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Moral Distress: A Living Nightmare
EMERGENCY NURSING ADVOCACY
MORAL DISTRESS: A LIVING NIGHTMARE Author: Julie A. Unruh, RN, BSN, BSE, CEN, Topeka, KS Section Editor: Kathleen A. Ream, BA, MBA.
oral distress is lurking in your emergency department. It does not present itself at triage. Moral distress does not ride in the back of the ambulance or helicopter. It sneaks in with the staff through the back door, leaching onto unsuspecting victims. Morally distressing situations are inescapable. Moral distress is a living nightmare. Nurses and health care team members experience morally and ethically distressing situations on a daily basis in the emergency department. Moral distress defined in a nursing context is the painful feelings and/or psychological disequilibrium that occurs when nurses are conscious of the morally appropriate action a situation requires but cannot carry out that action because of institutionalized obstacles, lack of time, lack of supervisory support, exercise of medical power, institutional policy, or legal limits.1 Situations arise where the nurse knows the moral values at issue, knows the ethical principles that ought to guide action, and has chosen the right course of action based on those values and principles but still cannot take the right action because he or she is being constrained from doing so.2 Moral distress is defined as feelings of frustration, anger, and anxiety when facing institutional obstacles and interpersonal conflicts about ones values. When professional goals of nurses are blocked, they suffer moral distress.2 Webster and Baylis3 state that moral distress could lead to compromised integrity and moral residue: betrayed cherished beliefs and values concentrated in a person’s thoughts.
M
Living Nightmare
Moral distress likes to prey on nurses—it sucks the life out of them. The situation plays out like a horror movie. It feels like a living nightmare that just will not end.
Julie A. Unruh, Member, Kansas State ENA Council, and President, Eastern Kansas ENA Chapter, is Trauma Nurse Coordinator, St Francis Health Center, Topeka, KS. For correspondence, write: Julie A. Unruh, RN, BSN, BSE, CEN, St Francis Health Center, 1700 SW 7th St, Topeka, KS 66606; E-mail: [email protected]. J Emerg Nurs 2010;36:253-5. 0099-1767/$36.00 Copyright © 2010 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2010.03.012
May 2010
VOLUME 36 • ISSUE 3
The movie starts with a view from triage. Two staff members are walking by the triage desk on their way out of the department, heading out the door to go home, leaving the building after an especially busy day. The waiting room has a few patients. Suddenly, the pregnant triage nurse runs from the triage room screaming, “She has a knife! She slit her throat! She is trying to stab me!” The 2 staff nurses pull the pregnant nurse to safety. One nurse bangs on the security room door yelling for help. Security walks outs and safely apprehends the patient. The patient hisses to the nurse, “I told you I was serious!” Luckily, the patient sustained only minor abrasions to her throat from the knife. The triage nurse is unharmed . . . this time. She is physically intact but emotionally injured, traumatized from this event. Frequently, nurses are the walking wounded, although their injuries are not always visible. Unsafe working conditions and violence cause nurses anxiety, fear, frustration, and disillusionment with regard to institutional leaders.1 Over the last 3 years, in many hospitals throughout the United States, emergency departments have struggled with financial constraints that will not support major capitol safety improvements. The lack of buy-in from the hospital administration, shrinking capital funds, and other factors have delayed the process. Each time staff come to work and are sent to triage, anxiety and moral distress rear their ugly heads. Staff wonder who is going to get hurt or ponder what kind of horrible event will have to take place in order to make safety changes. The pregnant nurse goes to triage, wondering if she and her unborn child will be safe, thus preventing her from giving her best caring response. She worries that next time a situation takes place, someone may not be so lucky. This is an example of a morally distressed staff. Recently, the ENA has studied the increasing frequency of violence in emergency departments across the nation. Nurses working in today’s emergency departments are vulnerable to many forms of violence. Potential violent and actual violent incidences happen in the emergency department. These incidents can affect the safety of the emergency nurse as well as that of the patient. According to the International Council of Nurses, the nurse is ethically bound to protect patients and their families from harm, to provide care that prevents complications, and to maintain a healing psychological environment. Because most patients are vulnerable, they need protection as well as competent and timely care.4 Many reasons exist (eg, low staffing levels, inadequately trained staff, or ineffective pain
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control orders) for why nurses cannot always achieve what is best for each specific patient. Frequent discussions occur between nurses and physicians on “what is best for the patient.” The inability of the nurse to provide the ultimate safe, healing environment for the patient lends the nurse to suffer moral distress. Sicker patients, insufficient numbers of staff, inadequately trained staff, and organizational policies and procedures make it difficult, or even impossible, for nurses to meet the needs of patients and their families.1 An emergency nurse’s turmoil festers within himself or herself. Moral distress silently eats away at the character of a healthy nurse. The challenge of moral distress management is how to work through the symptoms. According to a recent study, over 80% of nurses reported medium to high levels of moral distress. Moral distress can manifest as anger, frustration, guilt, loss of self-worth, depression and nightmares, anxiety, helplessness, embarrassment, heartache, pain, sorrow, and anguish. It can also result in symptoms that nurses carry over into their personal lives, such as burnout, resignation, and leaving nursing all together.4 Some of these nurses may be the wounded ones who have lost their ability to care for and be involved with patients and their families. Some nurses have recurrent nightmares about being treated as they had treated patients.4 High levels of moral distress directly impact patients. They have longer hospital stays, have increased pain, and receive inadequate and inappropriate care. Some nurses use negative coping tactics to manage moral distress, including distancing and escape-avoidance strategies toward patients.7 Moral distress leads many nurses to avoid patients. Conversely, some nurses are overly solicitous to patients because they feel guilty about what is happening to them.8 Lions, Tigers, and Moral Distress . . . Oh No!
