Moral distress among ICU nurses was found to be high at 83.7% according to a recent study. Common sources of moral distress included poor communication, inadequate staffing, feeling powerless in decision making, and inappropriate care. The document outlines strategies for identifying and addressing moral distress using the 4 A's model of ask, affirm, assess, and act. This includes recognizing the experience, validating feelings with others, identifying sources, and taking action to initiate desired changes. A scenario example is provided where a nurse prioritizes a ventilated COVID patient over another based on assessments and feels subsequent guilt, which can be addressed using reflection and preparedness training. Long term strategies include ongoing assessments, workshops, and structural changes.

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MRS .A.L MAHALAKSHMI
MEDICAL SURGICAL NURSING
PROFESSOR
MORAL DISTRESS AMONG
STAFF NURSES IN ICU

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BY
MRS .A.L MAHALAKSHMI
MEDICAL SURGICAL NURSING
PROFESSOR
A WEBINAR ON
MORAL DISTRESS AMONG
STAFF NURSES IN ICU

3. Introduction
 Moral distress (MD) was first
described in the 1980s and was
expressed as suffering that arises
from incoherence between one’s
actions and convictions. In other
words, one knows what is the right
thing to do but recognizes
herself/himself as unable to pursue
such an action.
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To do what nobody else will do, a way what nobody else can do in spite
of all we go through; is to be a Nurse
–

4. Current Impact of Moral Distress
among Staff Nurses
 A cross-sectional study was
conducted among ICU Nurses working
at Northwest Amhara regional state
referral hospitals during pandemic
 The proportion of moral distress
among nurses was found to be
83.7% which was high.
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5.  The findings of the study revealed
mainly due to Perceived poor team
communication, inadequate
staffing, perceived powerlessness in
decision making, Poor supply or
Lack of PPE and inappropriate
provision of care were factors
associated with moral distress.
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6. Moral distress is
Moral distress is the emotional state that
arises from a situation when a nurse feels
that she or he is ethically wants to do correct
action, but action taken is different from what
he or she is tasked or asked to do for. When
policies or procedures prevent a nurse from
doing what he or she thinks is right, that
presents a moral dilemma. This contributes
to the prevalence of moral distress.”
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7. Etiology of Moral Distress
Institutional constraints
Lack of power or lack of legal support
Declining resources or lack of resources
Violation of personal morals/values
Poor quality & futile care
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8. Contd:-
Conflict of use of resources
Policy constraints
Treatment of patients as objects
Unsuccessful advocacy
Inability to complete basic nursing function/ or
advance role
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9. Features of Moral Distress
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Mild Racing
Possible sleep
Disturbances
Feeling Breathlessness
Dizzy ,Disoriented
Breathing Fast& Shallow
Nausea & Lack of
appetite
Restlessness
Sweating or Shivering
Trembling
Heart Racing palpitations
Difficulty in swallowing
Mind Racing, Light
headedness
Jelly like Legs
Wanting to Run
To do what nobody else will do, a way what nobody else can do in spite
of all we go through; is to be a Nurse

10. Manifestations of Moral Distress
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DEPRESSION
DISTURBING
DREAMS
DIFFICULTY IN
SLEEPING
ANOREXIA
IRRITABILITY LONEINLESS CRYING
FATIGUE

11. Factors that increase susceptibility to develop
moral distress among Staff Nurses in ICU
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12. Main Sources of Moral Distress in ICU among staff
Nurses during the Coronavirus Pandemic
The following are commonly cited
sources of moral distress among
nurses, as noted by Corley :
Continued life support even though it is
not in the best interest of the patient
Inadequate communication about end
of life care between providers and
patients and families
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13. Contd:
Inappropriate use of healthcare
resources or poor resources
Inadequate staffing or staff who are
not adequately trained to provide the
required care
Inadequate pain relief provided to
patients
False hope given to patients and
families
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14. Five types of moral distress:
1. Moral-Uncertainty Distress
Are you asking yourself or others:
“I feel torn about what
we should do”
“I don’t know whether this is the right thing to
do”
You may be feeling:
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Torn Conflicted Uncertain Frustrated

15. 2. Moral-Conflict Distress
Are you asking yourself or others:
“I feel like they don’t understand
my point of view”
“I feel like we have different moral
perspectives”
You may be feeling:
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Conflicted Angry Frustrated Sad or upset

16. 3.Moral-Constraint Distress
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Are you asking yourself or others:
“I feel like I’m not doing
the right thing”
“I feel like I am complicit in
causing suffering”
You may be feeling:
Conflicted Angry Frustrated Sad or upset

