2. Read the case study entitled You be the Ethicist, presented at the end of Chapter 3 (Guido textbook). What are the compelling rights that this case addresses? Whose rights should take precedence? Does a child (specifically this competent 14-year-old) have the right to determine what will happen to him? Should he ethically have this right? How would you have decided the outcome if his disease state had not intervened? Now, examine the scenario from the perspective of health care policy. How would you begin to evaluate the need for the policy and the possible support or lack of support for the policy from your peers, nursing management, and others who might be affected by the policy? Do the 10 framework questions outlined by Malone in chapter 4 (Guido textbook) assist in this process? Create a process proposal for the organization with possible guidelines, procedures, and policies to address the issues you have identified. YOU BE THE ETHICIST Until recently, Tyrell Dueck was a normal eighth-grader in Canada, hoping that his favorite team would win the Stanley Cup for the third time. Then, early in the school year, he slipped climbing out of the shower and discovered a lump on his leg. He was then diagnosed with bone cancer. After receiving two rounds of chemotherapy and being told that further therapy would mean the amputation of his leg, he announced that he wanted therapy stopped. He and his parents, devout fundamentalist Christians, decided to leave his health in God’s hands and seek alternative therapy. The decision sparked a court battle between his parents, who supported Tyrell’s decision, and the health care team, who sought to compel continued medical treatment and the planned amputation. The battle ultimately ended when doctors said that his cancer had spread to his lungs and that there was little more that could be done for Tyrell. ETHICAL QUESTIONS 1. What are the compelling rights that this case addresses? 2. Whose rights should take precedence? 3. Does a child (specifically this competent 14-year-old) have the right to determine what will happen to him? Should he ethically have this right? 4. How would you have decided the outcome if his disease state have not intervened? Guido, Ginny Wacker, JD, MSN, RN. Legal and Ethical Issues in Nursing (Legal Issues in Nursing ( Guido)) (p. 41). Pearson Education. Kindle Edition. Do the 10 framework questions outlined by Malone in chapter 4 (Guido textbook) assist in this process? Create a process proposal for the organization with possible guidelines, procedures, and policies to address the issues you have identified. • What is the problem? • Where is the process? • How many are affected? • What possible solutions could be proposed? • What are the ethical arguments involved? • At what level is the problem most effectively addressed? • Who is in a position to make policy decisions? • What are the obstacles to policy interventions? • What resources are ava.

1. 2. Read the case study entitled You be the Ethicist, presented at
the end of Chapter 3 (Guido textbook). What are the compelling
rights that this case addresses? Whose rights should take
precedence? Does a child (specifically this competent 14-year-
old) have the right to determine what will happen to him?
Should he ethically have this right? How would you have
decided the outcome if his disease state had not intervened?
Now, examine the scenario from the perspective of health care
policy. How would you begin to evaluate the need for the policy
and the possible support or lack of support for the policy from
your peers, nursing management, and others who might be
affected by the policy?
Do the 10 framework questions outlined by Malone in chapter 4
(Guido textbook) assist in this process? Create a process
proposal for the organization with possible guidelines,
procedures, and policies to address the issues you have
identified.
YOU BE THE ETHICIST Until recently, Tyrell Dueck was a
normal eighth-grader in Canada, hoping that his favorite team
would win the Stanley Cup for the third time. Then, early in the
school year, he slipped climbing out of the shower and
discovered a lump on his leg. He was then diagnosed with bone
cancer. After receiving two rounds of chemotherapy and being
told that further therapy would mean the amputation of his leg,
he announced that he wanted therapy stopped. He and his
parents, devout fundamentalist Christians, decided to leave his
health in God’s hands and seek alternative therapy. The
decision sparked a court battle between his parents, who
supported Tyrell’s decision, and the health care team, who
sought to compel continued medical treatment and the planned
amputation. The battle ultimately ended when doctors said that
his cancer had spread to his lungs and that there was little more
that could be done for Tyrell.
ETHICAL QUESTIONS 1. What are the compelling rights that