Knowing what moral distress looks like is the first step to implementing a positive change in your emergency department. As a nurse practicing in Kansas, I find it interesting to use the movie The Wizard of Oz as a moral distress example. The tin man lacked a heart; the scarecrow, a brain; the lion, courage. These characters exhibited moral anxiety when monkeys flew and the wizard would not cooperate with the sweet little girl from Kansas. Dorothy and her companions knew the right answer, but obstacles kept getting in their way. The characters tried to take the correct path to achieve their goals, but the path was blocked by menacing monkeys (lack of supervisory support) and broom-wielding witches (institutional policies and/or inappropriate use of medical power), as well as
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the occasional munchkin (family). Nurses also can be morally distressed if they cannot attain their moral goal, a caring response. Managing Moral Distress
Pull the curtain back and visualize the moral distress monsters that are lurking in the corners of your emergency department. One strategy to stop moral distress is to identify it and provide supportive care to those who are feeling the painful symptoms. Learning how to advocate for staff and patients is a step in the right direction. Advocacy is a gift that keeps giving. Active listening can help staff walk through morally stressful situations. Start by helping staff talk through distressing times. Ask them to describe what is bothering them about a situation. This open, non-biased dialogue helps facilitate stress relief. As nurses, we can help foster each other toward self-assurance and a healthy caring attitude. Nurses have an obligation to take care of themselves, their patients, and their profession. Do we practice what we preach? It has often been said that nurses eat their young. Let us take a deeper look at moral distress and how it comes into full view. You may have a staff member who frequently resorts to placing blame on others or the institution. He or she is the first to complain or encourage loose-lipped negative gossip. Often, a snide, inappropriate comment or rolling of the eyes about how an ethical situation was handled hurts a coworker. This behavior makes team members feel uncomfortable and unappreciated. This coworker probably does not have the tools to work through what is bothering him or her about the situation. Those negative feelings fester internally, only adding to the destruction of a good nurse, let alone, a valued person. Frequently, nurses will disengage and use the excuse “I’m just one nurse.” If equipped with the right tools and proper ethical background, just one nurse can make a difference. Several identified approaches that oncology nurses use in resolving ethical dilemmas and related stress involve support from other nurses, clinical specialists, social workers, spouses/significant others, nurse managers, education programs, and hospital ethics committees.7 Advocacy
Moral distress exists in the emergency department. The need for further research in preventive solutions, including education and interventions, is warranted. Tools are limited but are available to help educate and train staff to deal with ethically and morally stressful situations. Professional resources such as peer-reviewed scholarly search engines, bioethics Web sites, and ethics committees are helpful.
VOLUME 36 • ISSUE 3
May 2010
Unruh/EMERGENCY NURSING ADVOCACY
Reading the Journal of Emergency Nursing, for example, promotes professional practice. Articles give continuing education credit and education opportunities. Learn how to access these resources. The ENA helps nurses realize the power of numbers. One is a lonely number, when feeling isolated and frustrated. Remember that the ENA promotes change, one nurse at a time. Talk to an educator, manager, or peer who has the tools to create change. Begin a dialogue to help turn those negative feelings into positive actions. Start with personal reflections by educating yourself outside the clinical unit, taking advantage of educational opportunities in ethical discussions, or attending a hospital/local ethics committee meeting. Try taking online continuing education courses or participate in ethical dilemma role playing within your department meetings. Read published case studies. These resources help nurses glean information relevant to practice. Finally, do not forget to encourage dialogue between preceptors and new nurses. By promoting advocacy within your department and institution, one nurse can make a difference. It is important for nurses to be empowered, encouraged, and supported by mentors and preceptors. Support yourself and your fellow emergency nurses through ENA programs and activities. Encourage them to join.
nurse, but the ENA values every nurse and supports emergency nursing wherever you practice.
