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Assignment Prompt & Instructions

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**files (5)**

– ## Moraldistress.pdf

– ## SU24.Recognizingaddressingmoraldistressquickreferenceguide.pdf

– Hamric.pdf
– Tigard.Thepositivevalueofmoraldistress.pdf
– Kerbache.MoralDistressinMedicine.pdf

**## Moraldistress.pdf**

Being the Ethical Nurse
Practitioner You Are Called to Be…

Moral
Integrity Values and Moral

Courage

SU24 MRM

Ethics and Morals
Objectives: Review Ethical and Moral Issues With Moral
Distress

Ethics
• the study of human behavior and actions that deal with human

conduct.
• Focuses on the rightness and wrongness of actions
• Seeks to identify human motives and ways of striving to meet

goals

Morals
• Beliefs about what are right or wrong ways to act
• These beliefs form guides to actions that individuals use to inform

their decision making and actions

Ethical Principles and Concepts

Ethical Dilemma

• Ethical dilemma refers to an ethical decision that
needs to be made and no choice seems totally
correct. This causes conflicts about what is the right
action to take.

• Some examples are:
• Two or more decisions seem correct, but only one

decision can be selected
• All decisions have a positive and a negative consequence
• All choices have negative consequences

Moral Distress
• Moral Distress refers to what happens to an individual

when that individual needs to make an Ethical
Decision and does so, but does not think this was
necessarily the correct action to take. Ex.: When
something is an “undiscussable” and nothing is said
or addressed.

“Undiscussables” Related to Three
Concerns

“Undiscussables” refer to what can not be mentioned or
discussed. Research has identified three concerns nurses
have about colleagues that need to be discussed but are
not.

• Concerns about dangerous shortcuts

• Concerns about incompetence

• Concerns about disrespect

Silent Treatment 2011

Moral Residue

• Moral Residue refers to the thoughts and feelings a
person has after making an Ethical Decision and
whenever this is thought about the individual feels
that this decision and action was not correct.

• Lingering thoughts make it difficult for the
individual to be at peace and causes stress.

Professional Issue That Caused You
Stress and Maybe Internal Conflict

What Helps
• Being surrounded by professionals with the moral

courage to speak up.
• An ethical climate in the organization that supports

discussions about taking steps to address concerns.
• Telling success stories about preventing errors or about

addressing needs for improvement and rewarding
effective communication.

• Supporting professionals in practice who speak up and
not making them feel isolated but making them feel
heard.

• Addressing practice issues that could cause moral
distress.

Silent Treatment 2011

Assignment #1
Discussion Board Post: Moral Distress and Moral
Residue
Instructions: See Syllabus, Appendix B for complete
instructions

• Think of an example from your professional life that
caused you moral distress and/or moral residue.

• Write a brief reflection (no more than 1-2 pages double-
spaced) about what this was about and why this caused
you distress.

• What ethical principles were involved?

• Could there have been other ways to professionally
handle this?

Considerations for your post and
discussion responses

• How can you address the “undiscussables” in your
practice setting?

• How can you avoid situations in the future that will
lead to moral distress or moral residue?

• How can you prepare yourself and others to be able
to use moral courage to deal with situations that
could lead to moral distress?

References/ Resources
Beauchamp, T. & Childress, J. (2013). Principles of
biomedical ethics. (7th ed). Oxford Press.

Dissertation from Loyola Vincensi, B. (2011). Spiritual
care in advanced practice nursing. Dissertations. Paper
201. http://ecommons.luc.edu/luc_diss/201

Grace, P. (2014). Nursing ethics and professional
responsibility in advanced practice (2nd ed). Jones and
Bartlett.
Maxfield, D., Grenny J., Lavandero, R., & Groah, L.
(Sept/Oct.2011). The Silent Treatment: Why Safety Tools
and Checklists Aren’t Enough. PSQH, Retrieved from
http://psqh.com/the-silent-treatment-why-safety- tools-
and-checklists-aren’t-enough

Thank you for following your calling
to prepare yourself to be a
Nursing Leader

**## SU24.Recognizingaddressingmoraldistressquickreferenceguide.pdf**

RECOGNIZE & ADDRESS

Moral Distress
�is tool is intended to help nurses recognize and mitigate moral distress, a painful problem that
occurs all too often in ethically complex environments such as acute and critical care units, and is
distinct from burnout and compassion fatigue.

Recognizing the symptoms, causes and constraints associated with moral distress is the first step.
Developing strategies to address moral distress and build resilience is next, bringing new meaning
to the essential work we do and helping us make our optimal contribution to patient care.

001008 • Rev 07/20

N

W

S

E

BurnoutMoral Distress Compassion
Fatigue

Identify What You Are Experiencing

Physical, mental and
emotional weariness
related to caring for those
in significant pain or
emotional distress.

See Resources section for
more information.

When one knows the right
thing to do, but constraints,
conflict, dilemmas or
uncertainty make it nearly
impossible to pursue the
right course of action.