2. this case addresses? 2. Whose rights should take precedence?
3. Does a child (specifically this competent 14-year-old) have
the right to determine what will happen to him? Should he
ethically have this right? 4. How would you have decided the
outcome if his disease state have not intervened?
Guido, Ginny Wacker, JD, MSN, RN. Legal and Ethical Issues
in Nursing (Legal Issues in Nursing ( Guido)) (p. 41). Pearson
Education. Kindle Edition.
Do the 10 framework questions outlined by Malone in chapter 4
(Guido textbook) assist in this process? Create a process
proposal for the organization with possible guidelines,
procedures, and policies to address the issues you have
identified.
• What is the problem? • Where is the process? • How many
are affected? • What possible solutions could be proposed? •
What are the ethical arguments involved? • At what level is the
problem most effectively addressed? • Who is in a position to
make policy decisions? • What are the obstacles to policy
interventions? • What resources are available? • How can I get
involved? (Malone, 2005, p. 138)
Apply Guido's MORAL model to resolve the dilemma presented
in the case study described in EXERCISE 4–3 (Guido textbook).
How might the nurses in this scenario respond to the physician's
request? How would this scenario begin to cause moral distress
among the nursing staff, and what are the positive actions that
the nurses might begin to take to prevent moral distress?
MORAL DISTRESS Nurses experience stress in clinical
practice settings as they are confronted with situations
involving ethical dilemmas. Moral stress most often occurs
when faced with situations in which two ethical principles
compete, such as when the nurse is balancing the patient’s

3. autonomy issues with attempting to do what the nurse knows is
in the patient’s best interest. Though the dilemmas are
stressful, nurses can and do make decisions and implement
those decisions. Moral distress, first described within the
discipline of nursing by Jameton (1984), is a negative state of
painful psychological imbalance seen when nurses make moral
decisions, but are unable to implement these decisions because
of real or perceived institutional constraints. This author
acknowledged that there are three categories in this
phenomenon: moral uncertainty, moral dilemma, and moral
distress. Moral uncertainty is characterized by an uneasy
feeling wherein the individual questions the right course of
action. Generally, this uncertainty is short lived. Moral
dilemma, according to Jameton (1984), is characterized by
conflicting but morally justifiable courses of action. In such a
dilemma, the individual is uncertain about which course of
action should be enacted. Moral distress involves the individual
knowing the ethical course of action to take, but the individual
cannot implement the action because of institutional obstacles.
Seen as a major issue in nursing today, moral distress is
experienced when nurses are unable to provide what they
perceive to be best for a given patient. Examples of moral
distress include constraints caused by financial pressures,
limited patient care resources, disagreements among family
members regarding appropriate patient interventions, and/or
limitations imposed by primary health care providers. Moral
distress may also be experienced when actions nurses perform
violate their personal beliefs. A study by Zuzelo (2007)
concluded that the primary sources of moral distress included
the following: • Resenting physician reluctance to address
death and dying • Feeling frustrated in a subordinate role •
Confronting physicians • Ignoring patients’ wishes • Feeling
frustrated with family members • Treating patients as
experiments • Working with staff members perceived as
inadequate (pp. 353 – 356). These themes were present in
nurses practicing in multiple care settings who work with

