Nurses experience extreme ends of the emotion spectrum when doing their jobs, whether it’s overwhelming joy, exhausted relief, or excruciating sadness and frustration. There is no shortage of stories of exhaustion and resilience in the face of stress as a nurse, but for every devastating ending, there is also an inspirational hope found that makes it all worth it, in spite of the extreme demands of the job.
It’s not uncommon that nurses face distress during their day-to-day routines; distress can make a person feel afraid, overwhelmed, nervous, and can also cause physical symptoms like breathing issues, gastrointestinal upset, and more. Moral distress can lead to burn out, disengagement, lack of focus, and “hardening.”
Stress endured by nurses is often due to being in situations that others never encounter, from hard-to-handle family members of patients to end-of-life decisions, and from bullying by co-workers to heartbreaking patient deaths. Situations like these can turn into moral distress for nurses, and knowing how to deal with it is crucial. Patients put their very lives in the hands of nurses and depend on them to act in their best interest, no matter what. Fortunately, nurses are notorious for being courageous advocates for those they care for, and often come out as heroes to those people in the end. The courage of nurses changes lives, improves lives, and most importantly, it saves lives.
What is Moral Distress, Exactly?
One of the biggest causes of moral distress is when a nurse encounters something being done that triggers his or her ethical alarm, but “blowing the whistle” would come with personal risk. The distress appears when the nurse weighs the risk of disrupting his or her own well-being against the risk of disrupting the well-being of the patient.
Cynda Rushton, PhD, RN, FAAN at Johns Hopkins University Nursing states that “moral distress is a predictable response to situations where nurses recognize that there is a moral problem, have a responsibility to do something about it, but cannot act in a way that preserves their integrity.” And according to a well-known definition from Andrew Jameton, moral distress occurs when a nurse “knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.”
So basically, it happens when you know what the right thing to do is, but you’re afraid or feel powerless to do it.
This is when nurses have to dig deep and summon moral courage.
Moral Courage: Courage Despite Fear
Gaining and strengthening moral courage takes practice, and just because a nurse has it, doesn’t mean that nurse won’t experience moral distress. Having moral courage means speaking up and challenging unacceptable practices in spite of being in moral distress. According to a study published by the American Nurses Association, “even the most morally courageous staff may fear speaking up.”
While nurses every day face moral challenges like speaking out about lapses in patient care, medical errors, prescription errors, and the like, it’s done as part of the obligation of nurses as patient advocates. However, sometimes actions go above and beyond ordinary practice and become acts of moral courage that change everything.
Is Speaking Up Worth the Risk?
It’s a common question, and it’s one that only nurses can answer if and when a time comes to choose whether to challenge actions. Oftentimes, the answer will only become evident after the event and any resulting actions have occurred. This is where resilience comes in. According to the journal MedSurg Nursing, “Moral resilience is the ability to deal with an ethically adverse situation without lasting effects of moral distress. It requires morally courageous action, activating needed supports, and doing the right thing.”
Nurses must assess the risk and believe that the outcome of speaking out is worth it. Vicki Lachman, PhD, APRN, MBE, FAAN, a member of the American Nurses Association Center for Ethics and Human Rights Advisory Board explains, “If you saw someone break sterile technique and you don’t speak up , the risk is the patient having an infection. The risk is worth speaking up. She recommends nurses gain an understanding of the ANA’s Code of Ethics. The Code calls for nurses to act when a patient’s or nurse’s rights are violated through decisions made by others.
Vickilyn Gall, RN and Anne Mitchell, RN
Take, for example, the story of two Texas nurses who reported wrongful behavior by a local physician; Vickilyn Gall, RN and Anne Mitchell, RN wrote a letter of complaint to the Texas Medical Board in 2009. They alleged that Dr. Rolando Arafiles, Jr. would routinely write improper prescriptions and perform improper surgical procedures – including a failed skin graft surgery (he is not a surgeon). The nurses had previously voiced concerns to hospital management but felt that their concerns were not taken seriously.