Physical, mental and
emotional exhaustion
caused by workplace stress
leading to disengagement
and depersonalization.

See Resources section for
more information.

In managing distress, it is important to identify specifically what type of distress
you are feeling. �e following three syndromes both present and are addressed di�erently.

1

N

W

S

E

Assess Your Level of Moral Distress

Use the thermometer to rate the severity of your moral
distress from one to 10, and note the accompanying
description. Use the result to prioritize actions you will take
to mitigate your distress and identify changes over time.

Moral distress symptoms vary and may include:

�e moral distress thermometer is adapted with permission. See
last page for full attribution.

• Frustration
• Anger
• Anxiety
• Guilt

• Sadness
• Powerlessness
• Withdrawal

• Muscle aches
• Headaches
• Heart palpitations

• Depression
• Emotional

exhaustion
• Loss of self-worth
• Nightmares

• Decreasing
job satisfaction

• Depersonalization
of patients

• Neck pain
• Diarrhea
• Vomiting

PS
YC

HOLOGICAL

0 None

1

2 Mild

3

4 Uncomfortable

5

6 Distressing

7

8 Intense

9

10 Worst Possible

2

EM
OTIONAL

PH

YSICAL

Specific situations trigger moral distress. Typically, there is a defining element that constrains or stops you from acting.
�is constraint may be related to internal or external factors (such as work environment or organizational pressures).

Identify Causes & Constraints3

Organization

• Performing care perceived
as futile

• Implementing
unnecessary treatments

• Providing end-of-life care
• Witnessing needless patient

su�ering/inadequate
pain relief

• Providing false hope
to patients

• Inadequate sta�ng
• Ine�ective communication
• Working with

incompetent colleague(s)
• Bullying
• Lack of a healthy

work environment

• Inadequate sta�ng
• Lack of resources
• Pressures to decrease costs
• Hospital policies
• Hierarchy of power
• Ine�ective communication
• Financial limitations

UnitSelf

Select Resources �at Can Help4

OrganizationUnitSelf

• Recognize symptoms of distress
• Tell a trusted colleague about

your concern
• Fact-check — gather relevant

information
• Connect with others for

validation and support
• Identify involved parties who

can help
• Participate in professional

development, such as palliative
care or ethics education

• Seek help from clinical leaders
and/or an employee assistance
program

• Pause after every patient death
• Conduct resilience rounds
• Create a mentoring program

for new sta�
• Identify ethics champions for

peer support
• Use a tool, such as the

thermometer graphic, to gauge
distress among unit sta�

• Recognize situations that
frequently cause distress

• Establish a committee to address
common sources of distress

• Use AACN’s Healthy Work
Environment Assessment Tool

• Promote actions that improve
the work environment, such as
implementing AACN’s Healthy
Work Environment standards

• O�er resources to support
healthcare teams, e.g., palliative
care, moral distress or ethics
consultation services

• Provide training on critical
debrie�ng, resilience and
skilled communication

• Adopt zero-tolerance policies
on bullying and violence

• Build programs that promote
the well-being of the entire
healthcare team

Choose strategies to address moral distress based on the type of constraint. Solutions may be
actions nurses can take individually, contribute to as part of a unit or escalate to organization leaders.

Moral Distress Support at My Facility5
Use this worksheet to identify Moral Distress resources

and strategies available to you at your workplace.

My OrganizationMy UnitMyself

Enhancing Nurse Well-Being
• ANA Enterprise. �e Well-being Initiative. Accessed

May 20, 2020. https://www.nursingworld.org/practice-
policy/work-environment/health-safety/disaster-
preparedness/coronavirus/what-you-need-to-know/the-
well-being-initiative/

• Barron B, Cusack C, Lux L, Patterson V. Creating Resiliency and
Improving Retention Among Nurses. Updated December 6,
2019. Accessed May 20, 2020. https://www.aacn.org/clinical-
resources/csi-projects/creating-resiliency-and-improving-
retention-among-nurses

Understanding Moral Distress
• Forozeiya D, Vanderspank-Wright B, Bourbonnais FF,

Moreau D, Wright DK. Coping with moral distress –
�e experiences of intensive care nurses: An interpretive
descriptive study. Intensive Crit Care Nurs. 2019;53:23–29.
https://doi.org/10.1016/j.iccn.2019.03.002

• Dudzinski DM. Navigating moral distress using the moral
distress map. J Med Ethics. 2016;42(5):321–324.
https://doi.org/10.1136/medethics-2015-103156

• Pavlish CL, Brown-Saltzman K, Raho JA, Chen B. A national
survey on moral obligations in critical care. Am J Crit Care.
2019;2(3):183–192. https://doi.org/10.4037/ajcc2019512

Understanding Moral Distress (cont.)
• Ulrich C, Grady C, eds. Moral Distress in the Health Professions.

