10 Best Practices for Addressing Ethical Issues and Moral Distress

Ethical issues in healthcare settings are pervasive, where organizations are trying to do more with less and medical advances and life-extending treatments often cause suffering. When unable to do what they consider the correct action, clinicians—nurses and other healthcare providers—may experience moral distress.

Ramon Lavandero, RN, MA, MSN, FAAN, said we need to be sure conflict or disagreement is not mistaken for moral distress.

“Our challenge isn’t to eliminate moral distress; it is becoming part of our new normal and not going away, so our new goals have become learning how to recognize and address it effectively,” said Ramon Lavandero, RN, MA, MSN, FAAN, senior director of the American Association of Critical-Care Nurses (AACN) and clinical associate professor at Yale University School of Nursing. “Healthcare leaders can start by helping clinicians learn how to recognize moral distress and point them to resources to help address it.”

Clinicians often think moral distress is limited to situations involving treatment and end-of-life decisions, but that’s not true, Lavandero added.

“Things are changing,” he explained. “Now they’re also experiencing it in situations that involve workarounds, bullying and disasters.”

The American Nurses Association (ANA) also has found work environments and genomics are areas of ethical concern.

Finding ways to successfully deal with ethical conflicts is critical not only to the distressed clinicians but also to organizations striving to improve outcomes, since moral distress can adversely affect patient care and is associated with employee burnout and job turnover.

Carol Pavlish, RN, PhD, FAAN, said ethical situations become powerful experiences for nurses.

Nurse leaders are in a key position to defuse ethical conflicts, said Carol Pavlish, RN, PhD, FAAN, associate professor at the UCLA School of Nursing in Los Angeles.

“The nurse manager sets the tone, makes sure the nurses know the resources and provides the resources herself if the institution doesn’t have them,…and creates an environment that allows nurses to practice ethically,” added Barbara J. Daly, PhD, RN, FAAN, a professor at the School of Nursing, Case Western Reserve University, and director of clinical ethics at University Hospitals Case Medical Center in Cleveland, Ohio.

Mary K. Walton, MSN, MBE, RN, discussed how an onsite nurse ethicist can meet with nurses and help them work through ethical dilemmas.

Support from leaders at the top is essential, said Mary K. Walton, MSN, MBE, RN, nurse ethicist at the Hospital of the University of Pennsylvania in Philadelphia.

Katherine Wasson, PhD, MPH, assistant professor in the Neiswanger Institute for Bioethics of Loyola University Chicago Stritch School of Medicine in Maywood, Ill., called moral distress a multifactoral issue.

“The method of coping is not the same for everybody,” Wasson said. “And there are situations that may cause one person moral distress and not another.”

Experts contacted for this article suggested several strategies organizations can implement to address ethical issues and reduce nurses’ and other clinicians’ moral distress:

1. Support the nursing code of ethics

The ANA Code of Ethics presents a framework for practice. Nurses should be familiar with the code and use it on a daily basis, Turner said. Hospitals should incorporate behavior consistent with the code of ethics into job descriptions and consider that during annual performance reviews.

Additionally, some specialty nursing organizations have position statements related to ethical issues which nurses can use as a guide. Competencies for genetics and genomics include an ethics component.

2. Offer ongoing education

Martha Turner, PhD, RN-BC, emphasized including the Code of Ethics into job descriptions and daily practice.

“Ethics, like most other disciplines, must be learned,” said Martha Turner, PhD, RN-BC, assistant director of ANA’s Center for Ethics and Human Rights. “Ethics is not intuitive or just ‘being good.’”

New employee orientation and all educational programs should include ethics content, with specific examples of how to apply theoretical principles to concrete issues, Daly said.

Education gives nurses tools for decision making, added Marsha D. Fowler, PhD, MDiv, MS, RN, FAAN, who served on ANA’s Code of Ethics task force and teaches ethics and spirituality at the Haggard Graduate School of Theology at Azusa Pacific University in Azusa, Calif.

“When they encounter moral dilemmas in clinical practice, they need to think in ethical categories, and that does not come by osmosis,” Fowler said.

Education may not always produce the expected results. Researchers at Loyola found that burn ICU nurses actually reported higher moral distress scores after participating in a four-week intervention about moral distress. But six weeks later, the scores went back down. Wasson, a co-investigator, surmised that the program may have raised awareness or brought up thoughts of past cases. But later the nurses were able to process the information.

“It was worth it,” said lead author Jeanie M. Leggett, RN, BSN, MA, manager of Loyola’s Burn Center. “Nurses told us they appreciated it. And the younger nurses said they sometimes wonder if anyone else feels that way.”

3. Create an environment where nurses can speak up

Having a practice environment that supports nurses in raising ethical questions and empowering them to address those concerns also is vital, Daly said.

