Posted: October 9th, 2022

Moral distress among the nursing staff

Nursing staff members are experiencing morale issues.

Module 1 Assignment

Complete both case studies:

1. 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?

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) Help in this process? Create a process proposal for the organization with possible guidelines, procedures, and policies to address the issues you have identified.

REQUIRED TEXTS

Guido, G. W. (2014). Legal and ethical issues in nursing (6th ed.). Upper Saddle River, NJ:
Prentice Hall. (Chapter 3 and 4)
Pozgar, G. D. (2013). Legal and ethical issues for health professionals (3rd ed.). Boston: Jones and
Bartlett. (Chapter 1 and 4)
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As a result of being confronted with situations involving ethical dilemmas, nurses experience stress in clinical practice settings. Typically, moral stress manifests itself when a nurse is confronted with situations in which two ethical principles are at odds with one another, such as when a nurse must strike a balance between respecting the patient’s autonomy while also attempting to do what the nurse believes is in the patient’s best interests. Despite the fact that the dilemmas are stressful, nurses can and do make decisions and put those decisions into action. As first described in the discipline of nursing by Jameton (1984), moral distress refers to a negative psychological state of painful imbalance that occurs when nurses make moral decisions but are unable to put those decisions into action because of real or perceived institutional constraints. Moral uncertainty, moral dilemma, and moral distress are all recognized as distinct categories in this phenomenon, according to the author. Moral uncertainty is characterized by an uneasy feeling in which the individual questions whether or not a particular course of action is the best course of action. In most cases, this uncertainty is only temporary. According to Jameton (1984), a moral dilemma is characterized by opposing but morally justifiable courses of action that must be chosen. An individual who finds himself or herself in this situation is unsure about the best course of action to take. Moral distress occurs when an individual understands the ethical course of action to take but is unable to put the action into action because of institutional obstacles. Moral distress, which is considered a major issue in nursing today, is experienced when nurses are unable to provide what they believe is the best care for a given patient. Financial pressures, limited patient care resources, disagreements among family members about appropriate patient interventions, and/or limitations imposed by primary health care providers are all examples of moral distress that can be experienced. Moral distress can also be experienced by nurses when the actions they take are in conflict with their personal beliefs. According to the findings of a study conducted by Zuzelo (2007), the following were the primary sources of moral distress: 353–356. • Resenting physicians’ reluctance to address death and dying. • Feeling frustrated in a subordinate role. • Confronting physicians. • Ignoring patients’ wishes. • Feeling frustrated with family members. These themes were prevalent among nurses working in a variety of care settings and with a diverse range of patient populations at all stages of their professional careers. Later research by Pauly and colleagues (2009) came to the conclusion that high levels of moral distress among nurses working in clinical settings were caused by “nurses’ own feelings of competency and their confidence in the competence of other registered nurses” (p. 569). An earlier study by Corley (2002) had found, among other things, that a lack of adequate nursing ethics education, specifically a lack of ability to apply ethical decision-making models, may also be a contributing factor to some of the moral distress experienced by nurses in clinical settings. A further observation made by him was that there is a relationship between moral distress, nurse satisfaction, and nurse attrition. A further division of moral distress is that it is divided into two types: initial moral distress and reactive moral distress (Jameton, 1993). Nursing students and residents who are experiencing initial moral distress are more likely to experience feelings of frustration, anger, and anxiety when confronted with value conflicts and organizational obstacles. The frustration, anger, and anxiety that the nurse feels as a result of being prevented from performing what she believes to be the proper course of action. It is possible to experience reactive distress even when the nurse is unable to act on the distress that caused it in the first place. Reactive distress is characterized by an inability to recognize the ethical issues at stake or by a lack of knowledge about possible alternatives to the course of action. Powerlessness, guilt, loss of self-worth, self-criticism, and low self-esteem are some of the signs and symptoms of reactive moral distress, as are physiologic responses such as crying, depression, loss of sleep, nightmares, and loss of appetite. In extreme cases, moral distress can lead to moral outrage, which can result in burnout and the inability to provide effective patient-centered care. The consequences of moral distress among nurses can be extremely detrimental. There is evidence to suggest that moral distress occurs.
– There is a sense of moral distress among the nursing staff
promises patient care and acknowledges that moral distress may manifest itself in behaviors such as avoiding or withdrawing from patients (McAndrew, Leske, & Garcia, 2011). Nurses who are experiencing moral distress may avoid aspects of patient care, diminishing the nurse’s role as patient advocate and further contributing to the discomfort and suffering of patients, according to the findings of their study. According to the findings of the study, there was a negative relationship between all aspects of professional practice with the exception of the foundations for quality care. While pointing out that the study’s tool measures foundations for quality care such as clinical competence and the availability of ongoing education for nurses, the authors also pointed out that the study’s tool does not measure actual patient outcomes such as nurse reports on the quality of care they received. As a result, they recommended that additional research be conducted to investigate the issue of moral distress and its impact on the quality of care provided to patients and their families. There are a variety of approaches that can be used to begin addressing moral distress in clinical practice settings. The moral distress experienced by nurses may be reduced if they feel empowered to express their ethical concerns within their respective institutions. Nurses will continue to experience moral distress in clinical settings, according to the findings of Storch, Rodney, Brown, and Starzomski (2002). This conclusion was reached as a result of the nurses’ ongoing concerns about the ethical nature of the institution, the appropriate use of resources, and the lack of time available for direct patient contact. These researchers, on the other hand, noted that there is a significant relationship between ethics and political power. Nursing power manifests itself in a variety of ways when nurses have the ability to raise legitimate ethical concerns, including the ability to influence quality practice environments and the ability to better cope with moral distress. Aspects such as educating nurses about the concept of moral distress and providing opportunities for them to discuss moral distress in neutral settings may also be beneficial in reducing moral distress among nurses in nursing care settings, among other things. New employees should be provided with information about moral distress as part of their orientation programs. Other strategies for reducing moral distress include identifying and addressing impediments to the delivery of high-quality nursing care, incorporating conflict resolution and mediation techniques so that nurses can work through their concerns and bring them to a close, and allowing nurses to serve on the ethics committees of their respective institutions or organizations. When dealing with moral distress, the latter method encourages nurses to not only identify and understand the resources that are available to them, but also to make use of these valuable resources when possible. These strategies may also aid in the improvement of working relationships with colleagues, management, and other members of the interdisciplinary health care team, among other things. Finally, by establishing systems that recognize and value the active participation of nurses in clinical and ethical decision-making, we can ensure that nurses have a voice in the future. Nursing staff members are experiencing morale issues.
Encouraging and rewarding collaborative teamwork, and open communications Help 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, 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. Moral distress among the nursing staff
Guido, Ginny Wacker, JD, MSN, RN. Legal and Ethical Issues in Nursing (Legal Issues in Nursing ( Guido)) (p. 48). Pearson Education. Kindle Edition.
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Sample 2:
Responses to Guido’s Book on Nursing Ethical Dilemmas