4. various populations of patients across the lifespan. A later
study by Pauly and colleagues (2009) concluded that high
levels of moral distress for nurses in clinical settings involved
“nurses’ own feelings of competency and their confidence in
the competence of registered nurses” (p. 569). Corley (2002)
had found in an earlier study that lack of adequate education in
nursing ethics, specifically in being able to apply ethical
decision-making models, may also account for some of the
moral distress experienced by nurses in clinical settings. He
further noted that there is a relationship between moral distress,
nurse satisfaction, and nurse attrition. Moral distress may be
further subdivided into initial moral distress and reactive moral
distress (Jameton, 1993). Nurses who are experiencing initial
moral distress generally experience frustration, anger, and
anxiety when confronted with value conflicts and institutional
obstacles. This frustration, anger, and anxiety result from being
prevented from doing what the nurse sees as the correct course
of action. Reactive distress incorporates negative feelings when
the nurse is unable to act on his or her initial distress. Reactive
distress involves the inability to identify the ethical issues
involved or may result from a lack of knowledge regarding
possible alternative actions. Signs and symptoms of reactive
moral distress include powerlessness, guilt, loss of self-worth,
self-criticism, and low self-esteem and physiologic responses
such as crying, depression, loss of sleep, nightmares, and loss
of appetite. In extreme cases, moral distress may culminate in
moral outrage, causing burnout and inability to effectively care
for patients. The impact of moral distress among nurses can be
quite serious. There is evidence that moral distress com-
promises patient care and that moral distress may be
manifested in such behaviors as avoiding or withdrawing from
patients (McAndrew, Leske, & Garcia, 2011). Their study
noted that nurses who experienced moral distress may avoid
aspects of patient care, decreasing the nurse’s role as patient
advocate and further contributing to patient discomfort and
suffering. The study noted that there was a negative

5. relationship with all aspects of professional practice except for
foundations for quality care. The authors, though, additionally
noted that in this study the tool used for the study measures
foundations for quality care such as clinically competent care
and availability of ongoing education for nurses rather than
nurse reports about the quality of care actually delivered to
patients. Thus, they recommended that further research explore
the issue of moral distress and its influence on quality of care
provided to patients and family members. There are several
strategies for beginning to address moral distress in clinical
practice settings. Nurses who feel empowered to voice their
ethical concerns within their institutions may experience less
moral distress. Storch, Rodney, Brown, and Starzomski (2002)
concluded that nurses will continue to feel moral distress in
clinical settings. This conclusion was based on the participant
nurses’ ongoing concerns about the ethical nature of the
institution, appropriate resource utilization, and lack of time
for working directly with patients. These researchers noted,
though, that there is an important relationship between ethics
and power. When nurses have the ability to raise legitimate
ethical concerns, power is manifested in ways that affect
quality practice environments and allows the nurses to better
cope with moral distress. Additional aspects that may assist in
reducing moral distress among nurses in nursing care settings
include educating nurses about the concept and offering
opportunities to discuss moral distress in neutral settings.
Information about moral distress should be part of orientation
programs for new employees. Other means of reducing moral
distress include identifying and addressing impediments to
delivery of quality nursing care, incorporating conflict
resolution and mediation techniques so that nurses can work
through their concerns and bring them to closure, and allowing
nurses to serve on the institution ethics committees. This latter
means of working with moral distress encourages nurses not
only to identify and understand resources that are available to
them, but also to use these valuable resources. These strategies

6. may also improve working relationships with peers,
management staff, and other members of the interdisciplinary
health care team. Finally, establishing systems that value the
active participation of nurses in clinical and ethical decision
making,
encouraging and rewarding collaborative teamwork, and open
communications assist nurses in appropriately dealing with
moral distress. Individual nurses, though, have learned to
employ additional strategies in preserving their dignity and in
compensating patients for perceived wrongdoing (McCarthy &
Deady, 2008). These strategies include self-care, such as
working on a part-time basis and accepting personal
limitations; assertiveness; collective action; and reexamining
basic nursing ethical values. Lutzen and colleagues (2003)
noted that moral distress can also be an energizing factor that
results in the person having an enhanced feeling of
accomplishment of professional goals. They concluded that
moral distress may begin to make individuals more aware of
their own beliefs and strive to handle ethical issues more
effectively in future encounters. EXERCISE 4–3 Mrs. R., an
87-year-old patient, has a past history that includes coronary
artery disease, a previous stroke, and advanced Alzheimer’s
disease. Ten days ago, Mrs. R. was hospitalized for aspiration
pneumonia and has been ventilator dependent since being
admitted to the intensive care unit in a small rural hospital.
Family members visit daily and have repeatedly voiced their
concern to the nursing staff about the continued ventilator
support that Mrs. R. is receiving, most notably the fact that
Mrs. R. would never have wanted such care. They also note
that Mrs. R. has not recognized them in past months and that
they plan to visit less in future days, but can be contacted
should any change in Mrs. R.’s condition occur. Her primary
physician has practiced in this community for multiple years;
he is well-known for his reluctance to discontinue any type of
life support for any patient. When questioned, Dr. G.’s
consistent response is, if this were his frail 92-year-old mother,

