The Impact Of Moral Distress On Nurses

4.2.4 Impacts of moral distress on critical care nurses
Moral distress has been a topic of interest to many nursing researchers due to the consequences that it poses, however few studies have examined the impacts of moral distress on nurses. By utilizing existing research on the topic, Corley (2002) proposed a theory of moral distress that encompassed its negative effects. Corley (2002) theorized that moral distress negatively affects nurses, patients and organizations. When subjected to moral distress, nurses can suffer, feel burnt-out, resign from positions, and/or leave the profession (Corley, 2002). As a result of their moral distress, nurses can distance themselves from patients and cease to advocate for them, resulting in suboptimal patient
care (Corley, 2002). As the quality of nursing care declines, patient satisfaction decreases, leading to the reputation of the organization being perceived as negative (Corley, 2002). Furthermore, when nurses resign from positions, organizations develop high turnover rates in staffing which can cause difficulty in recruiting new nurses (Corley, 2002). Four studies have supported Corley’s (2002) theory by validating the negative impacts that moral distress has on nurses’ emotional, physical, and psychosocial well-being (Choe et al., 2015; Wiegand and Funk, 2012; McClendon and Buckner 2007; Elpern et al., 2005).
The first study evident that moral distress was associated with effects on one’s emotional health as a qualitative study was conducted by Choe et al. (2015) to identify and analyse the experience of moral distress among critical care nurses in Korea. Qualitative approaches seek to understand the interpretations and motivations of people, and as such this is an appropriate methodology for answering the research question posed here (Cormack, 2000). In-depth face-to-face interviews with purposive sampling of fourteen female critical care Korean nurses were used to collect data. Data then analysed using the framework analysis approach to compare and contrast the data and draw conclusions (Burns and Grove, 2009). To ensure credibility, copies of the transcripts were returned to respondents to see if on reflection the elements described were essential to the experience. In addition to these emergent themes from transcription were co-verified by a second researcher, thus strengthening dependability of findings presented (Parahoo, 2006).
Choe et al. (2015) found that the moral distress of nurses was expressed through ambivalence towards treatment and care, such as prioritizing tasks over human dignity, unnecessary medical treatment and the compulsory application of restrains. Nurses express suffering resulting from a lack of ethical sensitivity and dilemmas resulting from their limited autonomy in treatments (Choe et al., 2015). Furthermore, they reported moral distress from conflicts with physicians and conflict with instructional policies, for example, discontinuing treatment when patients are not able to pay, hospital economic benefits prioritized over human rights, and shortage of staff preventing nurses from providing appropriate care. All these situations made them feel powerless. A point to take in consideration that participants were all female nurses and were selected from two university hospitals located in the capital, Seoul, which may limit the generalisability of the study (Polit and Beck, 2010), the results should therefore be interpreted cautiously when applying them to other populations.

The second study was by Wiegand and Funk (2012) who seek to understand the impacts of moral distress for the nurses. The researchers used an open-ended survey . The researchers recruited a convenience sample of 204 critical nurses from six critical care units in university hospital, and described the themes in terms of percentages, which is not typical of most qualitative research (Polit and Beck,2010). It was not clear in the study how did the participant recruited and this is interduce a study bias (Polit and Beck, 2010).Response rate was 23%.

Seventy-nine percent of the participants experienced moral distress attributable to end of life and medically futile care.
The consequences reported from moral distress on nurses include suffering, disappointment, sadness, helplessness, physical exhaustion, frustration, psychological exhaustion, anger, distress and depression. In addition, nurses described feelings of decreased job satisfaction and considered leaving their positions. Nurses repeatedly described providing a lower standard of care. However, 62% of the participants would not have changed their actions if faced with a similar situation. The authors advise that moral distress can be minimized, but not eliminated, and therefore nurses must learn from their previous experiences and take better care of themselves. Nurses’ previous experiences help them to be stronger and act better in future morally distressful situations. Findings also suggest that the experience of moral distress has the possibility to cause negative consequences not only on the nurse, but also on patient
outcomes.

This study has some limitations. First data were collected from a convenience sample of nurses from one university medical centre, thus limiting generalizability (Polit and Beck, 2010). This study is limited by a low response rate (23%) of nurses responding to the survey, therefore this study is less representative to the targeted population (Parahoo 2006), however, completing a written questionnaire may also have limited the response rate. Nurses may not have wanted to take the time needed to answer the questions.

The third study encompassed how moral distress impacted the participants’ psychological and social well-being. McClendon and Buckner (2007) conducted a study to describe critical care the effects of moral distress on nurses’ personal and professional lives. The study consisted of open-ended questions to elicit qualitatively the nurses' feelings about moral distress. n=37. 28% was the response rate . The questionnaires were then analysed to assess the nurses' opinions regarding moral distress, how their self-perceived job performance is affected.

Nurses feel that their personal lives are somewhat affected by distress in the workplace.
Some felt that they were short-tempered, grouchy, irritable, or ill with their family after a bad day at work. Others had a decreased level of patience with their family. One nurse felt that her life was greatly affected. Distress made her feel ‘‘disgusted’’ with her job. One nurse feels that the situations experienced at work can make one question one’s own beliefs and give new perspectives . Work performance is also felt to be negatively affected by distress. Some nurses experience burnout and lose focus of the task at hand. Others feel that they do not have enough time to complete tasks and have less time to care for the families. Others feel like they have a ‘‘short fuse’’ and less patience with the job; others feel ineffective, wondering why time is wasted treating someone who refuses care when others need help. Some nurses have difficulty concentrating and cry about situations, but then they put it behind them and look ahead. Overall moral distress has negative effects on critical care nurses personal and professional life. However, this study has a small sample size and lack of return of the questionnaires which introduce study bias (Polit and Beck,
2010).

Lastly, Elpern et al. (2005) conducted a descriptive, questionnaire study was used to explore the implications of moral distress, and evaluate associations among moral distress and individual characteristics of nurses. A total of 28 nurses working in a medical intensive care unit anonymously completed a 38-item moral distress scale and described implications of experiences of moral distress. Respondents were asked to describe the personal impact of morally distressing situations. Nurses reported that moral distress adversely affected job satisfaction, retention, psychological and physical well-being, self-image, and spirituality. Experience of moral distress also influenced attitudes toward advance directives and participation in blood donation and organ donation.

The limitations of this exploratory study must be considered in interpreting the results . The study involved a small sample of nurses from a single unit of a single medical center, and the findings may not be representative of the experiences of moral distress of critical care nurses in other settings (Polit and Beck, 2010). The clinical situations included in the moral distress instrument do not necessarily reflect the breadth of morally distressing circumstances, and scenarios that result in marked moral distress may have been missed. Finally, implications of experiences of moral distress were simply noted, and no information is available on the degree, significance, or pervasiveness of any of the implications reported.

In summary, the literature above has shown that moral distress is associated with several negative outcomes for critical care nurses. It affects nurses’ emotional, physical and psychosocial well-being and professional lives. However, implications of moral distress and how nurses cope with moral distress have been little explored. The next section discusses the literature surrounding potential coping strategies which may help nurses cope better with moral distress.