The Texas Medical Board notified the doctor of the complaint anonymously, but in the tiny town of Kermit, with only 5,000 residents, it didn’t take long until the nurses were named and found themselves under arrest, facing a decade in jail. What were the charges? “Disseminating confidential information for a nongovernmental purpose with intent to harm Dr. Arafiles.”
Nurse Galle had her charges dropped, but the prosecution of Nurse Mitchell proceeded. Eventually, however, a jury found her not guilty after deliberating for less than an hour. The two nurses fought back with a lawsuit of their own, contending that they had endured malicious prosecution that violated their rights of free speech, as well as the state’s whistleblower laws.
The case settled out of court with monetary payment to both nurses. Their moral courage launched watchdog agencies and medical associations into action toward protecting those with an obligation to advocate for patients; in addition, their case prompted legislation empowering licensing agencies to impose fines up to $25,000 against license holders who retaliate against nurses who report abuses.
Irena Sendler was a nurse in Nazi-occupied Poland, although she started out as a social worker. She earned her nursing certifications in order to sneak food and medicines into the ghettos in Poland; these ghettos had been created by the Nazis and were designed to segregate Jews.
During her time working as a nurse in the ghettos, she successfully saved more than 2,500 children from almost certain death at the hands of the Nazis. She would medically sedate the children in order to help them stay quiet, and would sneak them out in toolboxes, potato sacks, and more. Working through a resistance network and with Christian orphanages, the children were given new identities and new lives, escaping the Holocaust, thanks to Nurse Sendler. Of course, she took a tremendous amount of risk with her own life each and every time she walked out with a child.
To her, the risk to her own well-being was worth it.
Eventually, Nurse Sendler was caught and imprisoned by the Nazis from 1948-1949. Once the war ended, she was freed, and lived the rest of her life in Warsaw. However, her days of moral courage didn’t end when the war did; she remained active with the Polish communist movement until her death.
In 2007, Nurse Sendler was nominated for a Nobel Peace Prize for risking her life as she defied the Nazis, but lost to Al Gore.
Strengthening Moral Courage and Resilience as a Nurse
The ANA has nine recommendations for nurses who want to develop and strengthen moral courage and resilience:
- Adopt ANA’s Healthy Nurse Healthy Nation strategies as a foundation for moral cultivation and general well-being.
- Review and implement the ANA Code of Ethics for Nurses to strengthen ethical competence.
- Pay attention to opportunities to recognize, analyze, and take ethical action in response to conflict.
- Cultivate self-awareness to respond to your own symptoms of moral distress and moral suffering.
- Pursue educational opportunities to cultivate mindfulness.
- Develop a personal plan to support your own well-being and strengthen moral resilience.
- Engage in workplace efforts to address causes of moral distress and moral suffering
- Develop skills in mindfulness, conflict transformation, communication, and interprofessional collaboration.
- Identify personal resources within your community or organizations like peer-to-peer support, counseling, and employee assistance programs – and use them.
The Scope of Moral Courage
Moral courage in nursing can be seen in the staff nurse who refuses to document patient care that was never provided, even when under administrative pressure to do so. It can be seen in the nurse who declines to engage in misconduct despite offers of a promotion. Moral courage is present when the teaching nurse refuses to pass students despite receiving threats to tenure.
Professional nursing organizations, including travel healthcare organizations, nursing agencies, and staffing firms, must encourage members to take actions when faced with stress, distress, and moral dilemmas – even when others differ in opinion or are silent. Scrubs Magazine proudly supports those nurses who routinely act in the best interests of their patients and exude moral courage for the sake of us all – despite the possible repercussions.
The healthcare industry needs leaders with strong ethical values, integrity, and moral courage, even when doing so comes with great risk.
“Stand up for what you believe, even if you stand alone.” – Anonymous