7. he would prescribe the very same treatment for her. Dr. G. has
now requested that the nurses talk to the family about moving
Mrs. R. to a major medical center, where she can receive more
advanced care, including vigorous rehabilitation and physical
therapy, so that she may eventually return to a long-term
nursing care facility. How might the nurses in this scenario
respond to the physician’s request? How would this scenario
begin to cause moral distress among the nursing staff and what
are the positive actions that the nurses should begin to take to
prevent moral distress.
2. Read the case study entitled You be the Ethicist, presented at
the end of Chapter 3 (Guido textbook). What are the compelling
rights that this case addresses? Whose rights should take
precedence? Does a child (specifically this competent 14-year-
old) have the right to determine what will happen to him?
Should he ethically have this right? How would you have
decided the outcome if his disease state had not intervened?
Now, examine the scenario from the perspective of health care
policy. How would you begin to evaluate the need for the policy
and the possible support or lack of support for the policy from
your peers, nursing management, and others who might be
affected by the policy?
Do the 10 framework questions outlined by Malone in chapter 4
(Guido textbook) assist in this process? Create a process
proposal for the organization with possible guidelines,
procedures, and policies to address the issues you have
identified.
YOU BE THE ETHICIST Until recently, Tyrell Dueck was a
normal eighth-grader in Canada, hoping that his favorite team
would win the Stanley Cup for the third time. Then, early in the
school year, he slipped climbing out of the shower and
discovered a lump on his leg. He was then diagnosed with bone
cancer. After receiving two rounds of chemotherapy and being
told that further therapy would mean the amputation of his leg,
he announced that he wanted therapy stopped. He and his
parents, devout fundamentalist Christians, decided to leave his

8. health in God’s hands and seek alternative therapy. The
decision sparked a court battle between his parents, who
supported Tyrell’s decision, and the health care team, who
sought to compel continued medical treatment and the planned
amputation. The battle ultimately ended when doctors said that
his cancer had spread to his lungs and that there was little more
that could be done for Tyrell.
ETHICAL QUESTIONS 1. What are the compelling rights that
this case addresses? 2. Whose rights should take precedence?
3. Does a child (specifically this competent 14-year-old) have
the right to determine what will happen to him? Should he
ethically have this right? 4. How would you have decided the
outcome if his disease state have not intervened?
Guido, Ginny Wacker, JD, MSN, RN. Legal and Ethical Issues
in Nursing (Legal Issues in Nursing ( Guido)) (p. 41). Pearson
Education. Kindle Edition.
Do the 10 framework questions outlined by Malone in chapter 4
(Guido textbook) assist in this process? Create a process
proposal for the organization with possible guidelines,
procedures, and policies to address the issues you have
identified.
• What is the problem? • Where is the process? • How many
are affected? • What possible solutions could be proposed? •
What are the ethical arguments involved? • At what level is the
problem most effectively addressed? • Who is in a position to
make policy decisions? • What are the obstacles to policy
interventions? • What resources are available? • How can I get
involved? (Malone, 2005, p. 138)
Apply Guido's MORAL model to resolve the dilemma presented
in the case study described in EXERCISE 4–3 (Guido textbook).

