Moral Distress of a Patient When in Critical Care Unit Essay

Moral distress has been something that every healthcare professional has encountered in their career. “Researchers have shown that moral distress is a wide spread problem for health care providers including nurses, pharmacists, social workers, physicians, and health care managers in a wide range of acute and community health care settings” (Pauly et al., 2012). A clinical situation that a nurse may encounter that may cause moral distress is when a patient in critical care unit has a poor prognosis and on the ventilator. Family would still want to have everything done on the patient and keep the patient on the ventilator even if the physicians state that the patient might not be able to be weaned off the ventilator. The Four A’s is used as a guide to identify and analyze moral distress. The four A’s are: ask, affirm, assess, and act. The first A is ask. Ask the appropriate question to be aware that moral distress is present. The questions that should be asked in this situation are: “what would the patient want,” “what are the reasons for the family to have the patient kept on life support,” “what is the prognosis of the patient.” The next A is affirming the distress. Affirming the distress is letting your fellow colleagues know and aware why you feel that way. Moral Distress of a Patient When in Critical Care Unit Essay Next A is to assess sources of moral distress to prepare for an action plan. The sources would be the patient’s prognosis and the family’s decision about the patient. Last part of the Four A’s is to act to implement strategies to preserve integrity and authenticity (Butts, 2016). By talking to family and the healthcare team, that would be acting to preserve integrity and authenticity to have the moral distress addressed.Moral Distress of a Patient When in Critical Care Unit Essay

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Moral Distress is caused by nurses’ work that involves hard moral choices that result in an emotional or physical suffering, painful ambiguity, contradiction, frustration, anger, guilt and an avoidance of patients (Butts, 2015). Furthermore, it is a situation when a nurse feels that task differs from what he/she thinks it is ethically the correct thing to do. According to American Association of Critical-care Nurses (2004), nurses use the Four A’s plan as a guide to identify and analyze moral distress:Moral Distress of a Patient When in Critical Care Unit Essay

Ask appropriate questions to become aware that moral distress is present. For example, a nurse is faced with a situation when family members decide to remove do not resuscitate (DNR) orders for a 90 year old terminally ill patient because the family states “We are not yet ready to let go, we need to give our dad a fighting chance”. They still decided this even though they were given all the information they needed to make a decision. The nurse follows the wishes of the family to get the order done, even though the nurse feels like it is the wrong decision to do. The nurse feels angered and frustrated with this decision. The nurse then asks herself “Am I feeling this way because of this decision by my patient’s family?”

Affirm your distress and commitment to take care of yourself and address moral distress. The nurse in this situation acknowledges the feeling of distress and decides to make a commitment to address the moral distress.Moral Distress of a Patient When in Critical Care Unit Essay

Assess sources of your moral distress to prepare for an action plan. In this situation the nurse recognizes that the source is the decision of family members to remove DNR orders for the patient who is elderly and terminally ill. She feels it’s futile. She feels like the patient would suffer unnecessarily when the patient arrests.

Act to implement strategies for changes to preserve your integrity and authenticity. In this situation, she may decide to seek support from her charge nurse or other senior nurses on how they dealt with this type of situation.

Two types of moral distress
Moral distress was originally defined in 1984 as the phenomenon in which a person knows the right action to take but is constrained from taking it.3 In 1992, a distinction was made between two types of moral distress: initial and reactive.4 Initial moral distress is the acute phase when a person is faced with institutional obstacles and conflicts that cause feelings of anger, frustration, and anxiety. Once the acute phase ends, the individual may experience reactive moral distress-also known as moral residue-when the distress isn’t resolved in an acceptable way.Moral Distress of a Patient When in Critical Care Unit Essay

Although definitions have varied and evolved since the idea of moral distress was first introduced, its central meaning remains the same: moral distress is an ethical dilemma where the nurse believes he or she knows the right action to take but feels unable to act due to internal or external influences.6,7

The concept has recently garnered a lot of attention in the nursing world. Many nurses experience moral distress but fail to recognize it. Research has shown that moral distress may eventually lead to burnout and an increase in nurses’ intentions to leave their jobs, and potentially the nursing profession, due to the stress and psychological impact.8,9 Nurses, administrators, and educators must be able to recognize moral distress and intervene as appropriate.Moral Distress of a Patient When in Critical Care Unit Essay

