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Canadian Public Health Association

Moral Distress in Healthcare: A Public Health Issue

Elisabeth Fortier

Imagine facing a moral dilemma at work: you know what needs to be done, but feel prevented from doing what you think is right because of complex healthcare limitations such as understaffing, time constraints or a lack of resources (Rodney, 2017; Fortier, 2018). Moral distress is present in every field of nursing, and can happen even more frequently in fields where Registered Nurses (RNs) engage with vulnerable, disadvantaged and marginalized patient populations such as in the intensive care unit, emergency medicine, public health and community medicine (Walton, 2018).

Moral distress is often mislabeled as stress, burnout and job dissatisfaction accompanied with physical and psychological signs (Pendry, 2007). These symptoms may have an impact on nurses leaving the profession and is a concern in public health. It is important to explore this issue as it has been shown that health organizations who identify and address moral distress have lower staff turnover (Pendry, 2007).

A series of semi-structured interviews were conducted with 20 RNs in a Northern Urban Canadian region with a goal to explore their experiences with moral distress and moral agency in their healthcare contexts (Fortier, 2018). Empowering RNs’ ethical voices is important as these professionals are advocates for patients; “We want to advocate for our profession and we want to advocate for our patients” (Nurse 7; Fortier, 2018). Advocating for patients means being a moral agent. This signifies having an ethical voice and being committed to the core values of the nursing profession (Milliken, 2018).

Jameton (1984) has suggested that healthcare organizations have the power and capacity to limit the moral agency of their personnel. An RN may know what choice to make, but because of external factors such as limited resources, under staffing and time constraints they may feel morally distressed in making decisions based on moral values (Fortier, 2019).

Nobody’s gonna think for you. Nobody’s gonna make that decision for you. You’re always thinking on the spot, you have to be morally aware when you enter our workforce. Because you don’t get to sit down and talk with somebody for 20 minutes being like ‘should I do this or should I do this’… We don’t have that time. (Nurse 9; Fortier, 2018)

External factors such as institutional or administrative constraints play an important role in experiencing moral distress. Examples of these factors are understaffing, time constraints and other constrictive policies within healthcare. There may also be internal factors at play including personal barriers (i.e. when personal values conflict with tasks) (Carnevale, 2013; Rodney, 2013). Unfortunately, RNs frequently experience external factors leading to moral distress. While it is important for RNs to be efficient and effective in nursing, external factors such as time and workload put pressure on RNs and can conflict with internal factors such as the desire to provide compassionate care (Liaschenko & Peter, 2016); “Did I do my job or did I give care? because I can't give both…” (Nurse 14; Fortier, 2018).

The norm, now, is to work short-staffed, that’s the culture . . . It’s so overwhelming and you just want to cry sometimes. It’s just painful to uphold. . . but it happens all the time, all the time. (Nurse 16; Fortier, 2018)

Moral distress among nurses leads to turnover, burnout and can have downstream effects on patient care (Rodney et al., 2013). How can we prevent this? By fostering a system that empowers nurses to use their ethical voice. Nursing is a demanding career; to be effective moral agents, it is important for RNs to feel they are making a difference in patients’ lives (Fortier, 2019). Educational systems in collaboration with health administrations may prioritize teaching nursing students’ strategies to respond and minimize moral distress. This is done, for example, through resilience training, mentorships between expert and novice RNs and the creation of moral communities where RNs voices are heard and valued (Fortier, 2018). Nurses are the largest body of health professionals in Canada and worldwide, therefore we as physicians, researchers, public health experts, educators, patients and the public should work towards creating a system that empowers nurses to be moral agents. Why? Because our care depends on it (Fortier, 2018).
 
References:

Carnevale, F. A. (2013). Confronting moral distress in nursing: Recognizing nurses as moral agents. Revista brasileira de enfermagem, 66(SPE), 33-38.

Fortier, E., & Malloy, D. (2019). Moral Agency, Bureaucracy & Nurses: A Qualitative Study. Canadian Journal of Practical Philosophy. University of Windsor. 3. 1-14

Fortier, E. (2018). Moral Agency and Moral Distress Among Registered Nurses: Novice to Expert (Master dissertation, Faculty of Graduate Studies and Research, University of Regina).

Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs: Prentice-Hall.

Liaschenko, J., & Peter, E. (2016). Fostering nurses’ moral agency and moral identity: The importance of moral community. Hastings Center Report, 46(S1).

Milliken, A. (2018). Refining moral agency: Insights from moral psychology and moral philosophy. Nursing Philosophy, 19(1).

Pendry, P. S. (2007). Moral distress: Recognizing it to retain nurses. Nursing economics, 25(4), 217.

Rodney, P. A. (2013). Seeing ourselves as moral agents in relation to our organizational and sociopolitical contexts: Commentary on "a reflection on moral distress in nursing together with a current application of the concept" by Andrew Jameton. Journal of Bioethical Inquiry, 10(3), 313-315.

Rodney, P., Kadyschuk, S., Liaschenko, J., Brown, H., Musto, L., & Snyder, N. (2012). Moral agency: Relational connections and support. In J. L. Storch, P. Rodney, & R. Starzomski (Eds.), Toward a moral horizon: Nursing ethics for leadership and practice (2nd ed., pp. 160-187). Toronto, ON: Pearson Prentice Hall.

Rodney, P. A. (2017). What we know about moral distress. The American Journal of Nursing, 117(2), S7-S10.

Walton, M. K. (2018). Sources of moral distress. In Moral Distress in the Health Professions (pp. 79-93). Springer, Cham.


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