9. How might the nurses in this scenario respond to the physician's
request? How would this scenario begin to cause moral distress
among the nursing staff, and what are the positive actions that
the nurses might begin to take to prevent moral distress?
MORAL DISTRESS Nurses experience stress in clinical
practice settings as they are confronted with situations
involving ethical dilemmas. Moral stress most often occurs
when faced with situations in which two ethical principles
compete, such as when the nurse is balancing the patient’s
autonomy issues with attempting to do what the nurse knows is
in the patient’s best interest. Though the dilemmas are
stressful, nurses can and do make decisions and implement
those decisions. Moral distress, first described within the
discipline of nursing by Jameton (1984), is a negative state of
painful psychological imbalance seen when nurses make moral
decisions, but are unable to implement these decisions because
of real or perceived institutional constraints. This author
acknowledged that there are three categories in this
phenomenon: moral uncertainty, moral dilemma, and moral
distress. Moral uncertainty is characterized by an uneasy
feeling wherein the individual questions the right course of
action. Generally, this uncertainty is short lived. Moral
dilemma, according to Jameton (1984), is characterized by
conflicting but morally justifiable courses of action. In such a
dilemma, the individual is uncertain about which course of
action should be enacted. Moral distress involves the individual
knowing the ethical course of action to take, but the individual
cannot implement the action because of institutional obstacles.
Seen as a major issue in nursing today, moral distress is
experienced when nurses are unable to provide what they
perceive to be best for a given patient. Examples of moral
distress include constraints caused by financial pressures,
limited patient care resources, disagreements among family
members regarding appropriate patient interventions, and/or
limitations imposed by primary health care providers. Moral
distress may also be experienced when actions nurses perform

10. violate their personal beliefs. A study by Zuzelo (2007)
concluded that the primary sources of moral distress included
the following: • Resenting physician reluctance to address
death and dying • Feeling frustrated in a subordinate role •
Confronting physicians • Ignoring patients’ wishes • Feeling
frustrated with family members • Treating patients as
experiments • Working with staff members perceived as
inadequate (pp. 353 – 356). These themes were present in
nurses practicing in multiple care settings who work with
various populations of patients across the lifespan. A later
study by Pauly and colleagues (2009) concluded that high
levels of moral distress for nurses in clinical settings involved
“nurses’ own feelings of competency and their confidence in
the competence of registered nurses” (p. 569). Corley (2002)
had found in an earlier study that lack of adequate education in
nursing ethics, specifically in being able to apply ethical
decision-making models, may also account for some of the
moral distress experienced by nurses in clinical settings. He
further noted that there is a relationship between moral distress,
nurse satisfaction, and nurse attrition. Moral distress may be
further subdivided into initial moral distress and reactive moral
distress (Jameton, 1993). Nurses who are experiencing initial
moral distress generally experience frustration, anger, and
anxiety when confronted with value conflicts and institutional
obstacles. This frustration, anger, and anxiety result from being
prevented from doing what the nurse sees as the correct course
of action. Reactive distress incorporates negative feelings when
the nurse is unable to act on his or her initial distress. Reactive
distress involves the inability to identify the ethical issues
involved or may result from a lack of knowledge regarding
possible alternative actions. Signs and symptoms of reactive
moral distress include powerlessness, guilt, loss of self-worth,
self-criticism, and low self-esteem and physiologic responses
such as crying, depression, loss of sleep, nightmares, and loss
of appetite. In extreme cases, moral distress may culminate in
moral outrage, causing burnout and inability to effectively care

