In 1984, Andrew Jameton identified moral distress in nursing as:
When one knows the right thing to do, but institutional contraints make it nearly impossible to pursue the right course of action.
Since then, nursing and midwifery scholarship has continually revisited the concept, as synthesised in the 2017 Nursing Ethics paper What is ‘moral distress’? A narrative synthesis of the literature.
I’m going to make my own attempt to define moral distress, but it isn’t exactly easy. Many interlinking ideas and theoretical frameworks underpin understandings of the topic.
Before I attempt to define moral distress, it’s important to talk about a person’s moral agency, or as some know it better, a person’s conscience. Moral agency refers to an individual’s ability to ethically assess a situation or problem with consideration to their beliefs and responsibilities for other people.
Nurses and midwives’ responsibilities extend well beyond their patients. As professionals they must also consider best practice guidelines, codes of conduct, hospital policies and procedures, and changeable government guidance (highlighted during the pandemic).
Morally conflicting situations are unavoidable aspects of nurses’ and midwives' everyday realities due to the nature of our work. Moral conflict can support clinical decision-making and act as a subconscious alert system that initiates caution and questioning. Although elements of moral conflict can be valuable, these experiences are not always linked to positive emotions for the nurses and midwives involved.
I define moral distress as the outcome of morally challenging situations that leave nurses and midwives feeling uncomfortable and as though they have not been able to provide the care they feel is right or required due to constraints that are out of their control, causing conflict within their moral compass, or stress to their conscience.
That is, when nurses or midwives are not able to use their moral agency to satisfactorily resolve a moral conflict they encounter in their practice, they are left with moral distress.
Nurses and midwives are not the only population that experience morally challenging situations. These situations can and do happen in everyday life to many people in many professions.
Nurses and midwives are usually hardworking, resilient people who are conscientious to the needs of their communities. Unfortunately, it seems that situations in which they are unable to use their agency to satisfactorily resolve feelings of moral conflict are growing more frequent.
Nursing and midwifery have always been busy professions ripe with opportunities for moral quandary, but as the pandemic has unfolded and left many workplaces overloaded and understaffed, many clinicians are facing moral conflicts more frequently and seriously than before.
As the list of responsibilities and tasks nurses and midwives are expected to do grows, many of us are left feeling like we don’t have enough support, resources, or the requisite training to not only provide the level of care we feel is right, but also to handle the moral residue that is left behind from the increasingly frequent moral challenges we are facing. This means that moral distress becomes more frequent and more acute.
Moral residue is the guilt, unease and psychological — and often physical — discomfort that can remain after a person is exposed to a morally challenging or distressing situation. This residue can accumulate and has the potential to be personally and professionally destructive, impacting the wellbeing of nurses and midwives.
Many of us are also carrying our frustration and shame outside the workplace, becoming agitated when we see members of the public disregarding basic preventative procedures like mask-wearing, hand-washing, self-isolating through potentially contagious symptoms, or vaccines. This additional frustration may complicate our feelings of moral distress.
The accumulation of these experiences can lead to burnout and professional disconnect, which is increasingly leading to nurses and midwives leaving the profession. Usually, I would put a statistic here, but I sadly don’t feel this is necessary — we can all see it happening around us.
I don’t by any means feel I have all the answers on how we can remove moral distress from our profession. As I mentioned previously, morally challenging experiences can have positive elements in a workplace — besides, they’re virtually impossible to avoid in professions that deal so intimately with the most important aspects of people’s health and wellbeing.
It would potentially be detrimental to the care we provide and the status of our profession should we remove ourselves from the experience of moral challenge or the emotions they can elicit. Our feelings of shame, guilt, frustration or even anger are human and sometimes unavoidable.
However, I believe that there are methods of managing the moral residue that we are left with.
I hope this article raises awareness into the need to talk about the things that make us feel uncomfortable to support safe psychological processing of workplace situations that may be morally conflicting. In addition, I want to highlight that the nursing and midwifery industry needs help now so that our profession can continue to evolve and provide care to our future community — but then, I suppose many of you reading this already know we need help.