Springer; 2018. ISBN-13: 978-3319646251.
• University of Kentucky Program for Bioethics. �e Moral

Distress Education Project. Accessed May 20, 2020.
https://moraldistressproject.med.uky.edu/moral-distress-home

• Vincent H, Jones DJ, Engebretson J. Moral distress
perspectives among interprofessional intensive care unit
team members [published online May 14, 2020]. Nurs Ethics.
https://doi.org/10.1177/0969733020916747

• Deschenes S, Gagnon M, Park T, Kunyk D. Moral distress:
A concept clarification [published online April 6, 2020].
Nurs Ethics. https://doi.org/10.1177/0969733020909523

Mitigating Moral Distress
• Hamric AB, Epstein EG. A health system-wide moral distress

consultation service: development and evaluation. HEC Forum.
2017;29(2):127–143. https://doi.org/10.1007/s10730-016-9315-y

• Rushton C, Schoonover-Sho�ner K, Kennedy MS.
Executive summary: transforming moral distress into moral
resilience in nursing. Am J Nurs. 2017;117(2):52–56.
https://doi.org/10.1097/01.NAJ.0000512298.18641.31

Moral Distress Resources

Explore these resources to learn more about recognizing and addressing Moral Distress.

Mitigating Moral Distress (cont.)
• American Association of Critical-Care Nurses. AACN

Standards for Establishing and Sustaining Healthy Work
Environments: A Journey to Excellence. Accessed May 20,
2020. https://www.aacn.org/nursing-excellence/healthy-
work-environments

• Wolf AT, White KT, Epstein EG, Enfield KB. Palliative
care and moral distress: An institutional survey of
critical care nurses. Crit Care Nurse. 2019;39(5):38–49.
https://doi.org/10.4037/ccn2019645

• Wocial LD, Weaver MT. Development and psychometric
testing of a new tool for detecting moral distress: �e moral
distress thermometer. J Adv Nurs. 2013;69(1):167–174.
https://doi.org/10.1111/j.1365-2648.2012.06036.x

• Pavlish CL, Henriksen J, Brown-Saltzman K, et al.
A team-based early action protocol to address ethical
concerns in the intensive care unit. Am J Crit Care.
2020;29(1):49–61. https://doi.org/10.4037/ajcc2020915

Burnout
• National Academy of Medicine. Sharing Knowledge to

Combat Clinician Burnout. Accessed May 20, 2020.
https://nam.edu/clinicianwellbeing/

• Bancroft H, Guidry B, Rodrigue C, Rouyer H, Wilson N.
Blow Out Burnout: Decreasing Turnover, Increasing Self-Care.
Updated March 5, 2020. Accessed May 20, 2020.
https://www.aacn.org/clinical-resources/csi-projects/blow-out-
burnout-decreasing-turnover-increasing-self-care

Compassion Fatigue
• Burger C. Understand & Overcome Your Compassion

Fatigue: An Online Guide. Accessed May 20, 2020.
https://www.edumed.org/resources/compassion-fatigue-
online-guide/

Moral Distress Resources (cont.)

�e moral distress thermometer on page three is adapted with permission. �e moral distress thermometer is the result of research works authored by
Lucia Wocial, PhD, RN and Dr. Michael Weaver at the Indiana University School of Nursing, with graphics and associated software developed
by Robert ‘Skip’ Comer, research associate at the Indiana University-Purdue University Indianapolis School of Informatics and Computing.

**Hamric.pdf**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/hamric-pdf)

**Tigard.Thepositivevalueofmoraldistress.pdf**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/tigard-thepositivevalueofmoraldistress-pdf)

**Kerbache.MoralDistressinMedicine.pdf**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/kerbache-moraldistressinmedicine-pdf)

**Kerbache.MoralDistressinMedicine.pdf**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/kerbache-moraldistressinmedicine-pdf)

**## Moraldistress.pdf**

Being the Ethical Nurse
Practitioner You Are Called to Be…

Moral
Integrity Values and Moral

Courage

SU24 MRM

Ethics and Morals
Objectives: Review Ethical and Moral Issues With Moral
Distress

Ethics
• the study of human behavior and actions that deal with human

conduct.
• Focuses on the rightness and wrongness of actions
• Seeks to identify human motives and ways of striving to meet

goals

Morals
• Beliefs about what are right or wrong ways to act
• These beliefs form guides to actions that individuals use to inform

their decision making and actions

Ethical Principles and Concepts

Ethical Dilemma

• Ethical dilemma refers to an ethical decision that
needs to be made and no choice seems totally
correct. This causes conflicts about what is the right
action to take.

• Some examples are:
• Two or more decisions seem correct, but only one

decision can be selected
• All decisions have a positive and a negative consequence
• All choices have negative consequences

Moral Distress
• Moral Distress refers to what happens to an individual

when that individual needs to make an Ethical
Decision and does so, but does not think this was
necessarily the correct action to take. Ex.: When
something is an “undiscussable” and nothing is said
or addressed.

“Undiscussables” Related to Three
Concerns

“Undiscussables” refer to what can not be mentioned or
discussed. Research has identified three concerns nurses
have about colleagues that need to be discussed but are
not.

