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Tuesday, January 29, 2008

Moral distress

"Recognizing moral distress is an important step toward resolution, yet many nurses are unaware of how it may be manifested. Examples from current literature along with vignettes from the author's experience are presented to illustrate the concept."

"Job satisfaction and moral distress. Bowles and Candela (2005) studied new nurses' perceptions of their job satisfaction. Nearly one-third of participants reported leaving their first nursing position within 1 year; 57% left by 2 years. When asked the reason for leaving their first job, nurses' answers predominantly fell into four theme areas: (a) patient care (acuity of patients, nurse-to-patient ratios, ability to provide safe care), (b) work environment (management issues, lack of support and guidance, too much responsibility), (c) location or nursing area move (moving to another area of nursing or physical relocation which included travel nurse positions), and (d) employment factors (salary, schedule, benefits). Participants felt the work was stressful, conditions were not conducive to safe patient care, staffing was inadequate, and there was not enough time to spend with patients. "Nurses do not speak of moral distress in terms of personal moral failure or inability to overcome in stitutional barriers. Nurses speak of anguish, sleeplessness, nausea, migraine headaches, gastrointestinal upset, tearfulness, a sense of isolation, or of knowing very early the immorality of a situation that others haven't grasped" (Hanna, 2004, p. 73)."

"Moral distress has recently been approved as a new nursing diagnosis and will be included in the 2007-2008 edition of Nursing Diagnoses: Definitions and Classi fication (L.M. Scroggins, personal communication, April 1, 2006). This will provide nurses a means to recognize and intervene with moral distress situations in their patients. For now, however, nurses often seem un aware of this experience in themselves. Feelings labeled as stress, burnout, emotional exhaustion, and job dissatisfaction may actually be symptomatic of moral distress. These symptoms may be the reason given by nurses for leaving a specific work environment or even for departure from the nursing profession (Elpern et al., 2005). As mentioned earlier, 15% of the nurses in one study reported resigning a position due to experiencing moral distress (Corley et al., 2001). Nearly 23% of nurses in another study plan to leave their current position within 1 year. When only nurses under 30 years of age are considered, this number increases to 33% (Aiken et al., 2001). The potential to influence the nursing shortage at an institutional level is clear. Facilities that identify and respond to the experience of moral distress could experience higher levels of staff satisfaction resulting in a decrease in staff turnover."

"Turnover of nursing staff is costly. Considering recruiting costs, training expenses, and termination costs, a Voluntary Hospital Asso ci a tion study by Kosel and Olivo (2002) counted the average cost to replace one medical/surgical nurse at $46,000. Replacing a specialty nurse such as a critical care nurse was estimated at $64,000. Adding additional personnel costs to cover the shortage created by turnover, costs increase to greater than $92,000 for a medical/surgical nurse and $145,000 for a specialty nurse (Hatcher et al., 2006). Though more difficult to quantify, turnover also impacts staff and patient satisfaction, quality of care, and patient outcomes. The Joint Commission on Accreditation of Healthcare Organi zations (2002) also recognizes the high cost of turnover, challenging nursing leaders to create a culture of retention for nursing staff."

"The AACN has issued a position statement recognizing moral distress as a serious, but often ignored problem in nursing. Nurses are individually challenged to recognize and name the experience of moral distress and to commit to addressing the issue. At an institutional level, employers are charged with establishing processes supportive of increasing recognition of moral distress and decreasing its occurrence in the workplace."

Author Information

Patricia S. Pendry, MSN, RN, CCRN-CSC, is a Team Leader, Surgical Intensive Care Unit, Lakeland Regional Medical Center, Lakeland, FL.

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