Moral vs. emotional distress
Emotional distress, which is also common in nursing, is separate and distinct from moral distress. It arises when the individual faces distressing situations, whereas moral distress develops when a person acts against his or her core values. In the case study, for example, Gina may experience emotional distress when she provides care for a child who may have been a victim of abuse. She experiences moral distress when she must provide aggressive care that she believes to be futile and inhumane. While emotional distress can be considered a healthy, normal process, moral distress is decidedly not because it reflects a violation of a person’s core values and responsibilities, which can have powerful negative consequences on the individual.5

Sources of moral distress
Moral distress in nursing has been attributed to three sources: clinical situations, internal constraints, and external constraints.10

* Conflicts with other healthcare providers, controversial end-of-life decisions, excessive workload, and working with colleagues believed to be incompetent are examples of clinical situations that cause moral distress to nurses.Moral Distress of a Patient When in Critical Care Unit Essay

* Internal constraints exist within the nurse and include individual character traits such as the nurse’s conscience, ethical competence, level of assertiveness, and religious values. Personal qualities, such as his or her educational level, experience, perceived powerlessness, and perceptions of autonomy are also internal constraints.

* External constraints are outside the nurse’s control, such as hospital policies, interests of the patient’s family members, hierarchy within the healthcare system, and poor communication between team members.Moral Distress of a Patient When in Critical Care Unit Essay

Researchers have found that the most common cause of moral distress for nurses is when a patient continues to receive aggressive treatment when he or she is unlikely to have a positive outcome.11 Gina’s case is an example of moral distress caused by a clinical situation and external constraints.

Moral residue and the crescendo effect
What happens when moral distress continues for an extended period? Moral residue occurs when individuals feel they’ve allowed themselves to seriously compromise their core values.12 Nurses who repeatedly experience moral distress may lose their moral identity leading to moral residue, which has powerful and long-lasting consequences. Moral residue is related to anxiety, depression, and burnout. Understandably, it also leads nurses to withdraw from any ethically challenging situations.Moral Distress of a Patient When in Critical Care Unit Essay

The moral residue crescendo effect is the increase of moral distress and the increase of moral residue. With the end of the patient’s crisis, nurses’ moral distress decreases, but the painful feelings remain. New situations cause stronger reactions because they remind them of past distress. Every morally difficult case is experienced in the context of the previous unresolved situation, creating the moral residue crescendo effect.5

Consequences of moral distress on nurses
The manifestations of moral distress vary from one person to another depending on each individual’s physiologic and psychological characteristics and their unique life experiences. Moral distress has been consistently related to negative consequences in nurses and in the healthcare system. Broadly, nurses who experience moral distress are stressed and, therefore, predisposed to illnesses.5,15 Moral distress may cause nurses to have feelings of anger and frustration.16 Moral distress can also contribute to nurses’ self-doubt, loss of self-confidence, and loss of self-esteem.17 Moral distress may lead nurses to feel hopeless and helpless, which in turn contributes to depression.Moral Distress of a Patient When in Critical Care Unit Essay

On an organizational level, moral distress has been attributed to deterioration of teamwork and decreased quality of care, which can jeopardize patient safety.10

Developing moral resilience
Moral resilience is a person’s ability to restore or sustain his or her moral integrity and to recover from morally distressing situations.18 Nurses must learn to respond to ethically challenging situations in ways that help them protect their integrity, minimize their suffering, and provide the highest quality of care to their patients. Gina’s moral distress is related to the infant’s mother not accepting the healthcare team’s recommendations. Moral resilience will help her recognize that the patient’s family has a justifiable, permissible, and legitimate point of view. Fully recognizing that the mother’s decision is also ethical (even if it’s in direct contradiction to her own position) will help Gina support their preferences while maintaining her own professional responsibilities. This shift in thinking doesn’t mean that Gina is denying her personal views, but it’s allowing her to expand the possibilities, preserve her integrity, and increase her moral resiliency.Moral Distress of a Patient When in Critical Care Unit Essay

The take-away: What does this mean for Gina?
Gina’s feelings of helplessness can be more easily understood when viewed through the lens of moral distress. She was in a situation where her personal values conflicted with the care she was being asked to provide for her patient, and she felt powerless. She had to reevaluate her approach to care for her patient. Because of her strong emotional response to the situation, she’d likely benefit from some professional guidance. For example, in response to the demand for interventions, the American Association of Critical Care Nurses (AACN) introduced the “The 4 A’s to Rise Above Moral Distress.”19 In brief, the AACN advises nurses to:20

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* Ask: Is this moral distress? Am I feeling frustrated because I can’t provide the care I think I should be providing? During this step, the nurse becomes aware of the moral distress that he or she is experiencing.Moral Distress of a Patient When in Critical Care Unit Essay

* Affirm: Recognize the moral distress for what it is and accept the professional and personal obligation to resolve it.