Engage in or advocate for clinical supervision
I want to ask you a question… Have you been getting clinical supervision? As I write this, I reflect on some of the answers I received during a pre-pandemic survey I conducted on the mental wellbeing of nurses and midwives in Victoria. I am sure many of you will be answering ‘no’ to my question about clinical supervision, with respondents frequently citing a lack of time during the working day as a reason. Some of you may even be saying that your workplace doesn’t have a program offering such services. With frustration, I know that many of you reading this will not have even heard of clinical supervision, and it’s not your fault.
Clinical Supervision is a professional development activity in which nurses and midwives (or other health professionals) meet with a clinical supervisor regularly for discussions to reflect on recent work experiences. Nurse and Midwife Support offer some resources to explain how clinical supervision works:
Clinical supervision encourages the safe psychological processing of challenging workplace experiences with a trained supervisor. This structured and confidential practice facilitates reflective practice while providing clinicians with a safe space to work through situations that may have left them feeling uneasy, unsure, or conflicted. Clinical supervision is not counselling or engagement with EAP programs, nor is it a disciplinary or management procedure. Instead, it aims to promote professional growth and clinical understanding by empowering clinicians to learn from their experiences, mitigating the damage moral residue can cause.
I understand that clinical supervision is time-consuming and many may feel it isn’t an option in their workplace, and won’t be until it becomes part of expected or required practices system-wide, as it has in some other countries. With the current resource deficits we see in our workplaces, I can't be sure that this practice will become widely available despite the need and evidence outlining the benefits — but if you think it could play a beneficial role in your practice, it’s important to speak up and ask for it so that the desires of the workforce are clear to those making decisions.
Self-directed reflection: The 4 Rs
It might be a while before clinical supervision becomes ubiquitous in our workforce, but there are other steps we can take. We need to take action to try and protect ourselves from the residue of moral distress, because our wellbeing matters!
Have a look at The 4Rs. This tool was created by Cyndy Hylton Rushton and Kathleen Turner (both nurses and academics) to support individuals in processing situations that may be morally distressing and have the potential to leave harmful residue. You may try doing this in your head, writing it down in a journal or even in the notes section of your phone. It can be in the moment or as a reflective practice post a morally conflicting situation.
- Recognise the situation for what it is. Some situations are complex and have multiple stakeholders involved. To do this effectively, you need to acknowledge and consider the patient, their family, and the healthcare services’ abilities and limitations alongside the desired outcomes and emotional processes of each party involved. Not easy, but writing this one down can help.
- Release yourself from the things you cannot change. Consider what you can change and focus on that!
- Reconsider the issue or morally challenging situation. Can you look at the challenges within this situation in another way? Can you reframe the issue? Do you need to get another opinion to help you understand conflicting views or perspectives? What we don’t know, we don’t know, be open to new knowledge – even if it challenges you, your knowledge, and your beliefs.
- Restart. Can you pack away this conundrum, having explored new perspectives, limitations and the barriers that contributed to you not being able to act in accordance with your moral compass?
At this point, I would hope you could move forward. If you can’t, then I think you need to talk to someone to explore this further and decide on your next steps. This could be your manager, educator, mentor, EAP services or even Nurse and Midwife Support.
If you feel you have been impacted by moral distress or have some residue you would like to talk through, think about calling Nurse and Midwife Support to explore how you can mitigate the impacts of this workplace experience. You can give them a call on 1800 667 877 or send them an email — they’re here for nurses, midwives and students nationwide, free, confidential, 24/7.
You may also be interested in joining the Pheonix Australia study of Moral Distress and Wellbeing of Health Workers during the COVID-19 Pandemic.
Don’t sit with the residue, the discomfort, or the unease. You are not alone, and your health and wellbeing matters.
Tayla Vella RN is an experienced mental health nurse. She says:
After a few years working as a mental health nurse my passion for staff safety and wellbeing ignited and led me to Nurse and Midwife Support where I worked as one of the program’s first employees.
I then went on an adventure to work and study in the UK getting a Masters in Workplace Health and Wellbeing. I am now working for NSW Health planting the seed of wellbeing in everything I do.
Sending a big thank you to all of you, for the amazing work you do!