11. for patients. The impact of moral distress among nurses can be
quite serious. There is evidence that moral distress com-
promises patient care and that moral distress may be
manifested in such behaviors as avoiding or withdrawing from
patients (McAndrew, Leske, & Garcia, 2011). Their study
noted that nurses who experienced moral distress may avoid
aspects of patient care, decreasing the nurse’s role as patient
advocate and further contributing to patient discomfort and
suffering. The study noted that there was a negative
relationship with all aspects of professional practice except for
foundations for quality care. The authors, though, additionally
noted that in this study the tool used for the study measures
foundations for quality care such as clinically competent care
and availability of ongoing education for nurses rather than
nurse reports about the quality of care actually delivered to
patients. Thus, they recommended that further research explore
the issue of moral distress and its influence on quality of care
provided to patients and family members. There are several
strategies for beginning to address moral distress in clinical
practice settings. Nurses who feel empowered to voice their
ethical concerns within their institutions may experience less
moral distress. Storch, Rodney, Brown, and Starzomski (2002)
concluded that nurses will continue to feel moral distress in
clinical settings. This conclusion was based on the participant
nurses’ ongoing concerns about the ethical nature of the
institution, appropriate resource utilization, and lack of time
for working directly with patients. These researchers noted,
though, that there is an important relationship between ethics
and power. When nurses have the ability to raise legitimate
ethical concerns, power is manifested in ways that affect
quality practice environments and allows the nurses to better
cope with moral distress. Additional aspects that may assist in
reducing moral distress among nurses in nursing care settings
include educating nurses about the concept and offering
opportunities to discuss moral distress in neutral settings.
Information about moral distress should be part of orientation

12. programs for new employees. Other means of reducing moral
distress include identifying and addressing impediments to
delivery of quality nursing care, incorporating conflict
resolution and mediation techniques so that nurses can work
through their concerns and bring them to closure, and allowing
nurses to serve on the institution ethics committees. This latter
means of working with moral distress encourages nurses not
only to identify and understand resources that are available to
them, but also to use these valuable resources. These strategies
may also improve working relationships with peers,
management staff, and other members of the interdisciplinary
health care team. Finally, establishing systems that value the
active participation of nurses in clinical and ethical decision
making,
encouraging and rewarding collaborative teamwork, and open
communications assist nurses in appropriately dealing with
moral distress. Individual nurses, though, have learned to
employ additional strategies in preserving their dignity and in
compensating patients for perceived wrongdoing (McCarthy &
Deady, 2008). These strategies include self-care, such as
working on a part-time basis and accepting personal
limitations; assertiveness; collective action; and reexamining
basic nursing ethical values. Lutzen and colleagues (2003)
noted that moral distress can also be an energizing factor that
results in the person having an enhanced feeling of
accomplishment of professional goals. They concluded that
moral distress may begin to make individuals more aware of
their own beliefs and strive to handle ethical issues more
effectively in future encounters. EXERCISE 4–3 Mrs. R., an
87-year-old patient, has a past history that includes coronary
artery disease, a previous stroke, and advanced Alzheimer’s
disease. Ten days ago, Mrs. R. was hospitalized for aspiration
pneumonia and has been ventilator dependent since being
admitted to the intensive care unit in a small rural hospital.
Family members visit daily and have repeatedly voiced their
concern to the nursing staff about the continued ventilator

13. support that Mrs. R. is receiving, most notably the fact that
Mrs. R. would never have wanted such care. They also note
that Mrs. R. has not recognized them in past months and that
they plan to visit less in future days, but can be contacted
should any change in Mrs. R.’s condition occur. Her primary
physician has practiced in this community for multiple years;
he is well-known for his reluctance to discontinue any type of
life support for any patient. When questioned, Dr. G.’s
consistent response is, if this were his frail 92-year-old mother,
he would prescribe the very same treatment for her. Dr. G. has
now requested that the nurses talk to the family about moving
Mrs. R. to a major medical center, where she can receive more
advanced care, including vigorous rehabilitation and physical
therapy, so that she may eventually return to a long-term
nursing care facility. How might the nurses in this scenario
respond to the physician’s request? How would this scenario
begin to cause moral distress among the nursing staff and what
are the positive actions that the nurses should begin to take to
prevent moral distress.
Guido, Ginny Wacker, JD, MSN, RN. Legal and Ethical Issues
in Nursing (Legal Issues in Nursing ( Guido)) (p. 48). Pearson
Education. Kindle Edition.