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RECOGNIZE & ADDRESS

Moral Distress �is tool is intended to help nurses recognize and mitigate moral distress, a painful problem that occurs all too often in ethically complex environments such as acute and critical care units, and is distinct from burnout and compassion fatigue.

Recognizing the symptoms, causes and constraints associated with moral distress is the first step. Developing strategies to address moral distress and build resilience is next, bringing new meaning to the essential work we do and helping us make our optimal contribution to patient care.

001008 • Rev 07/20

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W

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BurnoutMoral Distress Compassion Fatigue

Identify What You Are Experiencing

Physical, mental and emotional weariness related to caring for those in significant pain or emotional distress.

See Resources section for more information.

When one knows the right thing to do, but constraints, conflict, dilemmas or uncertainty make it nearly impossible to pursue the right course of action.

Physical, mental and emotional exhaustion caused by workplace stress leading to disengagement and depersonalization.

See Resources section for more information.

In managing distress, it is important to identify specifically what type of distress you are feeling. �e following three syndromes both present and are addressed di�erently.

1

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Assess Your Level of Moral Distress

Use the thermometer to rate the severity of your moral distress from one to 10, and note the accompanying description. Use the result to prioritize actions you will take to mitigate your distress and identify changes over time.

Moral distress symptoms vary and may include:

�e moral distress thermometer is adapted with permission. See last page for full attribution.

• Frustration • Anger • Anxiety • Guilt

• Sadness • Powerlessness • Withdrawal

• Muscle aches • Headaches • Heart palpitations

• Depression • Emotional

exhaustion • Loss of self-worth • Nightmares

• Decreasing job satisfaction

• Depersonalization of patients

• Neck pain • Diarrhea • Vomiting

PS YC

HOLOGICAL

0 None

1

2 Mild

3

4 Uncomfortable

5

6 Distressing

7

8 Intense

9

10 Worst Possible

2

EM OTIONAL

PH

YSICAL

Specific situations trigger moral distress. Typically, there is a defining element that constrains or stops you from acting. �is constraint may be related to internal or external factors (such as work environment or organizational pressures).

Identify Causes & Constraints3

Organization

• Performing care perceived as futile

• Implementing unnecessary treatments

• Providing end-of-life care • Witnessing needless patient

su�ering/inadequate pain relief

• Providing false hope to patients

• Inadequate sta�ng • Ine�ective communication • Working with

incompetent colleague(s) • Bullying • Lack of a healthy

work environment

• Inadequate sta�ng • Lack of resources • Pressures to decrease costs • Hospital policies • Hierarchy of power • Ine�ective communication • Financial limitations

UnitSelf

Select Resources �at Can Help4

OrganizationUnitSelf

• Recognize symptoms of distress • Tell a trusted colleague about

your concern • Fact-check — gather relevant

information • Connect with others for

validation and support • Identify involved parties who

can help • Participate in professional

development, such as palliative care or ethics education

• Seek help from clinical leaders and/or an employee assistance program

• Pause after every patient death • Conduct resilience rounds • Create a mentoring program

for new sta� • Identify ethics champions for

peer support • Use a tool, such as the

thermometer graphic, to gauge distress among unit sta�

• Recognize situations that frequently cause distress

• Establish a committee to address common sources of distress

• Use AACN’s Healthy Work Environment Assessment Tool

• Promote actions that improve the work environment, such as implementing AACN’s Healthy Work Environment standards

• O�er resources to support healthcare teams, e.g., palliative care, moral distress or ethics consultation services

• Provide training on critical debrie�ng, resilience and skilled communication

• Adopt zero-tolerance policies on bullying and violence

• Build programs that promote the well-being of the entire healthcare team

Choose strategies to address moral distress based on the type of constraint. Solutions may be actions nurses can take individually, contribute to as part of a unit or escalate to organization leaders.

Moral Distress Support at My Facility5 Use this worksheet to identify Moral Distress resources

and strategies available to you at your workplace.

