The Rev. Dan Dixson on the problem with heightened expectations

Moral Distress in Clinical Staff

A Pediatric ICU nurse comes to the chaplain to talk about a three-year-old boy on a ventilator. He has little hope for survival. The nurse states that she and others are feeling badly about the painful procedures to which they must subject this boy. They do not believe they can “torture” him any longer and often go home in tears.

An ICU nurse comes to the chaplain stating that the family of an 82-year-old man cannot bring themselves to offer him comfort care or even a DNR. The treatment that the patient receives causes him incredible pain. The nurse does not feel that she can morally care for this patient any longer due to the painful but futile nature of the care being provided. She states that it goes against everything she believes.

These cases demonstrate the kinds of issues that can lead to significant moral distress in clinical staff who provide care for seriously ill patients. Moral distress generally is seen in situations where a person must go against one’s own principled beliefs because of imposed constraints. In the setting of nursing care, those constraints often come from a physician, a patient’s family, or the hospital administration. When one knows the right course of action but is required to follow a different course in the care of a patient, or when patient care is endangered by staffing situations, moral distress may sometimes result and can become professionally and emotionally debilitating.

Symptoms of moral distress may include fatigue, fear, frustration, depression, withdrawal, blaming, feelings of victimization, as well as a sense of loss of personal and professional integrity. It is one of the reasons given for nurses leaving critical care nursing or nursing altogether.

With the increasing improvement of life-sustaining procedures comes a sense of heightened expectations on the part of patients and family for good clinical outcomes to nearly every serious illness. Add to that the nursing shortages and organizational changes to increase efficiency in the hospitals and you have a recipe for moral distress.

The hospital chaplain, who serves both patients and staff, is in a unique position to assist in the identification and prevention of moral distress. There are a number of things that might be done by chaplains to address this issue, including:

- Encourage and take part in frequent patient care conferences that bring together an interdisciplinary team to discuss a patient’s situation and treatment plan.
- Build rapport with nurses and give them a safe place to talk about such issues.
- Be available to verify that patients and families are hearing the entire message that the medical team is giving to them about conditions and options.
- Be an active proponent of the Medical Ethics Committee process.
- Make sure that critical care nurse managers and directors are aware of the Position Statement on Moral Distress created by the American Association of Critical Care Nurses (www.aacn.org).

The role of chaplain places us at the forefront of these issues. We cannot change the fact that there will always be hard cases involving hard decisions. Through education and advocacy, however, we can help create an environment where such cases do not have to destroy the integrity or career of some of our finest nurses.

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