordance with values, goals, and beliefs
Regain confidence in the ability to make decisions and/or act in accord with values, goals, and beliefs
Express satisfaction with the ability to make decisions consistent with values, goals, and beliefs
Have choices respected
Nursing Interventions Classification (NIC) Interventions
Patient Rights Protection, Emotional Support
Nursing Interventions Classification (NIC) Activities—Patient Rights Protection
Create an environment that facilitates private conversations between patient, family, and health care professionals
Nursing Interventions Rationales
Ask about the nature of the problem and determine that moral distress is present. Expert opinion recommends this as the first step in the 4As to Rise Above Moral Distress model (Ethics Work Group of FY 04, AACN, nd). Affirm the distress, commitment, “to take care of yourself” and your obligations. Validate feelings and perceptions with others. Expert opinion recommends this as the second step in the 4As to Rise Above Moral Distress model (Ethics Work Group of FY 04, AACN, nd).
Prepare to take Action, implement strategies to “initiate the changes you desire. “Anticipate and manage setbacks. Expert opinion recommends this as the third step of the 4As to Rise Above Moral Distress model (Ethics Work Group of FY 04, AACN, nd).
Assess sources and severity of distress. Expert opinion recommends this as the final step of the 4As to Rise Above Moral Distress model (Ethics Work Group of FY 04, AACN, nd).
Expert opinion suggests that the 4As model can be adapted and applied to noncritical care settings in addition to the critical care setting for which it was originally designed (Epstein and Delgado, 2010).
Give voice/recognition to moral distress and express concerns about constraints to supportive patients. A review/analysis/metasyntheses of 39 qualitative studies revealed that expression of concerns about institutional constraints and involvement in problem solving is essential for nurses (Rittenmeyer and Huffman, 2009). An exploratory, descriptive study of CRNAs found that spouses and significant others were helpful when ethical issues arose (Radzvin, 2011).
Engage in problem-solving. A review/analysis/metasyntheses of 39 qualitative studies revealed that expression of concerns about institutional constraints and involvement in problem solving is essential for nurses (Rittenmeyer and Huffman, 2009).
Engage in interdisciplinary problem-solving forums including family meeting and/or interdisciplinary rounds. Expert opinion suggests this as a strategy to improve communication and collaboration between patient, family, and the health care team (Epstein and Hamric, 2009).
Initiate multidisciplinary interventions/strategies to address moral distress. Expert opinion recommends collaboration to improve a system such as a hospital unit (Epstein and Delgado, 2010).
Identify/use a support system. An exploratory, descriptive study of CRNAs found that engaging support of colleagues did not compromise patient well-being (Radzvin, 2011). Expert opinion recommends development and use of a network of support including chaplains (Epstein and Delgado, 2010; Ulrich, Hamric, and Grady, 2010).
Initiate an ethics consult or ethics committee review. An exploratory, descriptive study of CRNAs suggests increased involvement of ethics committees as a strategy for dealing with ethical dilemmas (Radzvin, 2011). Expert opinion supports utilization of ethics consultants/committees to address moral distress (Ulrich, Hamric, and Grady, 2010).
Pediatric
Consider the developmental age of children when evaluating decisions and conflict. A study of children’s emotional consequences of desire fulfillment versus desire inhibition demonstrated differences in psychological, deontic, and future-oriented reasoning about emotions as well as the development of self-control (Lagattuta, 2005). This study demonstrated differences in conflict communication in Japan and the United States between teenagers and their parents (Shearman, Dumlao, and Kagawa, 2011).
Multicultural
Acknowledge and understand that cultural differences may influence a patient’s moral choices. In this study it was demonstrated that African Americans and Caucasians differ in beliefs about genetic testing and the basis for moral decision making (Zimmerman et al, 2006). Islamic medical ethics upholds the principles of biomedical ethics to include preservation of life, to promote and restore health, to alleviate human suffering, to respect patients’ autonomy, to perform medical justice, to tell the truth, and to do no harm (Athar, 2008).
Geriatric and Home Care
Previous interventions may be adapted for geriatric or home care use. REFERENCES
Athar S: Enhancement technologies and the person: an Islamic view, J Law Med Ethics 36(1):59-64, 2008.
Epstein EG, Delgado S: Understanding and addressing moral distress, Online J Issues Nurs 15(3), manuscript 1, 2010.
Epstein EG, Hamric AB: Moral distress, moral residue, and the crescendo effect, J Clin Ethics 20:330-342, 2009.
Ethics Work Group of FY 04, American Association of Critical Care Nurses: AACN 4 A’s to rise above moral distress handbook, nd. Retrieved July 17, 2011, from http://www.aacn.org/WD/Practice/Docs/4As_to_Rise_Above_Moral_Distress.pdf.
Lagattuta KH: When you shouldn’t do what you want to do: young children’s understanding of desires, rules, and emotions, Child Dev 76(3):713-733, 2005.
Radzvin LC: Moral distress in certified registered nurse anesthetists: implications for nursing practice, AANA J 79(1):39-45, 2011.
Rittenmeyer L, Huffmann D: How professional nurses working in hospital environments experience moral distress: a systematic review, J Adv Nurs 66(5):962-967, 2009.
Shearman SM, Dumlao R, Kagawa N: Cultural variations in accounts by American and Japanese young adults: recalling a major conflict with parents, J Fam Commun 11(2):105-125, 2011.
Ulrich CM, Hamric AN, Grady C: Moral distress: a growing problem in health professions? Hastings Cent Rep 40(1):20-22, 2010.
Zimmerman RK, et al: Racial differences in beliefs about genetic screening among patients at inner-city neighborhood health centers, J Natl Med Assoc 98(3):370-377, 2006.

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