17. 4. Moral-Dilemma Distress
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Are you asking yourself or others:
“I feel like I’m like I’m stuck
between a rock and a hard place”
“Both options seem to be equally bad”
You may be feeling:
Torn Sense of injustice Sadness Regret Guilt

18. 5. Moral-Tension Distress
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Are you asking yourself or others:
“I don’t feel like that ,
I can talk to anyone about my beliefs”
“Nobody wants to hear my opinion about this”
You may be feeling:
Sadness Angry Frustration Powerlessness

19. 4 A’s to Rise Above Moral
Distress
They suggest going through 4 steps in
order to:
1. Recognize an experience of moral
distress
2. Affirm that experience (with self or
others)
3. Assess your source of moral distress
and
4. Identify an action to take to overcome
your moral distress. 19

20. 4 A’s cycle
4 A’s
Ask
Affirm
Assess
Act
20

21. 1. ASK:
“Am I feeling distressed or showing
signs of suffering?
Is the source of my distress work
related?
Am I observing symptoms of distress
within my team?
Goal: You become aware that moral
distress is present.
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22. 2. AFFIRM:
Affirm your distress and your
commitment to take care of yourself.
Validate feelings and perceptions with
others.
Affirm professional obligation to act.
Goal: You make a commitment to
address moral distress.
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23. 3. ASSESS:
Identify sources of your distress.
• Personal
• Environment
Determine the severity of your distress.
Contemplate your readiness to act.
 You recognize there is an issue but may be
ambivalent about taking action to change it.
 You analyse risks and benefits.
Goal: You are ready to make an action plan.
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24. 4. ACT:
 Prepare to Act
 Prepare personally and professionally to
take action.
 Take Action
 Implement strategies to initiate the changes
you desire.
 Maintain Desired Change
 Anticipate and manage setbacks.
 Continue to implement the 4A’s to resolve
moral distress.
Goal: You preserve your integrity and
authenticity.
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25. Lets discuss on a Moral Distress scenario
in ICU during Pandemic
 There is an example of a morally
distressing scenario and how staff Nurses
might use the 4 A’s to guide either self-
reflection, paired or group reflection to
explore the ethical and moral issues.
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Nurse in the ICU has to care for two level types
of patients (Because of lack of staffing & the
influx of patients. )
Patient 1’s Hemodynamic monitoring starts
alarming due to drop in the vitals .At the same
time, Patient2’s: A COVID patient Ventilator
starts alarming , PEEP Pressure go high
,indicates Nurses actions immediately Such as
ET suctioning has to be done .
At this situation
 The nurse feels torn about what to do,
conflicted and frustrated.
 In this moment, they make the decision to
prioritize patient 2 because their
 Arterial blood gases of the patient 2 have
been terrible and need to make alterations in
the ventilator settings immediately. Whereas
patient 1’s would likely be ok .
 During such situations ,they ask to them self
whether they experienced moral distress or
not
Even after making the decision about
who to prioritize, the nurse continues to
feel guilty, angry and frustrated.
 They affirms to them self the
experience of moral distress
 After the shift, they go to speak to the
nurse-in-charge who affirms that this
was a difficult moral choice to make
which caused the nurse moral
distress towards them.
 The senior nurse listens, validates the
emotions expressed & guides the
nurses reflection & discourages
expressions of self-blame.

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 The nurse considers their
environment & as per the
pandemic situations. They
(staff Nurses) resolve not to
blame them self or feel guilty.
 They decides to act by asking
their nurse manager & CNS to
provide an education session to
help & prepare the nursing
team by brainstorming sessions
other similar scenarios that
might occur, so they feel
prepared to make these
decisions again in the future.
 The senior nurse affirms the decision
in this instance to prioritize the
patients ventilator settings to
maintain the patient airway.
 The nurse reflects upon the
emotions & assesses that they
experienced moral-uncertainty
distress (they were uncertain about
which individual to prioritize),
 moral-dilemma distress (guilt) &
moral-constraint distress (anger)
that they had to make this choice in
the first place,
 (Ideally ICU NP ratio should be 1:1
care-But due to staff shortage )

