AACN News—September 2008—Opinions

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Vol. 25, No. 9, SEPTEMBER 2008

President’s Note

Caryl Goodyear-Bruch RN, PhD, CCRN

With Confidence

It Has a Name

He was an older man in a coma with total body failure—heart, lungs, kidneys, pretty much every system. He was at the end of his life, which is why each intervention we put him through hurt so much. Probably hurt him and definitely hurt me. Before he lapsed into acoma he told us he didn’t want us to press ahead with treatment and heroics once there was no hope. The resident and I collaborated well and respected each other’s views. So I asked why he persisted in intervening when all this man wanted to do was die. “He reminds me of my grandfather,” the resident said, “so why shouldn’t I do everything I can to save him?”

Learning Its Name

I’ll never forget that answer. I felt frustrated. Sad. Uncertain. Even a little angry and afraid. I was confused about what to do. I had experienced these feelings in similar situations before. Only this time I chose to confide in a wise colleague. “Moral distress is a tough one, isn’t it?” she said gently. So my dilemma had a name.

Moral distress, I repeated to myself and set out to learn more. The situation I encountered had so many layers of emotional complexity. Not just for the resident and me, but probably for the man’s family and our fellow caregivers. It was the kind of everyday event that shakes one’s confidence. My values clashed with the resident’s and the ensuing emotions made it difficult for me to act.

Being a nurse is ultimately about the relationships we nurture with patients and their families. As nurses we want to do what is right in caring for patients. Our values are rooted in the desire (and need) to provide quality care that is dignified and respectful. Moral distress intrudes when we want to do the right thing but cannot. In some cases we know the ethically appropriate action to take, but just can’t do it. In others we act, but do it by going against our personal and professional values.

What Gets in the Way

We may run into barriers that interfere with our genuine desire to act when faced with moral distress. Some barriers are within us—insufficient skills to handle the situation, fear of acting or lack of confidence that we can make an impact. We may not even recognize moral distress and dismiss it as being tired and overworked. Other barriers are external—lack of time, power structures, weak administrative support, institutional policies.

Connie Ulrich at the University of Pennsylvania studied the relationship between ethical values and intent to leave a current job. A group of more than 1,200 nurses and social workers said moral distress can lead to feelings of powerlessness 33% of the time, feeling overwhelmed 35%, fatigue 40% and frustration 53% of the time. At Riverview Regional Medical Center a study found that wanting to do the right thing and not being able to do it leads to pain and suffering that is exhibited by feelings of tiredness, burnout, irritability, losing focus, being ineffective and having an overall dissatisfaction with working as a nurse.

As acute and critical care nurses we’re at even higher risk for moral distress because patient acuity, advanced technology and the complexity of our healthcare system often collide in our chosen work. This is when we have the overwhelming desire to quit—to go elsewhere to work or leave the profession altogether. But those are extreme alternatives. At the time I didn’t find many resources. Now we’re supported by growing research evidence along with AACN’s position statement and tools such as the 4A’s guide to dealing with moral distress.(www.aacn.org/moraldistress4As).

It’s Your Turn

Here’s where you come in. How would you continue a confident dialogue with the resident? What questions would you ask? How would you help the resident to affirm his moral distress and your own? Would you then be ready to act? Maybe together with the resident. How would you do that while allowing each of you to preserve your integrity and authenticity?

My questions aren’t just rhetorical. I need your answers so I can share them for us to learn together. Please send them to me at confidence@aacn.org.

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