Uncited references
[5] [6] REFERENCES 1. Corley M. Nurse moral distress: A proposed theory and research agenda. Nurs Ethics. 2002;9(6):636-50. 2. Brenner P. The role of experience, narrative, and community in skilled ethical comportment. ANS Adv Nurs Sci. 1991;14(2):1-21. 3. Webster GC, Baylis F. Margin of Error: The Ethics of Mistakes in the Practice of Medicine. 4th ed. Rubin SB, Zoloth L, eds. Hagerstown, MD: University Publishing; 2000. p. 217-32.
Conclusion
4. Foley BJ, Minick P, Kee C. Nursing advocacy during a military operation. West J Nurs Res. 2000;22(4):492-507. 5. Jameton A. Nursing Practice: The Ethical Issues. Englewood Cliffs, NJ: Prentice Hall; 1984. 6. Wilkinson JM. Moral distress in nursing practice: experience and effect. Nurs Forum. 1988;23(1):16-29. 7. Raines DA. Values influencing nursing practice: responses from neonatal nurses. J Soc Pediatr Nurs. 1997;2(2):20-41. 8. Rubin J. Impediments to the development of clinical knowledge and ethical judgement in critical care nursing. In: Expertise in Nursing Practice. Brenner P, Tanner C, Chesla C, eds. New York, NY: Springer; 1996. p. 170-92.
Emergency nursing takes a special kind of nurse—one who is brave, selfless, caring, and compassionate; valued by his or her team; and committed to taking care of whoever walks, rolls, or is wheeled into the emergency department. Moral distress makes you feel as though you are only one
Submissions to this column are encouraged and may be sent to Kathleen A. Ream, BA, MBA [email protected]
May 2010
VOLUME 36 • ISSUE 3
WWW.JENONLINE.ORG
255
MORAL DISTRESS: A LIVING NIGHTMARE Author: Julie A. Unruh, RN, BSN, BSE, CEN, Topeka, KS Section Editor: Kathleen A. Ream, BA, MBA.
oral distress is lurking in your emergency department. It does not present itself at triage. Moral distress does not ride in the back of the ambulance or helicopter. It sneaks in with the staff through the back door, leaching onto unsuspecting victims. Morally distressing situations are inescapable. Moral distress is a living nightmare. Nurses and health care team members experience morally and ethically distressing situations on a daily basis in the emergency department. Moral distress defined in a nursing context is the painful feelings and/or psychological disequilibrium that occurs when nurses are conscious of the morally appropriate action a situation requires but cannot carry out that action because of institutionalized obstacles, lack of time, lack of supervisory support, exercise of medical power, institutional policy, or legal limits.1 Situations arise where the nurse knows the moral values at issue, knows the ethical principles that ought to guide action, and has chosen the right course of action based on those values and principles but still cannot take the right action because he or she is being constrained from doing so.2 Moral distress is defined as feelings of frustration, anger, and anxiety when facing institutional obstacles and interpersonal conflicts about ones values. When professional goals of nurses are blocked, they suffer moral distress.2 Webster and Baylis3 state that moral distress could lead to compromised integrity and moral residue: betrayed cherished beliefs and values concentrated in a person’s thoughts.
M
Living Nightmare
Moral distress likes to prey on nurses—it sucks the life out of them. The situation plays out like a horror movie. It feels like a living nightmare that just will not end.
