In 1984, Andrew Jameton defined moral distress as “a phenomenon in which one knows the right action to take, but is constrained from taking it.” Moral distress was never mentioned when I was in nursing school. Even as a graduate student now, no course has mentioned its existence, let alone its importance. Despite this, it’s something I’ve seen countless times in varying levels of care. From outpatient clinics to intensive care units, nurses are deeply familiar with moral distress.
When I was a nursing student, I did my practicum on an intensive care unit. One day I my preceptor assigned me to prep an elderly gentleman for a nasogastric tube (NGT) insertion. There is no getting around the discomfort of this procedure. The tube is inserted through a nostril, down the esophagus and ends at the gastric portion of the GI tract. These tubes are inserted for various reasons: to meet nutritional needs, to suction out the stomach contents to prevent distention, or to prevent vomiting and possible aspiration after bowel surgery. None of these reasons, I should add, seem to justify the procedure in the moment- no matter how well one articulates them to the patient. The NG tube placement is done by a nurse, without sedation, and often accompanied by nausea and severe gagging. While I respect and understand the necessity of NGTs, I agonize over the patients’ discomfort each and every time I’m involved. More often than not, it’s described as painful, and disturbing—a patient once told me, “I feel everything you’re doing. I feel it inside me now!” This same man told me a week later, “I would have died if you didn’t insert the gastric tube. Thank you for doing what was necessary but I’m still upset. That was brute force…medicine at its worst.”
I could hear him in his room screaming, “No please, I don’t want this. Please don’t do this!”
This same sentiment was shared by a patient I encountered later as a nursing student. I could hear him in his room screaming, “No please, I don’t want this. Please don’t do this!” The door was wide open, and all I an older man—someone’s loved one—in sheer distress. Then I looked over and saw a younger man yelling at him. It was his son yelling, “Dad, the DNR (do not resuscitate) was rescinded. We want this. Don’t you love us?”
The patient stopped fighting, started crying, and said, “Okay, I want the tube…for my family.”
He cried the entire procedure and for a full hour afterward. To this date it was one of the saddest things I’ve ever witnessed. After the nasogastric tube was successfully inserted, and the crowd left the room, one of the other nurses and I locked eyes for a brief moment. What I remember is the look of shame I registered on his face. I spent the next several hours speaking to management and clinical staff, debriefing the situation. The response was virtually the same among my colleagues: an unsatisfying yet factually sound response: “The patient agreed, and we must follow his wishes.”
It was the first of many encounters with moral distress in my nursing career. There have been countless situations since that day where I’ve sat in my car and cried after work. I cry when I feel helpless, when I feel a decision I’ve made wasn’t in the patient’s best interest. It’s easy to feel I have no choice but to suppress the emotions and return to work.
The typical shift is twelve hours. A lot happens in twelve hours. A world unfolds.
Healthcare is a complex machine with many moving parts. Generally, a decision is never made by just one person. Groups of individuals make decisions. Agency is complicated. It is this lack of control that causes moral distress. What people forget is that as a nurse, one is present for the entire decision process and its outcome, whether positive or negative. As nurses, we build relationships. We are drawn to connection and community. Feelings of loss, anger, shame, and disappointment arise too easily when we aren’t instructed on how to identify and manage this dissonance when it occurs. I feel that nurses, in particular, experience moral distress more than other medical professionals because we are there from the beginning to the end. The typical shift is twelve hours. A lot happens in twelve hours. A world unfolds.
Since becoming a critical care nurse, one tool that has helped me to process moral distress is speaking to nursing management or a counselor. I’ve tried ignoring my feelings and found it was ineffective and even harmful. Moral distress can seep into your interpersonal relationships if left untreated. It’s hard to admit, but nurses care to the point of our own self-destruction sometimes. I’ve had many people tell me, “It’s not a big deal. Do your job and go home.” I wish I could. I wish it were that simple. The consequences, though, are real. I’ve witnessed many nurses leave the profession due to the sheer inability to handle moral distress, and this includes nurses who love their work. Healthcare is a matter of life and death, and the decisions we make not only affect our patients and their loved ones, but haunt us too. Though we have little control over some of the decisions made, when things turn out for the worse it stays with us.
I strongly believe there needs to be a nursing curriculum on examining moral distress. It’s essential to the psyche of nursing students before entering the profession. This curriculum should include information on how to identify signs and symptoms of distress, maladaptive versus adaptive coping mechanisms, and leadership skills in the area of support.
Moral distress also requires more attention and care in the workplace. Often, this problem isn’t a singular event but rather an occupational hazard endorsed by a broken culture. Each medical case brings its own level of anxiety to healthcare professionals. Forming a support group at work can offer at-risk nurses a platform to express themselves. It creates a community and a culture that is proactive rather than reactive. Research has shown these discussions open the door to policy change and institutional analyses. When nurses come together as a group, amazing things usually happen.
Just in the act of naming and identifying moral distress as a real phenomenon impacting healthcare professionals we have come a long way. Nightingale is a place where we can bring issues of moral distress out into the light and talk about them together. The nurses of today have the task of respecting and understand its power, embracing its presence through open discussion and building resilient networks of support for generations of nurses to come.
Nacole Riccaboni, BSN, RN, CCRN-CMC is a critical care nurse living in the south. She has worked as a travel intensive care nurse and an ICU nurse for the U.S. Department of Veterans Affairs. Presently, she writes about advanced nursing education, as well as designs and publishes innovative study guides for new nursing students around the country. She will complete her Doctorates of Nursing Practice in 2018.
(Accompanying Art: Ash’s Study by Suzanne Elizabeth)