Moral Distress

When Doctors and Nurses Can’t Do the Right Thing
Pauline W. Chen, M.D.
The New York Times
Doctor and Patient
February 6, 2009

The writer, a physician, describes her experiences of witnessing what an ethics consultant she knew called “moral distress.” The ethics consultant, also a medical doctor, stated that this was a growing concern at her hospital. Moral distress is the feeling of being trapped by competing demands from bureaucracy, family, and professional peers that forces doctors and nurses to compromise their commitment to what is best for patients.

Dr. Chen described a scenario that involved a very talented nurse who possessed tremendous perspicacity regarding clinical situations. She noticed over the years, however, that this nurse’s communication style devolved from sharp insight to vague non-commitment when communicating with doctors and supervisors. One situation in particular provoked the writer of the article to question the nurse about her change in attitude.

An intensive care unit (ICU) patient who appeared beyond help was taken into the operating room repeatedly over a period of a month. The patient’s abdomen was riddled with an unrelenting bacterial infection that was refractory to treatment. The nurse’s concern for the welfare of her patient as well as her questions regarding the futility of the surgeries were repeatedly ignored by the surgical team. She began to resort to sarcasm and, ultimately, resigned herself to silence whenever she was asked to take the patient in for yet another unsuccessful surgery.

The nurse shared her frustration over not being able to advocate for her patients. She was faced with the moral dilemma of choosing to do what was right for the patient or protecting herself from being criticized by doctors or warned by her superiors. This frustration is shared by many nurses. A recent study found that 15 percent of nurses leave their jobs because of moral distress. Doctors grapple with their own version of moral distress but not to the same extent as nurses.

According to Ann B. Hamric PhD, RN, the lead author of a University of Virginia study of ICU nurses and physicians, moral distress may stem from a variety of situations, but it is, in large part, a product of the work environment. Doctors and nurses both suffer from feelings of a lack of autonomy and threatened integrity, fearfulness, and lack of respect. Doctors feel that lawyers and risk managers are dictating patient care over and above the physicians’ professional judgement. The United States has had a nursing shortage for years and a primary care shortage is pending. Dr. Hamric believes that the first step to dealing with moral distress is to recognize it as an issue and then to make a point of discussing it in the health care setting. If health care providers are unable to maintain their professional integrity and do what is right for their patients, the shortage will inevitably become a crisis.

I feel that respect, fairness, and autonomy are at the core of this issue. At the heart of nursing is the imperative to advocate for the patient. The nurse is the liaison between the physician, the social worker, the family, and the patient. No one is more intimately involved in the patient’s care than the nurse. This caregiving role distinguishes nursing from medicine and gives nurses a unique and valuable perspective. Patient hospital ratings are often directly proportional to the quality of nursing care received. Yet nursing professionals continue to feel undervalued and disrespected.

When healthcare providers work as a team of dedicated professionals rather than in the constraints of an outmoded hierarchy, everyone benefits. I was lucky enough to work with an amazing group of doctors and nurses (there were some bad apples, of course). I felt respected by the doctors, my colleagues supported me, my insights and recommendations were valued, and many of my patients appreciated the care I provided them. However, the manpower shortage confronted us on a daily basis. Mandated overtime was the norm. Burnout was common, resentment over not being able to give patients the full attention they deserved was an underlying theme, and safety was an overriding concern. Turnover was high as, week after week, my supervisor tried to balance the schedule, deal with upper management who had no clue about the realities of working on a hospital floor, and, somehow, appease the increasingly disgruntled troops. She too eventually left.

We were paid well and raises came often. But there was no life outside of work. We were required to work every other weekend. That meant working for two weeks at a time before getting two days off in a row. That, in addition to overtime. Days off had to be requested at least a month in advance and weren’t always granted. Sick days were offered but nurses who called out more than two days in a year were denied a raise. Some nurses did feel disrespected. On-call doctors were rude and imperious. The buck always stopped with the RN: Whatever the nurses aides didn’t get to or didn't feel like doing was dumped on the nurse; if social work wasn’t able to do something the nurse picked up the slack; doctors talked down to the nurses and some had the frightening reflex of blaming the nurse for their own mistakes. There were more patients than nurses to care for them.

Numerous studies, analyses, task forces and questionnaires later, nothing much has changed to improve the nursing shortage. The answers seem obvious to nurses but there seems to be a conspiracy of ignorance among the powers that be. The problem is systemic and one that is confronting professionals everywhere. Money is more important than people, timelines are more important than quality, the status quo is more important than teamwork, and upper management everywhere have their own agenda. There is no single solution to this problem but it doesn’t appear that any real efforts have been made to resolve it. If we were living in a different time, place, and culture, there would have been a revolution by now. But there seem to be too many competing interests for anyone to unify for a common goal and purpose. I don’t know the answer. I left nursing too for another job that has its own challenges with moral distress. That’s life in America I guess.