The Phenomenon of Moral Distress in Nursing Practice

Background: Moral distress (MD) is one of the dimensions of ethical problems that have only recently been documented in the international literature. MD occurs when the nurse knows the morally appropriate decision but either fails to follow it or acts in a manner opposed to his(her) personal and professional values. Aim: Review of the factors associated with MD in nursing, its consequences and the ways of managing it. Method: The material of this systematic review was studies published in English related to moral distress in nursing staff. A systematic search of reviews and research studies was made in the electronic databases EBCOhost, Science Direct, SCOPUS and Wiley Online Library for the period 1995-2010, using the key-words: “Moral distress”, “nursing”, and “nursing care”. Results: The literature review showed that MD is a multifactorial phenomenon involving the ethical work environment of nurses. It stems from both internal and external factors that affect the applicability and application of moral judgments. The most common conditions causing this phenomenon are related to: (a) the inability of nurses to influence medical decisions related to futile treatment and inadequate pain management, (b) ignoring the wishes of the patient and insufficient provision of information, and (c) inadequate staffing or cooperation with inefficient colleagues. MD is a significant contributing factor to the emotional fatigue and burnout of nurses, and it has been associated with attrition from professional positions or the profession altogether, job dissatisfaction and alienation from patients and relatives. In an attempt to manage MD, nurses adopt a variety of passive or active forms of behaviour, but they report a lack of available resources or barriers to their use. Possible strategies for prevention and treatment include structural changes in the workplace, development and implementation of continuing education programmes in ethics and deontology, the establishment of ethics committees, efforts to improve workplace relationships, communication and cooperation, and the participation of nurses in clinical decision making. Enhancement of the moral integrity of nurses and promotion of ethical behaviour, with an emphasis on maintaining high standards of care, are also required. Conclusions: MD is a serious problem for nurses in clinical practice. The recognition and externalization of MD is a duty for both individual nurses and the nursing leadership. The implementation of specific policies on patient care and development, and protection of the moral role of nurses can help towards the prevention and alleviation of MD.