• Concerns about dangerous shortcuts

• Concerns about incompetence

• Concerns about disrespect

Silent Treatment 2011

Moral Residue

• Moral Residue refers to the thoughts and feelings a
person has after making an Ethical Decision and
whenever this is thought about the individual feels
that this decision and action was not correct.

• Lingering thoughts make it difficult for the
individual to be at peace and causes stress.

Professional Issue That Caused You
Stress and Maybe Internal Conflict

What Helps
• Being surrounded by professionals with the moral

courage to speak up.
• An ethical climate in the organization that supports

discussions about taking steps to address concerns.
• Telling success stories about preventing errors or about

addressing needs for improvement and rewarding
effective communication.

• Supporting professionals in practice who speak up and
not making them feel isolated but making them feel
heard.

• Addressing practice issues that could cause moral
distress.

Silent Treatment 2011

Assignment #1
Discussion Board Post: Moral Distress and Moral
Residue
Instructions: See Syllabus, Appendix B for complete
instructions

• Think of an example from your professional life that
caused you moral distress and/or moral residue.

• Write a brief reflection (no more than 1-2 pages double-
spaced) about what this was about and why this caused
you distress.

• What ethical principles were involved?

• Could there have been other ways to professionally
handle this?

Considerations for your post and
discussion responses

• How can you address the “undiscussables” in your
practice setting?

• How can you avoid situations in the future that will
lead to moral distress or moral residue?

• How can you prepare yourself and others to be able
to use moral courage to deal with situations that
could lead to moral distress?

References/ Resources
Beauchamp, T. & Childress, J. (2013). Principles of
biomedical ethics. (7th ed). Oxford Press.

Dissertation from Loyola Vincensi, B. (2011). Spiritual
care in advanced practice nursing. Dissertations. Paper
201. http://ecommons.luc.edu/luc_diss/201

Grace, P. (2014). Nursing ethics and professional
responsibility in advanced practice (2nd ed). Jones and
Bartlett.
Maxfield, D., Grenny J., Lavandero, R., & Groah, L.
(Sept/Oct.2011). The Silent Treatment: Why Safety Tools
and Checklists Aren’t Enough. PSQH, Retrieved from
http://psqh.com/the-silent-treatment-why-safety- tools-
and-checklists-aren’t-enough

Thank you for following your calling
to prepare yourself to be a
Nursing Leader

**## SU24.Recognizingaddressingmoraldistressquickreferenceguide.pdf**

RECOGNIZE & ADDRESS

Moral Distress
�is tool is intended to help nurses recognize and mitigate moral distress, a painful problem that
occurs all too often in ethically complex environments such as acute and critical care units, and is
distinct from burnout and compassion fatigue.

Recognizing the symptoms, causes and constraints associated with moral distress is the first step.
Developing strategies to address moral distress and build resilience is next, bringing new meaning
to the essential work we do and helping us make our optimal contribution to patient care.

001008 • Rev 07/20

N

W

S

E

BurnoutMoral Distress Compassion
Fatigue

Identify What You Are Experiencing

Physical, mental and
emotional weariness
related to caring for those
in significant pain or
emotional distress.

See Resources section for
more information.

When one knows the right
thing to do, but constraints,
conflict, dilemmas or
uncertainty make it nearly
impossible to pursue the
right course of action.

Physical, mental and
emotional exhaustion
caused by workplace stress
leading to disengagement
and depersonalization.

See Resources section for
more information.

In managing distress, it is important to identify specifically what type of distress
you are feeling. �e following three syndromes both present and are addressed di�erently.

1

N

W

S

E

Assess Your Level of Moral Distress

Use the thermometer to rate the severity of your moral
distress from one to 10, and note the accompanying
description. Use the result to prioritize actions you will take
to mitigate your distress and identify changes over time.

Moral distress symptoms vary and may include:

�e moral distress thermometer is adapted with permission. See
last page for full attribution.

• Frustration
• Anger
• Anxiety
• Guilt

• Sadness
• Powerlessness
• Withdrawal

• Muscle aches
• Headaches
• Heart palpitations

• Depression
• Emotional

exhaustion
• Loss of self-worth
• Nightmares

• Decreasing
job satisfaction

• Depersonalization
of patients

• Neck pain
• Diarrhea
• Vomiting

PS
YC

HOLOGICAL

0 None

1

2 Mild

3

4 Uncomfortable

5

6 Distressing

7

8 Intense

9

10 Worst Possible

2

EM
OTIONAL

PH

YSICAL

Specific situations trigger moral distress. Typically, there is a defining element that constrains or stops you from acting.
�is constraint may be related to internal or external factors (such as work environment or organizational pressures).