Ethical issues are complicated and everyone brings their own experiences and values to the situation.

“Everybody wants to do a good job and the most important thing is the patient,” Daly said. “But these are complicated issues, and it is hard to work it through in your own head. The best ethical analysis is done in the open with other people.”

4. Bring different disciplines together

Physicians and nurses experience shared suffering. Working together could prove beneficial in addressing moral distress.

“Nurses and physicians don’t realize how helpful they can be to one another,” Pavlish said.

Loyola’s burn ICU conducts multidisciplinary debriefing conferences, both same-day and planned, depending on the situation.

Clinical ethics rounds often are helpful in addressing concerns, Turner added.

Nurses also should be included in discussions about patient goals.

“That’s a big part of acknowledging nurses’ contribution to the goals of care,” Pavlish said. “Even if they don’t agree: if they had that discussion, included their thoughts and are valued, it helps with moral distress.”

5. Provide ethics experts

On-site nurse ethicists or other ethics professionals who clinicians can confidentially talk with are valuable in helping people look at the situation from other perspectives.

“When we have different ideas about the right thing to do, it gets hard,” said Walton, who helps nurses reflect and refocus.

Watson often begins by asking questions to help nurses think through their concern and related values. Then she may suggest they talk with the patient or family to gain perspective or an understanding of their choices. She then can help the nurses focus on what went well, how they contributed to improving the situation, how they treated the person with respect and dignity and other positives.

All staff should feel safe in reaching out, perhaps to request a consultation or just to talk things through, Daly said.

“They often will call looking for affirmation they are thinking correctly and not going off base,” Daly said.

6. Add unit-based ethics mentors

Connie M. Ulrich, PhD, RN, FAAN, called ethical issues complex.

Everyday ethical issues need to be addressed, said Connie M. Ulrich, PhD, RN, FAAN, associate professor of bioethics and nursing at the University of Pennsylvania Schools of Nursing and Medicine in Philadelphia and author of Nursing Ethics in Everyday Practice. She suggested hospitals could develop unit-based ethics mentors, who could help their colleagues with those day-to-day concerns that come up.

“If you have someone unit-based, you could address the conflicts earlier and from a preventive ethics perspective, and therefore it could be readily resolved and not lead to further conflict,” Ulrich said.

7. Hold a family conference

Family conferences bring everyone together and should be planned, with clinicians thinking through uncertainties and recommendations before the meeting.

Cecile Yacat, RN, recommended family conferences to address important topics and ethical issues.

Cecile Yacat, RN, director of nursing at Workmen’s Circle, a subacute rehabilitation center in the Bronx, N.Y., agreed about the importance of getting the family involved in developing the plan of care. Workmen’s Circle holds advance care planning meetings with families and the interdisciplinary team to discuss options for changing the goals of care, such as enrolling in hospice or continuing more aggressive treatment.

“The family may need more education about palliative care,” Yacat said. “Families may have difficult decisions and cannot get together.”

8. Sponsor ethics journal or book clubs

Book clubs and journal clubs offer an opportunity to focus on ethics. Hospitals often can organize them, so participants can obtain continuing education credits, Turner said.

Reading articles helps nurses to realize other people have experienced similar feelings. A journal club can make it safe to talk about, because the discussion starts with the article, although it can move into personal values, Watson said.

Many nursing journals include an ethics column. The journal Nursing Ethics is dedicated to the topic. ANA publishes articles about ethical issues the Online Journal of Issues in Nursing, which is online and available at no cost. The National Institutes of Health, Hastings Center, the Institutes of Medicine and the President’s Council on Bioethics provide online information. The World Health Organization offers an international ethics perspective.

9. Reach out to professional associations

Professional associations often provide resources to assist with training and handling of ethical issues.

The ANA offers more than a dozen online ethics continuing education programs.

AACN has developed practical resources about identifying and addressing moral distress, including “4 As to Rise Above Moral Distress,” a handbook that guides clinicians through four steps when confronting moral distress: ask, affirm, assess and act. They’re available to any health professional free of charge at www.aacn.org/moraldistress. And on May 21, the AACN will hold a summit on moral distress during the 2014 AACN National Teaching Institute and Critical Care Exposition in Denver. Summit participants will discuss the inevitability of moral distress in familiar situations.

Organizations, such as the American Society of Bioethics and Humanities, which has an affinity group for nurses, hold annual conferences. ANA co-sponsors the National Nursing Ethics Conference.

10. Offer employee counseling services

Nurses especially troubled by an ethical issue—perhaps relating to something happening in their personal lives or how the current situation rekindles past events—may benefit from individual sessions with a counselor from an employee assistance program (EAP).

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