28. Identification of Moral Distress Among Staff
nurses during Pandemic and treat accordingly
 The following are necessary measures to properly
treat moral distress during the coronavirus pandemic
and beyond:
 Recognize that moral distress is likely to be experienced
across the board for those professionals (Staff Nurses)
working in health care during the pandemic
 Recognize that moral distress occurs on three levels:
moral, psychosocial and spiritual
 Responses should involve interdisciplinary teams of
mental health specialists, spiritual advisers and
ethicists.
 Implement both immediate and long-term responses
and action plans to address moral distress
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29. Immediate action:
Moral distress education (such as webinars,
web resources, pamphlets, etc.)
Assess moral distress levels (with the MMD-
HP -Measure of moral Distress for Health care
Professionals or through surveys, etc.)
Regular, frequent interdisciplinary
opportunities to discuss moral distress with an
interdisciplinary support team (weekly
conducting virtual moral health rounds,
virtual communication boards, etc.)
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30. Long-term action plan:
Regular moral distress assessments
Multi-session moral health workshops
for the Staff Nurses
 Implement structural changes where
appropriate
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31. Strategies to reduce moral distress
Strategy Implementation
Speak up! Identify the problem, gather the facts, and voice your
opinion
Be deliberate Know who you need to speak with and know what you
need to speak about
Be accountable Sometimes, our actions are not quite right. Be ready to
accept the consequences, should things not turn out the
way you had planned.
Build support networks Find colleagues who support you or who support acting
to address moral distress. Speak with one authoritative
voice.
Focus on changes in the
work environment
Focusing on the work environment will be more
productive than focusing on an individual patient.
Remember, similar problems tend to occur over and
over. It’s not usually the patient, but the system, that
needs changing.
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32. Participate in moral
distress education
Attend forums and discussions about moral
distress. Learn all you can about it.
Make it
interdisciplinary
Many causes of moral distress are interdisciplinary.
Nursing alone cannot change the work
environment. Multiple views and collaboration are
needed to improve a system, especially a complex
one, such as a hospital unit.
Find root causes What are the common causes of moral distress in
your unit? Target those.
Develop policies Develop policies to encourage open discussion,
interdisciplinary collaboration, and the initiation of
ethics consultations.
Design a workshop Train nursing staff to recognize moral distress,
identify barriers to change, and create a plan for
action.
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33. Moral distress after Corona Subsides
 Even after the coronavirus crisis
subsides, hospitals should remain
focused on dealing with moral
distress because the effects from the
pandemic will be long-lasting.
 Furthermore, moral distress will
persist as health care workers
continue to confront the regular
ethical challenges of health care.
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34. Conclusion
 As such, hospitals should continue to
monitor moral distress through the MMD-
HP or other staff surveys. In the long-term,
there should be workshops to process moral
distress and to build moral resilience. These
should be available to all health care
professionals and the programs should be
intensive, performed over a series of
sessions with an interdisciplinary team
approach.
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35. References:
 Adam Brenner as told to Anna Silman, "Diary of a NYC Hospital: Losing Hope in the
ICU," New York Magazine, April 8, 2020,
https://nymag.com/intelligencer/2020/04/coronavirus-nyc-hospital-
icu.html?fbclid=IwAR3E_-
l_Rr7XM9k5TwW2CrR9WjqTrJyQuit7JiurxgxaY1LTaJT54fLtWZM.
 Sadath A. Sayeed, "The Psychological Toll of Health Care Rationing Should Not Be
Underestimated, Newsweek, Opinion, April 6, 2020,
https://www.newsweek.com/2020/04/24/psychological-toll-health-care-rationing-
should-not-underestimated-opinion-1496321.html.
 Emma Goldberg, "Hospital Chaplains Try to Keep the Faith During the Coronavirus
Pandemic," New York Times, April 11, 2020,
https://www.nytimes.com/2020/04/11/health/coronavirus-chaplains-hospitals.html.
 Andrew Jameton, Nursing Practice: The Ethical Issues, (Englewood Cliffs, NJ: Pearson
College Div., 1984), 6.
 Stephen M. Campbell, Connie M. Ulrich and Christine Grady, "A Broader Understanding
of Moral Distress," American Journal of Bioethics 16, no. 12 (December 1, 2016)
35

36.  AACN. (2005). AACN standards for establishing and sustaining healthy
work environments. Retrieved from
www.aacn.org/WD/HWE/Content/hwehome.pcms?menu=Comm
unity
 Austin, W., Lemermeyer, G., Goldberg, L., Bergum, V., & Johnson,
M. S. (2005). Moral distress in healthcare practice: The situation of
nurses. HEC Forum, 17(1), 33-48.
 Austin, W., Rankel, M., Kagan, L., Bergum, V., & Lemermeyer, G.
(2005). To stay or to go, to speak or stay silent, to act or not to act:
Moral distress as experienced by psychologists. Ethics & Behavior,
15(3), 197-212.
 Austin, W. J., Kagan, L., Rankel, M., & Bergum, V. (2008). The
balancing act: Psychiatrists' experience of moral distress. Medicine,
Health Care & Philosophy, 11(1), 89-97.
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