Julie A. Unruh, Member, Kansas State ENA Council, and President, Eastern Kansas ENA Chapter, is Trauma Nurse Coordinator, St Francis Health Center, Topeka, KS. For correspondence, write: Julie A. Unruh, RN, BSN, BSE, CEN, St Francis Health Center, 1700 SW 7th St, Topeka, KS 66606; E-mail: [email protected]. J Emerg Nurs 2010;36:253-5. 0099-1767/$36.00 Copyright © 2010 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. doi: 10.1016/j.jen.2010.03.012
May 2010
VOLUME 36 • ISSUE 3
The movie starts with a view from triage. Two staff members are walking by the triage desk on their way out of the department, heading out the door to go home, leaving the building after an especially busy day. The waiting room has a few patients. Suddenly, the pregnant triage nurse runs from the triage room screaming, “She has a knife! She slit her throat! She is trying to stab me!” The 2 staff nurses pull the pregnant nurse to safety. One nurse bangs on the security room door yelling for help. Security walks outs and safely apprehends the patient. The patient hisses to the nurse, “I told you I was serious!” Luckily, the patient sustained only minor abrasions to her throat from the knife. The triage nurse is unharmed . . . this time. She is physically intact but emotionally injured, traumatized from this event. Frequently, nurses are the walking wounded, although their injuries are not always visible. Unsafe working conditions and violence cause nurses anxiety, fear, frustration, and disillusionment with regard to institutional leaders.1 Over the last 3 years, in many hospitals throughout the United States, emergency departments have struggled with financial constraints that will not support major capitol safety improvements. The lack of buy-in from the hospital administration, shrinking capital funds, and other factors have delayed the process. Each time staff come to work and are sent to triage, anxiety and moral distress rear their ugly heads. Staff wonder who is going to get hurt or ponder what kind of horrible event will have to take place in order to make safety changes. The pregnant nurse goes to triage, wondering if she and her unborn child will be safe, thus preventing her from giving her best caring response. She worries that next time a situation takes place, someone may not be so lucky. This is an example of a morally distressed staff. Recently, the ENA has studied the increasing frequency of violence in emergency departments across the nation. Nurses working in today’s emergency departments are vulnerable to many forms of violence. Potential violent and actual violent incidences happen in the emergency department. These incidents can affect the safety of the emergency nurse as well as that of the patient. According to the International Council of Nurses, the nurse is ethically bound to protect patients and their families from harm, to provide care that prevents complications, and to maintain a healing psychological environment. Because most patients are vulnerable, they need protection as well as competent and timely care.4 Many reasons exist (eg, low staffing levels, inadequately trained staff, or ineffective pain
WWW.JENONLINE.ORG
253
EMERGENCY NURSING ADVOCACY/Unruh
control orders) for why nurses cannot always achieve what is best for each specific patient. Frequent discussions occur between nurses and physicians on “what is best for the patient.” The inability of the nurse to provide the ultimate safe, healing environment for the patient lends the nurse to suffer moral distress. Sicker patients, insufficient numbers of staff, inadequately trained staff, and organizational policies and procedures make it difficult, or even impossible, for nurses to meet the needs of patients and their families.1 An emergency nurse’s turmoil festers within himself or herself. Moral distress silently eats away at the character of a healthy nurse. The challenge of moral distress management is how to work through the symptoms. According to a recent study, over 80% of nurses reported medium to high levels of moral distress. Moral distress can manifest as anger, frustration, guilt, loss of self-worth, depression and nightmares, anxiety, helplessness, embarrassment, heartache, pain, sorrow, and anguish. It can also result in symptoms that nurses carry over into their personal lives, such as burnout, resignation, and leaving nursing all together.4 Some of these nurses may be the wounded ones who have lost their ability to care for and be involved with patients and their families. Some nurses have recurrent nightmares about being treated as they had treated patients.4 High levels of moral distress directly impact patients. They have longer hospital stays, have increased pain, and receive inadequate and inappropriate care. Some nurses use negative coping tactics to manage moral distress, including distancing and escape-avoidance strategies toward patients.7 Moral distress leads many nurses to avoid patients. Conversely, some nurses are overly solicitous to patients because they feel guilty about what is happening to them.8 Lions, Tigers, and Moral Distress . . . Oh No!
