Moral distress is the psychological disequilibrium associated with knowing the ethical/appropriate action to take but being unable to take the action (Jameton, 1984). It is expected that all healthcare providers working in complex and constrained bureaucratic healthcare systems experience moral distress.
Moral courage is the willingness to take a difficult stance on a controversial issue (Corley, 2002). Moral residue is that which each of us carries with us from those times in our lives when in the face of moral distress we have seriously compromised ourselves or allowed ourselves to be compromised (Webster and Baylis, 2000).
Suffering for and with our patients is an integral dimension of caring. Clinicians commit to giving priority to serving others and subordination of self interest.
Our suffering is unjustified when it reaches a magnitude where the professional’s sense of identity and integrity is fractured and the well being of the person is threatened.
When arousal in response to another’s suffering is not regulated, it can give rise to personal distress (Eisenberg, et al., 1994), thereby undermining the possibility for expressing compassion. This can lead to a stress response and self-focused behaviors such as avoidance, abandonment, numbing aimed at relieving the distress.
The differing perspectives of nurses and physicians can lead to feelings of moral distress (Hamric, 2010). The physician’s focus is often on the “survival of the few”, while nurses focus on the “suffering of the many”. These value systems can lead to tension between the nurse and the physician as members of the healthcare team.
For clinicians of all levels of experience, inadequate coping with such stresses may lead to job dissatisfaction, burnout, isolation, and maladaptive behaviors. Personal reflection groups like Doctoring to Heal can be adapted for use in a variety of clinical settings. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1157069/
Managing Moral Distress with G.R.A.C.E© and the 4 “A’s”
G.R.A.C.E© (Joan Halifax, 2012)
Attuning to self and other
Considering what would really serve
Ethically enacting, ending
The Art of Pause
Anchor yourself in your breath, Pause, Be transparent, Monitor your mindset, Explore personal responses, Ask questions, Get clarification, Be open to new possibilities, Let go of outcome, Become a witness rather than an actor.
Bring into your awareness the memory of a patient that you were proud of your service and notice the sensations in your body as you recall this event
4A’s to resolve moral distress:
ASK: You may be unaware of the exact nature ofthe problem but are feeling distress. Ask: “Am I feeling distressed or showing signs of suffering? Is the source of my distress work related? Am I observing symptoms of distress within my team? Goal: You become aware that moral distress is present.
AFFIRM: Affirm your distress and your commitment to take care of yourself. Validate feelings and perceptions with others. Affirm professional obligation to act. Goal: You make a commitment to address moral distress.
ASSESS: Identify sources of your distress (Personal, Environment). Determine the severity of your distress. Contemplate your readiness to act. (You recognize there is an issue but may be ambivalent about taking action to change it. You analyze risks and benefits.) Goal: You are ready to make an action plan.
Prepare to Act: Prepare personally and professionally to take action. Take Action. Implement strategies to initiate the changes you desire. Maintain Desired Change. Anticipate and manage setbacks. Continue to implement the 4A’s to resolve moral distress. Goal: You preserve your integrity and authenticity.
Doctoring to Heal:
My body aches,
My thoughts scatter,
My back hurts,
My stomach aches.
When I'm asked how my mother is
I don't know.
I leave patients when they clearly need to talk.
I keep looking in the fridge.
I feel jittery.
I don't cry when it's sad.
I'm feeling all gummed-up.
I get angry with my cat.
I feel like I'm rattling around on a day off.
I don't know what to do.
I'm exhausted. I feel I can do nothing to right the balance.
I have let go of any semblance of a spiritual life.
I'm worried/anxious about what has been and what's next
Unable to be where I am.
I forget things
How might we create a healthy environment where nurses and other clinicians make their optimal contributions to patients and families?
It is one of the most beautiful compensations of this life that no man can sincerely try to help another without helping himself (Ralph Waldo Emerson)