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Common causes cited by nurses for not being able to fulfil their moral responsibility include a lack of confidence in the ability of colleagues, negative attitudes of colleagues towards patients and a team decision on care that does not follow the patients expressed wishes, or fear of reprisal resulting from the course of action they feel is best for the patient (Wojtowicz et al., 2014). For example, a nurse working in post-operative ward might experience a patient dying as the result of refusing a blood transfusion following surgery due to religious beliefs.
This study also showed that physicians and other healthcare professionals also rated these factors highly, but overall their scores were less than those of nurses. Moral distress, autonomy and nurse-physician collaboration among intensive care unit nurses in Italy.
The authors concluded that nurses are more likely to experience moral distress than other healthcare professionals, possibly due to a discrepancy between levels of responsibility for patient welfare and the required autonomy to make the decisions they believe should be made, as well as feelings of accepting treatment protocols from physicians which they feel are incorrect but unable to challenge or overrule.
Therefore nurses may better understand the thought processes involved, and be better equipped to identify unhelpful thinking patterns that may result from moral distress, thus limiting stress and avoiding the development of “burnout” (Stanley and Matchett, 2014; Severinsson, 2003). Moral distress: an emerging problem for nurses in long�? Quality in Ageing and Older Adults, 9 (2), p.39–48.
It has been shown by several studies that moral distress occurs less in institutions and teams where there is a healthy and positive attitude towards ethics and the discussion of the application of ethics (Whitehead et al., 2015).
When the patient died, the nurse may have experienced emotional and psychological distress in the form of guilt and anger that they had not saved a life that may have been possible to save, as well as feelings of helplessness that they could not overrule the patient’s wishes (Stanley and Matchett, 2014). Journal of Pediatric Oncology Nursing: Official Journal of the Association of Pediatric Oncology Nurses, 22 (1), p.48–57.
In 2015, Whitehead et al carried out a large scale questionnaire based study in the USA on moral distress amongst nurses and other healthcare professionals (592 participants, 395 of which were registered nurses). Poor team leadership and poor communication was also cited by nurses as a cause of moral distress (Whitehead et al., 2015). Moral distress appears to be more likely amongst nursing staff who are involved in patient care protocols that are considered to be aggressive and futile e.g. W., Drigo, E., Giannakopoulou, M., Kalafati, M., Mpouzika, M., Tsiaousis, G. For example, it is thought that nurses experiencing moral distress may self-blame or criticise themselves for an unsatisfactory outcome, and may experience emotions of anger, guilt, sadness or powerlessness (Fitzpatrick and Wallace, 2011; Borhani et al., 2014). They may shift blame onto others or exhibit avoidance behaviours such as taking time off for illness. However it is controversial whether or not this actually reduces moral distress, and of course raises questions about patient welfare with some suggesting that it is important that the nurse feels ethically responsible (Whitehead et al., 2015; Severinsson, 2003) and has a degree of emotional involvement in the situation in order to provide best possible care (Bryon et al., 2012; Linnard-Palmer and Kools, 2005; Severinsson, 2003). The majority of studies in this area recommend that moral distress should be included in the curriculum studied by student nurses, along with practical recommendations regarding measures that can be taken to deal with it as and when it occurs (Wojtowicz et al., 2014; Borhani et al., 2014; Matzo and Sherman, 2009; Stanley and Matchett, 2014; Whitehead et al., 2015), for example in the form of ethical philosophical discussion to facilitate students to explore their individual moral value systems and emotional responses, as well as be more informed regarding the underlying psychological processes involved. However, there are ways in which nurses and their management can prepare themselves to deal with these situations effectively, thus reducing the impact of the moral distress (Deady and Mc Carthy, 2010). Although it is important for nursing staff to be supported by their management, ultimately the nurse should be responsible for themselves and their own psychological wellbeing in order to prevent burnout from moral distress (Severinsson, 2003). The nurse’s personal judgement may be that the patient should receive the blood transfusion to give them the best chance of surviving the surgery. However, because the patient did not consent, the nurse could not carry out the action they perceived to be correct. Parents’ refusal of medical treatment for cultural or religious beliefs: an ethnographic study of health care professionals’ experiences.