Identify Causes & Constraints3

Organization

• Performing care perceived
as futile

• Implementing
unnecessary treatments

• Providing end-of-life care
• Witnessing needless patient

su�ering/inadequate
pain relief

• Providing false hope
to patients

• Inadequate sta�ng
• Ine�ective communication
• Working with

incompetent colleague(s)
• Bullying
• Lack of a healthy

work environment

• Inadequate sta�ng
• Lack of resources
• Pressures to decrease costs
• Hospital policies
• Hierarchy of power
• Ine�ective communication
• Financial limitations

UnitSelf

Select Resources �at Can Help4

OrganizationUnitSelf

• Recognize symptoms of distress
• Tell a trusted colleague about

your concern
• Fact-check — gather relevant

information
• Connect with others for

validation and support
• Identify involved parties who

can help
• Participate in professional

development, such as palliative
care or ethics education

• Seek help from clinical leaders
and/or an employee assistance
program

• Pause after every patient death
• Conduct resilience rounds
• Create a mentoring program

for new sta�
• Identify ethics champions for

peer support
• Use a tool, such as the

thermometer graphic, to gauge
distress among unit sta�

• Recognize situations that
frequently cause distress

• Establish a committee to address
common sources of distress

• Use AACN’s Healthy Work
Environment Assessment Tool

• Promote actions that improve
the work environment, such as
implementing AACN’s Healthy
Work Environment standards

• O�er resources to support
healthcare teams, e.g., palliative
care, moral distress or ethics
consultation services

• Provide training on critical
debrie�ng, resilience and
skilled communication

• Adopt zero-tolerance policies
on bullying and violence

• Build programs that promote
the well-being of the entire
healthcare team

Choose strategies to address moral distress based on the type of constraint. Solutions may be
actions nurses can take individually, contribute to as part of a unit or escalate to organization leaders.

Moral Distress Support at My Facility5
Use this worksheet to identify Moral Distress resources

and strategies available to you at your workplace.

My OrganizationMy UnitMyself

Enhancing Nurse Well-Being
• ANA Enterprise. �e Well-being Initiative. Accessed

May 20, 2020. https://www.nursingworld.org/practice-
policy/work-environment/health-safety/disaster-
preparedness/coronavirus/what-you-need-to-know/the-
well-being-initiative/

• Barron B, Cusack C, Lux L, Patterson V. Creating Resiliency and
Improving Retention Among Nurses. Updated December 6,
2019. Accessed May 20, 2020. https://www.aacn.org/clinical-
resources/csi-projects/creating-resiliency-and-improving-
retention-among-nurses

Understanding Moral Distress
• Forozeiya D, Vanderspank-Wright B, Bourbonnais FF,

Moreau D, Wright DK. Coping with moral distress –
�e experiences of intensive care nurses: An interpretive
descriptive study. Intensive Crit Care Nurs. 2019;53:23–29.
https://doi.org/10.1016/j.iccn.2019.03.002

• Dudzinski DM. Navigating moral distress using the moral
distress map. J Med Ethics. 2016;42(5):321–324.
https://doi.org/10.1136/medethics-2015-103156

• Pavlish CL, Brown-Saltzman K, Raho JA, Chen B. A national
survey on moral obligations in critical care. Am J Crit Care.
2019;2(3):183–192. https://doi.org/10.4037/ajcc2019512

Understanding Moral Distress (cont.)
• Ulrich C, Grady C, eds. Moral Distress in the Health Professions.

Springer; 2018. ISBN-13: 978-3319646251.
• University of Kentucky Program for Bioethics. �e Moral

Distress Education Project. Accessed May 20, 2020.
https://moraldistressproject.med.uky.edu/moral-distress-home

• Vincent H, Jones DJ, Engebretson J. Moral distress
perspectives among interprofessional intensive care unit
team members [published online May 14, 2020]. Nurs Ethics.
https://doi.org/10.1177/0969733020916747

• Deschenes S, Gagnon M, Park T, Kunyk D. Moral distress:
A concept clarification [published online April 6, 2020].
Nurs Ethics. https://doi.org/10.1177/0969733020909523

Mitigating Moral Distress
• Hamric AB, Epstein EG. A health system-wide moral distress

consultation service: development and evaluation. HEC Forum.
2017;29(2):127–143. https://doi.org/10.1007/s10730-016-9315-y

• Rushton C, Schoonover-Sho�ner K, Kennedy MS.
Executive summary: transforming moral distress into moral
resilience in nursing. Am J Nurs. 2017;117(2):52–56.
https://doi.org/10.1097/01.NAJ.0000512298.18641.31

Moral Distress Resources

Explore these resources to learn more about recognizing and addressing Moral Distress.

