Moral Distress: Responding with Education


Published: 14 November 2018

Moral distress has been described as:

“One or more deleterious self-directed feelings that arise in response to a nurse’s perceived participation in a patient care situation that the nurse believes to be morally undesirable” (Stokes, 2017).

When patient care situations or practice standards become barriers that prevent a rural nurse from engaging in actions that he/she believe are in the best interest of patient care or safety, that presents a moral dilemma. This dilemma may be identified as “moral distress” and it can make the nurse feel helpless, uneasy, and disheartened.

Moral distress is certainly not unique to rural nursing. “The intimate nature of the nurse-patient relationship enhances feelings of moral distress experienced by bedside nurses. Rural, bedside nurses spend several hours a day with patients and families. They experience the joy, but also the suffering and stress that sickness can cause them,” says Stokes (2017). “The intimate nature of the nurse-patient relationship contributes to the prevalence of moral distress.”

Signs and Symptoms of Moral Distress

The lived experience of a rural nurse who is challenged by feelings of moral distress may vary widely. The following signs and symptoms have been commonly reported;

  • Headaches;
  • Sleep pattern disturbances, including insomnia, nightmares or night-terrors; and
  • Gastrointestinal disturbances.

Patient Care Situations that May Contribute to Moral Distress

Regardless of the setting, rural nurses who provide care for patients may be at risk of experiencing symptoms of moral distress. However, the American Nurses Association (ANA, 2018) states that nurses who work in intensive care settings, emergency rooms, or operating rooms are at a greater risk for experiencing moral or ethical distress.

The following case examples put nurses at risk of moral distress:

  • A physician suggests traveling a distance to an urban medical centre for a child to receive a 4-month course of intravenous medication to treat a chronic health condition. The medication is not readily available in a rural setting. The child’s family declines the recommendation due to lack of finances and time to secure the treatments.
  • A nurse is the intensive care unit is asked to perform a painful procedure that the nurse feels may cause more harm than good on a patient with a poor likelihood for survival.
  • A nurse mentor working with a new graduate in a rural setting is concerned that the new nurse is lacking confidence in certain areas. The new graduate would like to spread her wings and work independently when the mentoring program ends in two weeks. The nurse mentor would like to keep her in the program for an additional month to assess, teach and evaluate her practice.

Educational Strategies to Address Moral Distress

The three case examples provided are but a few examples of common situations that may cause rural nurses to experience moral distress. When left unaddressed, issues that give rise to moral distress in rural nurses may lead to feelings of burnout, frustration, and ultimately fuel a desire to leave rural practice and transition to a new position or even away from direct patient care.

However, as nurse educators we can address issues of moral distress and create educational programs that build strength and resilience in our rural nursing workforce.

Debra Wood (2014) proposed several best practices to address moral distress. I have adapted these strategies to meet the needs of nurses working in rural and remote settings. These initiatives can be presented to nursing and health care team members via face-to-face, video, or podcast media.

Strategy One: Provide Readily Accessible Information Regarding the Nursing Code of Conduct

On March 1, 2018 the Nursing & Midwifery Board of Australia published an update to the Code of Conduct for Nurses. This document provides a foundation for nursing practice and research. Many rural nurses may not be familiar with recent changes to this foundational text or how it can be used to guide practice and policy decisions in rural settings.

Strategy Two: Encourage Interdisciplinary Learning Opportunities

Currently, I teach at a large university in Boston, Massachusetts. Our campus holds monthly lunch and learn opportunities called Scholarly Dialogues. These one-hour programs provide students and faculty opportunities to share best practices in research, policy and practice.

Consider alternating these types of programs with a program focused on case study presentations that may raise ethical, moral, and legal concerns. United States health care organisations often refer to these programs as “Ethical Grand Rounds.” The number of participants at these programs may vary from 5-50 audience members but the potential for sharing and learning is tremendous regardless of the number of attendees.

Remember, these meetings can be audio and/or video taped so that all shifts can benefit from the learning.

Further reading: Interprofessional Education in Healthcare - Exploring the Benefits

Strategy Three: Seek the Consult of an Ethics Expert

Moral distress is inexplicably connected to values, ideals and beliefs. It is vitally important that rural nurses have the support and counsel of an ethicist that can help them to process issues of moral distress.

In rural and remote areas, ethics experts may be available through local groups, social justice organisations or by utilising technology to seek out an expert at a distance.

Strategy Four: Launch an Ethics Journal Club

One of the biggest barriers for nurses to cope with is lack of time! Learning through sharing is an excellent way to invite nurses to review ethical issues that may affect their daily practice. In the United States that focus exclusively on nursing ethics.
The journal Nursing Ethics is dedicated to the topic. The National Institutes of Health, (NIH) Hastings Center, the Institutes of Medicine (IOM) and the President’s Council on Bioethics provide online information. The Australian Journal for Advanced Nursing offers insight and information regarding issues of ethics and moral distress. The World Health Organization offers an international ethics perspective.

Rural nurses who are afforded opportunities to review case studies and relate to situations where they may have faced moral distress may feel less reluctant to share their experiences.

Strategy Five: Develop Unit Based Ethics Mentors

Experienced rural nurses can be invited to participate in a mentoring program offered by a collaborative of nurse educators with the goal of building competence and confidence at each rural setting. This will require that nurse educators in various regions work together to develop, implement and evaluate the initiative.

The gains to this type of an initiative will serve to enhance patient care and nurse satisfaction.

Further reading: Developing Successful Mentoring Relationships

Final Thoughts

The concept of moral distress will confront all nurses at some point during their nursing practice due to the nature of our caring profession.

Moral distress should not be viewed as a barrier to practice.

The experience of this feeling can be shared through participating in educational programs that acknowledge its presence and propose effective strategies that will build resilience.



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Judith Paré View profile
Judith Paré joined the Massachusetts Nurses Association (MNA) in May, 2017 as the Director of Nursing Education/Workforce Quality and Safety. In 2014, Judith earned her Doctorate of Philosophy in the field of Nursing Education Capella University. Prior to joining the MNA she was Dean of the School of Nursing & Behavioral Sciences at Becker College in Worcester Massachusetts. She is an experienced educator in academic and continuing education settings. Judith is a member of more than ten professional nursing organisations and she devotes much of her time as an advocate for the Rural Nurse Organisation. Her expertise include curriculum design, assessment and evaluation in nursing and healthcare. Her research areas of expertise in rural healthcare and specifically the lived experiences of the rural nurse generalist. Judith is a published author and a national speaker in the field of rural nursing. Her recent writings includes: Montgomery, S, Sutton A & Paré, J 2017, ‘Rural Nursing & Synergy’, Online Journal of Rural Nursing & Health Care, vol. 17, no. 1, pp. 87-99.