Understanding the process of making ethical decisions in healthcare settings is necessary for nurses to do their tasks effectively. According to Pozgar (2013), nurses should utilize all available resources to ease the process of making ethical decisions. The ethics committee constitutes one of the supports. Institutions with an ethics committee should utilize it to Help nurses in making educated judgments about healthcare ethics. Guido (2014) says that nurses should make ethical judgements with appropriate time in order to arrive at a viable and supported solution. Guido (2014) states in his book that increasing impediments in the nursing environment have prohibited nurses from doing their duties ethically. According to Guido (2014), ethical decisions can be made by nurses in an environment that fosters creative thinking and educates them on the process. This study utilizes Guido’s book to address several crucial ethical dilemmas affecting nurses in their professional work.

Exercise 4–3

The Nurses’ Response Under This Circumstance

Before responding to the physician in this scenario, the nurse must be familiar with the hospital’s policies and standards governing the referral process. In addition, the nurse should be familiar with established standard care protocols before responding. The nurse should comply with the physician’s directives since Dr. G.’s justifications are sufficient and are focused on improving the patient’s health. However, because he is his superior, the nurse should not support the physician’s arguments (Rainer et al., 2018). He should make an impartial decision with the patient’s health in mind. The services described by the doctor to the nurse are unavailable at the local hospital. Therefore, the patient should be treated at a facility that can aid in his health improvement. Therefore, the nurse should request that the doctor grant him time to speak with family members. If they agree to change hospitals, the nurse should request a reference letter from the doctor so that the patient can be referred.

Causes of Emotional Distress in this Scenario and Ways to Deal with Them

Moral anguish is the inability of nurses to do their tasks due to institutional impediments (Aydin & Ersoy, 2017). When family members refuse to pay for the patient’s referral fees, this scenario might generate moral hardship among nurses. The nurse may be willing to follow the physician’s recommendation and negotiate hospital relocation with the patient’s family. However, when family members disagree with the nurse, the nurse can get quite upset. Thus, in this circumstance, the family members are the primary source of moral discomfort. Additionally, the physician may frustrate the nurse and push him or her to comply with orders. In order to learn how to manage it, nurses might educate themselves on moral distress (). They can also manage the problem by communicating their concerns to the appropriate individuals.