Mitigating Moral Distress (cont.)
• American Association of Critical-Care Nurses. AACN

Standards for Establishing and Sustaining Healthy Work
Environments: A Journey to Excellence. Accessed May 20,
2020. https://www.aacn.org/nursing-excellence/healthy-
work-environments

• Wolf AT, White KT, Epstein EG, Enfield KB. Palliative
care and moral distress: An institutional survey of
critical care nurses. Crit Care Nurse. 2019;39(5):38–49.
https://doi.org/10.4037/ccn2019645

• Wocial LD, Weaver MT. Development and psychometric
testing of a new tool for detecting moral distress: �e moral
distress thermometer. J Adv Nurs. 2013;69(1):167–174.
https://doi.org/10.1111/j.1365-2648.2012.06036.x

• Pavlish CL, Henriksen J, Brown-Saltzman K, et al.
A team-based early action protocol to address ethical
concerns in the intensive care unit. Am J Crit Care.
2020;29(1):49–61. https://doi.org/10.4037/ajcc2020915

Burnout
• National Academy of Medicine. Sharing Knowledge to

Combat Clinician Burnout. Accessed May 20, 2020.
https://nam.edu/clinicianwellbeing/

• Bancroft H, Guidry B, Rodrigue C, Rouyer H, Wilson N.
Blow Out Burnout: Decreasing Turnover, Increasing Self-Care.
Updated March 5, 2020. Accessed May 20, 2020.
https://www.aacn.org/clinical-resources/csi-projects/blow-out-
burnout-decreasing-turnover-increasing-self-care

Compassion Fatigue
• Burger C. Understand & Overcome Your Compassion

Fatigue: An Online Guide. Accessed May 20, 2020.
https://www.edumed.org/resources/compassion-fatigue-
online-guide/

Moral Distress Resources (cont.)

�e moral distress thermometer on page three is adapted with permission. �e moral distress thermometer is the result of research works authored by
Lucia Wocial, PhD, RN and Dr. Michael Weaver at the Indiana University School of Nursing, with graphics and associated software developed
by Robert ‘Skip’ Comer, research associate at the Indiana University-Purdue University Indianapolis School of Informatics and Computing.

**Hamric.pdf**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/hamric-pdf)

**Tigard.Thepositivevalueofmoraldistress.pdf**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/tigard-thepositivevalueofmoraldistress-pdf)

**Kerbache.MoralDistressinMedicine.pdf**

This file is too large to display. [View in new window](https://www.sweetstudy.com/files/kerbache-moraldistressinmedicine-pdf)

**## Moraldistress.pdf**

Being the Ethical Nurse
Practitioner You Are Called to Be…

Moral
Integrity Values and Moral

Courage

SU24 MRM

Ethics and Morals
Objectives: Review Ethical and Moral Issues With Moral
Distress

Ethics
• the study of human behavior and actions that deal with human

conduct.
• Focuses on the rightness and wrongness of actions
• Seeks to identify human motives and ways of striving to meet

goals

Morals
• Beliefs about what are right or wrong ways to act
• These beliefs form guides to actions that individuals use to inform

their decision making and actions

Ethical Principles and Concepts

Ethical Dilemma

• Ethical dilemma refers to an ethical decision that
needs to be made and no choice seems totally
correct. This causes conflicts about what is the right
action to take.

• Some examples are:
• Two or more decisions seem correct, but only one

decision can be selected
• All decisions have a positive and a negative consequence
• All choices have negative consequences

Moral Distress
• Moral Distress refers to what happens to an individual

when that individual needs to make an Ethical
Decision and does so, but does not think this was
necessarily the correct action to take. Ex.: When
something is an “undiscussable” and nothing is said
or addressed.

“Undiscussables” Related to Three
Concerns

“Undiscussables” refer to what can not be mentioned or
discussed. Research has identified three concerns nurses
have about colleagues that need to be discussed but are
not.

• Concerns about dangerous shortcuts

• Concerns about incompetence

• Concerns about disrespect

Silent Treatment 2011

Moral Residue

• Moral Residue refers to the thoughts and feelings a
person has after making an Ethical Decision and
whenever this is thought about the individual feels
that this decision and action was not correct.

• Lingering thoughts make it difficult for the
individual to be at peace and causes stress.

Professional Issue That Caused You
Stress and Maybe Internal Conflict

What Helps
• Being surrounded by professionals with the moral

courage to speak up.
• An ethical climate in the organization that supports

discussions about taking steps to address concerns.
• Telling success stories about preventing errors or about

addressing needs for improvement and rewarding
effective communication.

• Supporting professionals in practice who speak up and
not making them feel isolated but making them feel
heard.

• Addressing practice issues that could cause moral
distress.

Silent Treatment 2011

Assignment #1
Discussion Board Post: Moral Distress and Moral
Residue
Instructions: See Syllabus, Appendix B for complete
instructions

• Think of an example from your professional life that
caused you moral distress and/or moral residue.

• Write a brief reflection (no more than 1-2 pages double-
spaced) about what this was about and why this caused
you distress.

• What ethical principles were involved?

• Could there have been other ways to professionally
handle this?

Considerations for your post and
discussion responses

• How can you address the “undiscussables” in your
practice setting?

• How can you avoid situations in the future that will
lead to moral distress or moral residue?

• How can you prepare yourself and others to be able
to use moral courage to deal with situations that
could lead to moral distress?

References/ Resources
Beauchamp, T. & Childress, J. (2013). Principles of
biomedical ethics. (7th ed). Oxford Press.