My OrganizationMy UnitMyself

Enhancing Nurse Well-Being • ANA Enterprise. �e Well-being Initiative. Accessed

May 20, 2020. https://www.nursingworld.org/practice- policy/work-environment/health-safety/disaster- preparedness/coronavirus/what-you-need-to-know/the- well-being-initiative/

• Barron B, Cusack C, Lux L, Patterson V. Creating Resiliency and Improving Retention Among Nurses. Updated December 6, 2019. Accessed May 20, 2020. https://www.aacn.org/clinical- resources/csi-projects/creating-resiliency-and-improving- retention-among-nurses

Understanding Moral Distress • Forozeiya D, Vanderspank-Wright B, Bourbonnais FF,

Moreau D, Wright DK. Coping with moral distress – �e experiences of intensive care nurses: An interpretive descriptive study. Intensive Crit Care Nurs. 2019;53:23–29. https://doi.org/10.1016/j.iccn.2019.03.002

• Dudzinski DM. Navigating moral distress using the moral distress map. J Med Ethics. 2016;42(5):321–324. https://doi.org/10.1136/medethics-2015-103156

• Pavlish CL, Brown-Saltzman K, Raho JA, Chen B. A national survey on moral obligations in critical care. Am J Crit Care. 2019;2(3):183–192. https://doi.org/10.4037/ajcc2019512

Understanding Moral Distress (cont.) • Ulrich C, Grady C, eds. Moral Distress in the Health Professions.

Springer; 2018. ISBN-13: 978-3319646251. • University of Kentucky Program for Bioethics. �e Moral

Distress Education Project. Accessed May 20, 2020. https://moraldistressproject.med.uky.edu/moral-distress-home

• Vincent H, Jones DJ, Engebretson J. Moral distress perspectives among interprofessional intensive care unit team members [published online May 14, 2020]. Nurs Ethics. https://doi.org/10.1177/0969733020916747

• Deschenes S, Gagnon M, Park T, Kunyk D. Moral distress: A concept clarification [published online April 6, 2020]. Nurs Ethics. https://doi.org/10.1177/0969733020909523

Mitigating Moral Distress • Hamric AB, Epstein EG. A health system-wide moral distress

consultation service: development and evaluation. HEC Forum. 2017;29(2):127–143. https://doi.org/10.1007/s10730-016-9315-y

• Rushton C, Schoonover-Sho�ner K, Kennedy MS. Executive summary: transforming moral distress into moral resilience in nursing. Am J Nurs. 2017;117(2):52–56. https://doi.org/10.1097/01.NAJ.0000512298.18641.31

Moral Distress Resources

Explore these resources to learn more about recognizing and addressing Moral Distress.

Mitigating Moral Distress (cont.) • American Association of Critical-Care Nurses. AACN

Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. Accessed May 20, 2020. https://www.aacn.org/nursing-excellence/healthy- work-environments

• Wolf AT, White KT, Epstein EG, Enfield KB. Palliative care and moral distress: An institutional survey of critical care nurses. Crit Care Nurse. 2019;39(5):38–49. https://doi.org/10.4037/ccn2019645

• Wocial LD, Weaver MT. Development and psychometric testing of a new tool for detecting moral distress: �e moral distress thermometer. J Adv Nurs. 2013;69(1):167–174. https://doi.org/10.1111/j.1365-2648.2012.06036.x

• Pavlish CL, Henriksen J, Brown-Saltzman K, et al. A team-based early action protocol to address ethical concerns in the intensive care unit. Am J Crit Care. 2020;29(1):49–61. https://doi.org/10.4037/ajcc2020915

Burnout • National Academy of Medicine. Sharing Knowledge to

Combat Clinician Burnout. Accessed May 20, 2020. https://nam.edu/clinicianwellbeing/

• Bancroft H, Guidry B, Rodrigue C, Rouyer H, Wilson N. Blow Out Burnout: Decreasing Turnover, Increasing Self-Care. Updated March 5, 2020. Accessed May 20, 2020. https://www.aacn.org/clinical-resources/csi-projects/blow-out- burnout-decreasing-turnover-increasing-self-care

Compassion Fatigue • Burger C. Understand & Overcome Your Compassion

Fatigue: An Online Guide. Accessed May 20, 2020. https://www.edumed.org/resources/compassion-fatigue- online-guide/

Moral Distress Resources (cont.)

�e moral distress thermometer on page three is adapted with permission. �e moral distress thermometer is the result of research works authored by Lucia Wocial, PhD, RN and Dr. Michael Weaver at the Indiana University School of Nursing, with graphics and associated software developed by Robert ‘Skip’ Comer, research associate at the Indiana University-Purdue University Indianapolis School of Informatics and Computing.