* Assess: View the situation from the perspective of all involved parties, including family members, healthcare providers, and administrators. The goal is to identify the source of the distress, potential interventions, and the risks and benefits of taking action.

* Act: Take deliberate action to address the ambivalence and to try to reconcile differences.

This approach can provide nurses with a framework with which to view moral distress and a process that may let them move forward in a way that doesn’t require them to compromise their core values.Moral Distress of a Patient When in Critical Care Unit Essay

Gina knew she was experiencing some kind of conflict, but she couldn’t decide how best to handle it. She went to talk to her unit manager, a mentor who’d provided guidance in the past. Her unit manager introduced her to the “4 A’s.” Together, they saw that Gina was experiencing both emotional and moral distress in caring for this gravely ill infant, and that she needed to examine both types of distress.

Her unit manager helped Gina view the situation from the mother’s perspective, reminding Gina that the mother has the responsibility and the authority to make medical decisions on behalf of her child. Gina realized that although the boyfriend was suspected of child abuse, she wasn’t privy to the specifics of the case and that her role wasn’t to investigate or pass judgment. Rather, she should respect the mother’s wishes with the understanding that the mother is better situated than anyone else to make the decisions that are in her child’s best interest.Moral Distress of a Patient When in Critical Care Unit Essay

To resolve her moral conflict, Gina decided to focus on more open conversation with the mother, who shared for the first time that she hadn’t lost hope for her child, wasn’t ready to let go, and felt terribly guilty and ashamed. As a result of the more open lines of communication, Gina was better able to accept that although the mother’s decision was different from her own professional opinion and the physician’s recommendations, the mother’s determination to continue life-sustaining treatment should be respected. The conversation also revealed the mother’s need for more support and counseling.Moral Distress of a Patient When in Critical Care Unit Essay

The unit manager helped Gina understand the role of the hospital’s ethics committee, which could be called on if the situation continued unresolved and if the treatment team believes that outside consultation is needed. This also helped Gina resolve her moral distress without jeopardizing her core values.

Ethically challenging situations will never be eradicated in Gina’s job or from nursing in general; in fact, advances in care, new technology, and growing knowledge in fields like genetics and genomics suggest that we’ll see an increase in such dilemmas. To ensure the highest quality and most ethically sound care, nurses must be able to confront difficult situations in a manner that respects the point of view of the patient, the family, and other providers without undermining their moral integrity.Moral Distress of a Patient When in Critical Care Unit Essay

Background. Moral distress is experienced when nurses experience conflict while making an ethical decision. This is magnified when the decisions are about withholding or withdrawing life-sustaining treatment. Objective. To explore and describe nurses’ experiences of situations that involve end-of-life care and evoke moral distress in the intensive care units (ICUs) of two public tertiary-level hospitals in South Africa (SA), the personal consequences of these situations and the means employed to manage their distress. Methods. An exploratory, descriptive design was used. A short survey/interview guide was administered to registered and enrolled nurses (N=100) employed in the ICUs from two academic-affiliated, specialist public hospitals. Results. A total of 65 completed surveys were collected. Of these, 32 responses were judged not to be describing moral distress while 33 clearly described moral distress and were included and analysed by means of initial content analysis. The findings were presented in five major categories: (i) collegial incompetence or inexperience; (ii) resource constraints; (iii) end-of-life issues; (iv) lack of consultation, communication and negotiation; and (v) support. Conclusion. The study found that nurses experienced considerable moral distress. This is compounded in an environment where gender, professional and social status inhibit the nurses’ assertiveness, ‘voice’ and influence in the healthcare system. Parallels can be drawn between the microcosm of the ICU and the macrocosm of the SA social and ethical character. Moral Distress of a Patient When in Critical Care Unit Essay