Dissertation from Loyola Vincensi, B. (2011). Spiritual
care in advanced practice nursing. Dissertations. Paper
201. http://ecommons.luc.edu/luc_diss/201

Grace, P. (2014). Nursing ethics and professional
responsibility in advanced practice (2nd ed). Jones and
Bartlett.
Maxfield, D., Grenny J., Lavandero, R., & Groah, L.
(Sept/Oct.2011). The Silent Treatment: Why Safety Tools
and Checklists Aren’t Enough. PSQH, Retrieved from
http://psqh.com/the-silent-treatment-why-safety- tools-
and-checklists-aren’t-enough

Thank you for following your calling
to prepare yourself to be a
Nursing Leader

**## SU24.Recognizingaddressingmoraldistressquickreferenceguide.pdf**

RECOGNIZE & ADDRESS

Moral Distress
�is tool is intended to help nurses recognize and mitigate moral distress, a painful problem that
occurs all too often in ethically complex environments such as acute and critical care units, and is
distinct from burnout and compassion fatigue.

Recognizing the symptoms, causes and constraints associated with moral distress is the first step.
Developing strategies to address moral distress and build resilience is next, bringing new meaning
to the essential work we do and helping us make our optimal contribution to patient care.

001008 • Rev 07/20

N

W

S

E

BurnoutMoral Distress Compassion
Fatigue

Identify What You Are Experiencing

Physical, mental and
emotional weariness
related to caring for those
in significant pain or
emotional distress.

See Resources section for
more information.

When one knows the right
thing to do, but constraints,
conflict, dilemmas or
uncertainty make it nearly
impossible to pursue the
right course of action.

Physical, mental and
emotional exhaustion
caused by workplace stress
leading to disengagement
and depersonalization.

See Resources section for
more information.

In managing distress, it is important to identify specifically what type of distress
you are feeling. �e following three syndromes both present and are addressed di�erently.

1

N

W

S

E

Assess Your Level of Moral Distress

Use the thermometer to rate the severity of your moral
distress from one to 10, and note the accompanying
description. Use the result to prioritize actions you will take
to mitigate your distress and identify changes over time.

Moral distress symptoms vary and may include:

�e moral distress thermometer is adapted with permission. See
last page for full attribution.

• Frustration
• Anger
• Anxiety
• Guilt

• Sadness
• Powerlessness
• Withdrawal

• Muscle aches
• Headaches
• Heart palpitations

• Depression
• Emotional

exhaustion
• Loss of self-worth
• Nightmares

• Decreasing
job satisfaction

• Depersonalization
of patients

• Neck pain
• Diarrhea
• Vomiting

PS
YC

HOLOGICAL

0 None

1

2 Mild

3

4 Uncomfortable

5

6 Distressing

7

8 Intense

9

10 Worst Possible

2

EM
OTIONAL

PH

YSICAL

Specific situations trigger moral distress. Typically, there is a defining element that constrains or stops you from acting.
�is constraint may be related to internal or external factors (such as work environment or organizational pressures).

Identify Causes & Constraints3

Organization

• Performing care perceived
as futile

• Implementing
unnecessary treatments

• Providing end-of-life care
• Witnessing needless patient

su�ering/inadequate
pain relief

• Providing false hope
to patients

• Inadequate sta�ng
• Ine�ective communication
• Working with

incompetent colleague(s)
• Bullying
• Lack of a healthy

work environment

• Inadequate sta�ng
• Lack of resources
• Pressures to decrease costs
• Hospital policies
• Hierarchy of power
• Ine�ective communication
• Financial limitations

UnitSelf

Select Resources �at Can Help4

OrganizationUnitSelf

• Recognize symptoms of distress
• Tell a trusted colleague about

your concern
• Fact-check — gather relevant

information
• Connect with others for

validation and support
• Identify involved parties who

can help
• Participate in professional

development, such as palliative
care or ethics education

• Seek help from clinical leaders
and/or an employee assistance
program

• Pause after every patient death
• Conduct resilience rounds
• Create a mentoring program

for new sta�
• Identify ethics champions for

peer support
• Use a tool, such as the

thermometer graphic, to gauge
distress among unit sta�

• Recognize situations that
frequently cause distress

• Establish a committee to address
common sources of distress

• Use AACN’s Healthy Work
Environment Assessment Tool

• Promote actions that improve
the work environment, such as
implementing AACN’s Healthy
Work Environment standards

• O�er resources to support
healthcare teams, e.g., palliative
care, moral distress or ethics
consultation services

• Provide training on critical
debrie�ng, resilience and
skilled communication

• Adopt zero-tolerance policies
on bullying and violence

• Build programs that promote
the well-being of the entire
healthcare team

Choose strategies to address moral distress based on the type of constraint. Solutions may be
actions nurses can take individually, contribute to as part of a unit or escalate to organization leaders.

Moral Distress Support at My Facility5
Use this worksheet to identify Moral Distress resources

and strategies available to you at your workplace.

