Summarize the assigned article (see uploaded file) using 175-200 words. Include all of the main ideas from the assigned article. The Summary must contain the assigned sentence for quotation and citation as noted in the announcement, the assigned sentence for the paraphrased area with citation as noted in the announcement, several additional paraphrased areas, and appropriately formatted citations. You may also include one more short quotation if you wish.
Assigned sentence for quotation: “Moral distress can be noted in several ways,such as affective signs of anger, frustration, or anxiety.”
Assigned sentence for paraphrase: “Releiving moral distress can be a challenge if individuals are unaware of the unavailable effective interventions and tools.”
What is moral distress?
BY SOPHIE PARSH, RN, AND ELVIS VO
O UNIT, hospital, or occupation is immune to moral distress. Using the following case study, this
article examines moral distress in nursing students who are completing their clinical rotations, including the definition of moral distress, signs and symptoms, and relief methods.
Case study
During a day shift on the telemetry unit, Jamie, a third-semester nursing student, starts her first shift with Tom, an RN with 2 years of experi- ence. After patient handoff, they head into the first patient room for an hour-long visit, including assessment, medications, and
something to Tom, at the very least, to mitigate her own distress. When Jamie asked whether they should assess the third patient, Tom simply stated that the telemetry monitor will let them know if anything is wrong. Feeling the patients were inadequate- ly cared for, Jamie dealt with an in- ternal constraint that left her feeling frustrated and unhelpful not only to the patients but also to Tom.
What is moral distress?
Moral distress is knowing the ethical action to take but being unable to act on it.2 In these scenarios, an individu- al acts contrary to their personal and
knowledge or support), external constraints (e.g., staffing or supply issues), clinical constraints (e.g., feeling care is not helping the client), or seeing others giving a false sense of hope to a patient or their family.7 These feelings can linger and build over time, leading to a breaking point for the nurse.6
Signs of moral distress
Moral distress can be noted in several ways, such as affective signs of anger, frustration, or anxiety. (See Signs of moral distress.9) There can be behavioral signs such as withdrawal, cursing, or cynicism.
patient education. Although she was told by her clinical instructor to follow Toms lead, Jamie is uncom- fortable with not first seeing all four assigned patients briefly. She felt they should at least look in on each of the four patients before spending
Moral distress can occur in all areas of nursing and for a variety of reasons, including end-of-life challenges, team conflicts, decision-making hierarchies, and ethical dilemmas.
a lengthy amount of time with one of them. Since this is her first time on the telemetry unit and she is a nursing student, Jamie does not want to begin the shift in conflict with Tom. Jamie feels guilty and powerless, which can eventually lead to moral distress.1
Although Jamie trusted that Tom had a plan to assess all the patients, they stayed in the first patients room for 60 minutes. The next hour was spent in the second patients room. When they finished assessing and delivering care to that patient, Tom sat down and documented in the electronic health record. As the discomfort of not seeing all patients built up, Jamie knew she had to say
professional values, thereby under- mining their integrity and authentic- ity.3 Nurses typically experience moral distress several times per month, which can lead to poor patient care, decreased job satisfac- tion, staffing turnover, burnout, and psychological distress.2,4-6
Moral distress can occur in all areas of nursing and for a variety of reasons, including end-of-life challenges, team conflicts, decision- making hierarchies, and ethical dilemmas.2 Examples include working in a high-acuity ED with insufficient resources.2,7,8
Often in these situations, the nurse or nursing student feels powerless due to internal constraints (e.g., lack of
Powerlessness is common, as are changes in relationships. Physical signs may include insomnia or tachycardia.9
In this case study, not assess- ing the patients in a timely man- ner caused Jamie to feel guilty and powerless as a nursing student.
Even though she advocated for the patients, Jamie felt dismissed by Tom. Although Tom prioritized the pa- tients correctly and all the patients were safe and stable, the guilt and powerlessness still weighed on Jamie.
Relieving moral distress Relieving moral distress can be a challenge if individuals are unaware of the available effective interventions
www.Nursing2021.com November l Nursing2021 l 19
Affective signs Behavioral signs Cognitive/relational signs Physical signs
?anger, disdain
?feeling upset
?grief, crying, despair
?anxiety/worry/agitation/ angst
?frustration
?fear
?feeling hurt/devalued
?low morale/discouragement ?stating concerns about issues
?withdrawal/disengagement/ becoming silent
?increased vigilance for patient, family, each other
?resistance to plans
?persuasion
?dark humor, cynicism
?name-calling, cursing
?heightened sense of neutrality ?uncertainty
?feeling ambivalent/torn
?powerlessness/ hopelessness
?regret
?surprise, disbelief ?frequently ill or missing work
?fatigue/poor sleep
?increased heart rate
and tools. A helpful tool for nurses and students is the 4 As, which was originally developed for critical care nurses but has since been used by many nurses on all units. The 4 As are:
?Asking oneself whether he/she is experiencing moral distress
?Affirming feelings of distress
?Assessing the cause of the distress
?Acting on the distress to relieve it.
In addition, institutions have other tools that nurses can use to learn how to cope with moral distress.6 For example, hospitals have created ethics committees to address moral distress among healthcare providers. In addition to following the four As, ethics committees offer tools to support nurses in challenging situations.
To guide discussions, committees discuss the nurses response to the event and help nurses develop skills to address future ethical
dilemmas.
Although individuals need skills to relieve distress, real-time institu- tional approaches can be a long- term solution.6 Positive impacts
on reducing moral distress include adequate staffing, improving the units environment, leadership sup- port, collegial relationships with staff and physicians, hospital program
participation, and empowering nurses to choose the right option despite pressure not to.4,8 Supporting staff through moral distress includes grief intervention, education programs such as critical debriefs, and work-life balance committees.2,10
Code Lavender, a crisis inter- vention tool that supports nurses at the time of stressful events, has shown to help reduce moral distress, as have yoga classes and mindfulness sessions.6,11 Code
Lavender provides healing services for individuals and teams by pro- viding words of support, lavender essential oils, and spiritual care if appropriate.11,12
Mindfulness-based stress reduc- tion (MBSR) is another strategy that can decrease anxiety, depression, and perception of distress.7,13 Shown to improve the quality of life and reduce stress especially for health- care professionals, MBSR provides training on mindful meditation, yoga, reflection, and discussion.13
Discussion
The nursing student in this articles case scenario, Jamie, was unsure
of how to cope with her situation. Students may feel overwhelmed and conflicted about the plan of care, especially if they are not sure
of the clinical judgment involved. In this case, open communication about the situation with the RN and the clinical instructor is warranted. Jamie spoke with fellow nursing students, who confirmed that the incident was unusual and poten- tially put patients at risk. After de- briefing with fellow students, Jamie felt empowered to tell the clinical instructor what happened for fur- ther support and guidance. Speak- ing with nursing students and with the instructor eased Jamies worries and empowered her to speak up in the future.
A situation like Jamies can happen to any nurse, student, and guest on a unit. Guests, such as travel nurses and even patients, can potentially feel powerless, especially if they express concerns about unexpected outcomes.6 Openly discussing the situation with supervisors, friends, or professionals can alleviate distress.1,2
Moral distress can occur even when things do not go wrong. Having an open discussion about challenges, practicing relaxation techniques, and using resources like Code Lavender can help reduce moral distress and lead to a more positive nursing career. ¦
20 l Nursing2021 l Volume 51, Number 11 www.Nursing2021.com
