All nurses have patients and situations that stay with them. I have many wonderful memories from my years in critical care, but then there are the not so wonderful memories: the last glance between an elderly man with fatal injuries and his wife as he was rushed to surgery that everyone knew he wouldn't survive (he didn't); the woman with no brain function whose family camped out in the waiting room for two weeks, arguing among themselves over “pulling the plug”; the young stabbing victim who was needlessly subjected to multiple invasive procedures because “it was the protocol.” I can easily recall these patients’ faces, what beds they were in, and who was involved in their care. I also recall the discussions and tensions between nurses, physicians, and administrators over what we were doing and what some of us thought we ought to be doing. Sometimes, the conflicts pitted nurses against physicians; other times, clinicians were in agreement and at odds with administrators.
When these occurrences happened over decades ago, only a few hospitals had a formal process for addressing ethical issues; mine, a large city hospital, wasn't one of them. Ethical issues often became legal issues. Decisions about whether to withdraw life support often dragged on because the institution wanted to consult attorneys to limit liability and lawsuits. Conflicts over care were resolved by the hospital hierarchy, and this largely fell to whichever administrator and service chiefs were on call or on site at the time. Nurses were often absent from the high-level conversations. When our professional concerns were dismissed, it provoked resentment and anger at “the system,” casting a pall over the unit, straining relationships, and making work more difficult and stressful. One such situation was the impetus for my departure from clinical practice.
It wasn't until the 1980s that moral distress—an inability to act in congruence with one's values—was first recognized and defined. It has since been linked to burnout, increased staff turnover, and poor patient outcomes, among others. And it wasn't until the 1990s that ethics committees became common features in hospitals and that hospitals were required to have a process for addressing ethical issues. While this has certainly been a major step forward in helping hospitals, clinicians, and patients to navigate situations in which ethical values are in conflict, much more needs to be done. There's little research on how ethics committees should be implemented or what the best practices are, or how to help clinicians become resilient when facing repeated situations that create moral distress.
A few years ago, I had a lengthy discussion with Kathy Schoonover-Shoffner, editor-in-chief of the Journal of Christian Nursing, about nurses’ moral distress. Agreeing that this was an important topic for our respective readerships, we enlisted Cynda Hylton Rushton, a professor at the Johns Hopkins School of Nursing who is well known for her ethics work in critical care, and began brainstorming about how to bring this issue to the forefront. The timing seemed right, as we could build on the American Nurses Association (ANA) revision of the Code of Ethics for Nurses with Interpretive Statements and recommendations from the 2014 national summit on nursing ethics. We also enlisted the help of the American Association of Critical-Care Nurses and the ANA. Finally, after many conversations and hours of planning, we convened a meeting of 45 clinicians, researchers, ethicists, and key stakeholders to identify promising practices that individuals and systems could use to mitigate the effects of moral distress and develop moral resilience. The executive summary with consensus recommendations from this meeting is published in this issue and the full report is available online at http://journals.lww.com/ajnonline/Pages/Moral-Distress-Supplement.aspx.
We hope clinicians, administrators, educators, and researchers will use this report to initiate conversations, plan strategies and curricula, and conduct research toward creating effective ways to respond to situations that provoke moral distress. As we note in the executive summary, “With determined action, we can help nurses and other providers mitigate the effects of moral distress, enhance the ethical environment in which they practice, and improve the quality of health care.”