My OrganizationMy UnitMyself

Enhancing Nurse Well-Being
• ANA Enterprise. �e Well-being Initiative. Accessed

May 20, 2020. https://www.nursingworld.org/practice-
policy/work-environment/health-safety/disaster-
preparedness/coronavirus/what-you-need-to-know/the-
well-being-initiative/

• Barron B, Cusack C, Lux L, Patterson V. Creating Resiliency and
Improving Retention Among Nurses. Updated December 6,
2019. Accessed May 20, 2020. https://www.aacn.org/clinical-
resources/csi-projects/creating-resiliency-and-improving-
retention-among-nurses

Understanding Moral Distress
• Forozeiya D, Vanderspank-Wright B, Bourbonnais FF,

Moreau D, Wright DK. Coping with moral distress –
�e experiences of intensive care nurses: An interpretive
descriptive study. Intensive Crit Care Nurs. 2019;53:23–29.
https://doi.org/10.1016/j.iccn.2019.03.002

• Dudzinski DM. Navigating moral distress using the moral
distress map. J Med Ethics. 2016;42(5):321–324.
https://doi.org/10.1136/medethics-2015-103156

• Pavlish CL, Brown-Saltzman K, Raho JA, Chen B. A national
survey on moral obligations in critical care. Am J Crit Care.
2019;2(3):183–192. https://doi.org/10.4037/ajcc2019512

Understanding Moral Distress (cont.)
• Ulrich C, Grady C, eds. Moral Distress in the Health Professions.

Springer; 2018. ISBN-13: 978-3319646251.
• University of Kentucky Program for Bioethics. �e Moral

Distress Education Project. Accessed May 20, 2020.
https://moraldistressproject.med.uky.edu/moral-distress-home

• Vincent H, Jones DJ, Engebretson J. Moral distress
perspectives among interprofessional intensive care unit
team members [published online May 14, 2020]. Nurs Ethics.
https://doi.org/10.1177/0969733020916747

• Deschenes S, Gagnon M, Park T, Kunyk D. Moral distress:
A concept clarification [published online April 6, 2020].
Nurs Ethics. https://doi.org/10.1177/0969733020909523

Mitigating Moral Distress
• Hamric AB, Epstein EG. A health system-wide moral distress

consultation service: development and evaluation. HEC Forum.
2017;29(2):127–143. https://doi.org/10.1007/s10730-016-9315-y

• Rushton C, Schoonover-Sho�ner K, Kennedy MS.
Executive summary: transforming moral distress into moral
resilience in nursing. Am J Nurs. 2017;117(2):52–56.
https://doi.org/10.1097/01.NAJ.0000512298.18641.31

Moral Distress Resources

Explore these resources to learn more about recognizing and addressing Moral Distress.

Mitigating Moral Distress (cont.)
• American Association of Critical-Care Nurses. AACN

Standards for Establishing and Sustaining Healthy Work
Environments: A Journey to Excellence. Accessed May 20,
2020. https://www.aacn.org/nursing-excellence/healthy-
work-environments

• Wolf AT, White KT, Epstein EG, Enfield KB. Palliative
care and moral distress: An institutional survey of
critical care nurses. Crit Care Nurse. 2019;39(5):38–49.
https://doi.org/10.4037/ccn2019645

• Wocial LD, Weaver MT. Development and psychometric
testing of a new tool for detecting moral distress: �e moral
distress thermometer. J Adv Nurs. 2013;69(1):167–174.
https://doi.org/10.1111/j.1365-2648.2012.06036.x

• Pavlish CL, Henriksen J, Brown-Saltzman K, et al.
A team-based early action protocol to address ethical
concerns in the intensive care unit. Am J Crit Care.
2020;29(1):49–61. https://doi.org/10.4037/ajcc2020915

Burnout
• National Academy of Medicine. Sharing Knowledge to

Combat Clinician Burnout. Accessed May 20, 2020.
https://nam.edu/clinicianwellbeing/

• Bancroft H, Guidry B, Rodrigue C, Rouyer H, Wilson N.
Blow Out Burnout: Decreasing Turnover, Increasing Self-Care.
Updated March 5, 2020. Accessed May 20, 2020.
https://www.aacn.org/clinical-resources/csi-projects/blow-out-
burnout-decreasing-turnover-increasing-self-care

Compassion Fatigue
• Burger C. Understand & Overcome Your Compassion

Fatigue: An Online Guide. Accessed May 20, 2020.
https://www.edumed.org/resources/compassion-fatigue-
online-guide/

Moral Distress Resources (cont.)

�e moral distress thermometer on page three is adapted with permission. �e moral distress thermometer is the result of research works authored by
Lucia Wocial, PhD, RN and Dr. Michael Weaver at the Indiana University School of Nursing, with graphics and associated software developed
by Robert ‘Skip’ Comer, research associate at the Indiana University-Purdue University Indianapolis School of Informatics and Computing.

**Hamric.pdf**

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**Tigard.Thepositivevalueofmoraldistress.pdf**

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**Kerbache.MoralDistressinMedicine.pdf**

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