Knowing what moral distress looks like is the first step to implementing a positive change in your emergency department. As a nurse practicing in Kansas, I find it interesting to use the movie The Wizard of Oz as a moral distress example. The tin man lacked a heart; the scarecrow, a brain; the lion, courage. These characters exhibited moral anxiety when monkeys flew and the wizard would not cooperate with the sweet little girl from Kansas. Dorothy and her companions knew the right answer, but obstacles kept getting in their way. The characters tried to take the correct path to achieve their goals, but the path was blocked by menacing monkeys (lack of supervisory support) and broom-wielding witches (institutional policies and/or inappropriate use of medical power), as well as
254
JOURNAL OF EMERGENCY NURSING
the occasional munchkin (family). Nurses also can be morally distressed if they cannot attain their moral goal, a caring response. Managing Moral Distress
Pull the curtain back and visualize the moral distress monsters that are lurking in the corners of your emergency department. One strategy to stop moral distress is to identify it and provide supportive care to those who are feeling the painful symptoms. Learning how to advocate for staff and patients is a step in the right direction. Advocacy is a gift that keeps giving. Active listening can help staff walk through morally stressful situations. Start by helping staff talk through distressing times. Ask them to describe what is bothering them about a situation. This open, non-biased dialogue helps facilitate stress relief. As nurses, we can help foster each other toward self-assurance and a healthy caring attitude. Nurses have an obligation to take care of themselves, their patients, and their profession. Do we practice what we preach? It has often been said that nurses eat their young. Let us take a deeper look at moral distress and how it comes into full view. You may have a staff member who frequently resorts to placing blame on others or the institution. He or she is the first to complain or encourage loose-lipped negative gossip. Often, a snide, inappropriate comment or rolling of the eyes about how an ethical situation was handled hurts a coworker. This behavior makes team members feel uncomfortable and unappreciated. This coworker probably does not have the tools to work through what is bothering him or her about the situation. Those negative feelings fester internally, only adding to the destruction of a good nurse, let alone, a valued person. Frequently, nurses will disengage and use the excuse “I’m just one nurse.” If equipped with the right tools and proper ethical background, just one nurse can make a difference. Several identified approaches that oncology nurses use in resolving ethical dilemmas and related stress involve support from other nurses, clinical specialists, social workers, spouses/significant others, nurse managers, education programs, and hospital ethics committees.7 Advocacy
Moral distress exists in the emergency department. The need for further research in preventive solutions, including education and interventions, is warranted. Tools are limited but are available to help educate and train staff to deal with ethically and morally stressful situations. Professional resources such as peer-reviewed scholarly search engines, bioethics Web sites, and ethics committees are helpful.
VOLUME 36 • ISSUE 3
May 2010
Unruh/EMERGENCY NURSING ADVOCACY
Reading the Journal of Emergency Nursing, for example, promotes professional practice. Articles give continuing education credit and education opportunities. Learn how to access these resources. The ENA helps nurses realize the power of numbers. One is a lonely number, when feeling isolated and frustrated. Remember that the ENA promotes change, one nurse at a time. Talk to an educator, manager, or peer who has the tools to create change. Begin a dialogue to help turn those negative feelings into positive actions. Start with personal reflections by educating yourself outside the clinical unit, taking advantage of educational opportunities in ethical discussions, or attending a hospital/local ethics committee meeting. Try taking online continuing education courses or participate in ethical dilemma role playing within your department meetings. Read published case studies. These resources help nurses glean information relevant to practice. Finally, do not forget to encourage dialogue between preceptors and new nurses. By promoting advocacy within your department and institution, one nurse can make a difference. It is important for nurses to be empowered, encouraged, and supported by mentors and preceptors. Support yourself and your fellow emergency nurses through ENA programs and activities. Encourage them to join.
nurse, but the ENA values every nurse and supports emergency nursing wherever you practice.
Uncited references
[5] [6] REFERENCES 1. Corley M. Nurse moral distress: A proposed theory and research agenda. Nurs Ethics. 2002;9(6):636-50. 2. Brenner P. The role of experience, narrative, and community in skilled ethical comportment. ANS Adv Nurs Sci. 1991;14(2):1-21. 3. Webster GC, Baylis F. Margin of Error: The Ethics of Mistakes in the Practice of Medicine. 4th ed. Rubin SB, Zoloth L, eds. Hagerstown, MD: University Publishing; 2000. p. 217-32.
Conclusion
4. Foley BJ, Minick P, Kee C. Nursing advocacy during a military operation. West J Nurs Res. 2000;22(4):492-507. 5. Jameton A. Nursing Practice: The Ethical Issues. Englewood Cliffs, NJ: Prentice Hall; 1984. 6. Wilkinson JM. Moral distress in nursing practice: experience and effect. Nurs Forum. 1988;23(1):16-29. 7. Raines DA. Values influencing nursing practice: responses from neonatal nurses. J Soc Pediatr Nurs. 1997;2(2):20-41. 8. Rubin J. Impediments to the development of clinical knowledge and ethical judgement in critical care nursing. In: Expertise in Nursing Practice. Brenner P, Tanner C, Chesla C, eds. New York, NY: Springer; 1996. p. 170-92.
Emergency nursing takes a special kind of nurse—one who is brave, selfless, caring, and compassionate; valued by his or her team; and committed to taking care of whoever walks, rolls, or is wheeled into the emergency department. Moral distress makes you feel as though you are only one
Submissions to this column are encouraged and may be sent to Kathleen A. Ream, BA, MBA [email protected]
May 2010
VOLUME 36 • ISSUE 3
WWW.JENONLINE.ORG
255