You are the Ethicist, Part 2: Case Study Questions

Obligatory Rights Addressed in the Case

The case involves two constitutional rights. The first right is the autonomy of the patient. This right claims that patients should be permitted to determine their own health outcomes (Krautscheid et al., 2017). Second, nurses have the right to advocate for their patients.

Prioritizing the Rights That Should Come First

Autonomy is the right that should take precedence in this situation. The patient has been given the authority to make health-related decisions, and nurses are required to respect this right notwithstanding the severity of the patient’s condition.

Whether the Child Has the Right to Choose Their Own Destiny

Under the United States Constitution, children under the age of 14 do not have the right to decide their own fate (Krautscheid et al., 2017). Ethically and legally, the youngster should not have the right because he is not mature enough to make informed decisions.

How I Would Have Determined His Disease’s Outcome If I Had Not Intervened

I would have made my decision with the patient’s health in mind. To prevent the spread of cancer to other parts of the body, I would have opted for the subsequent treatment, which is amputation.

How I Would Start Evaluating the Policy’s Need

I would begin evaluating the necessity for a policy by demonstrating the current regulation’s flaws to other affected parties. I would inform my coworkers and superiors that the autonomy policy needs to be revised. I would persuade them that nurses should be permitted to make judgments when they determine that a patient has made a poor choice. My peers would support me since they find themselves in like circumstances.

The 10 Foundational Questions

The 10 framework questions contained in the book can Help with the process. Through the inquiries, a nurse can identify the issue and identify those who are afflicted. Additionally, using the questions, a nurse can identify policymakers (Guido, 2014). In other words, the questions are essential for the formation of policy. The proposed approach can be employed to remedy the case scenario’s identified issue.

A Process Proposal

Situation

The autonomy of patients has stopped nurses from performing their tasks to their fullest capacity. In this instance, the youngster could have been cured of cancer if his parents had agreed to amputation therapy. However, they refused, and the child now has liver cancer. The autonomy policy should be reexamined so that nurses and other medical professionals are permitted to confront patients when they believe the patients have crossed the line. In other words, nurses should have input in some instances involving the health of patients.

A Policy to Address the Situation

Patients who abuse their right to autonomy should be governed by a different policy. To resolve treatment difficulties between nurses, other healthcare workers, and patients, a committee should be formed. The tribunal should be comprised of healthcare specialists tasked with assessing the appropriateness of therapy and religious leaders who will provide religious viewpoints on the treatment. This court will govern patients who violate their rights.

Procedures and Guidelines for Policy Implementation

Implementation of the program will begin with a study of patients who perish in the name of autonomy (Pozgar, 2013). This data will be utilized to convince more healthcare experts to join the fight. A measure will be drafted and introduced to the legislature for debate. If it passes, more lives will be saved by nurses.

Affected Persons

The policy affects both healthcare workers and patients. When they believe that patients are abusing their right to autonomy, nurses will have the legal authority to file a complaint with a tribunal. In addition, patients will explain why they do not want particular treatments.

Conclusion

In all of their roles within healthcare facilities, nurses face moral quandaries. They can be annoyed by their supervisors, even doctors. Additionally, patients might disappoint nurses by asserting their autonomy. However, the challenges can be resolved by the nurses creating policies that make their work simpler and voicing their concerns to the appropriate authorities.

References
Aydin Er, R., & Ersoy, N. (2017). In Turkey, nurses who work in psychiatry clinics face ethical issues. Psychiatric Nursing Journal/Psikiyatri Hemsireleri Dernegi, 8 (2). https://pdfs.semanticscholar.org/4ab0/4d9127e461e2ea867d89535161d9e8dcf19e.pdf
de Camões, L. (2023). Dante and Camões: Epic and the Portrayal of Humanity. In the Footsteps of Dante: Crossroads of European Humanism, 99, 203.
Guido, G., Prete, M. I., Peluso, A. M., Maloumby-Baka, R. C., & Buffa, C. (2010). The role of ethics and product personality in the intention to purchase organic food products: A structural equation modeling approach. International Review of Economics, 57(1), 79-102.
Guido, G. W. (2014). Nursing legal and ethical issues (6th ed.). Prentice Hall, Upper Saddle River, New Jersey (Chapter 3 and 4)
Krautscheid, L. C., Luebbering, C. M., & Krautscheid, B. A. (2017). Styles of conflict resolution exhibited by nursing students in response to microethical problems. 143-145. doi: 10.1097/01.NEP.0000000000000132. Nursing Education Perspectives, 38(3).
Pozgar, G. D. (2013). Legal and ethical considerations for medical practitioners (3rd ed.). Jones and Bartlett, Boston (Chapter 1 and 4).
Rainer, J., Schneider, J. K., & Lorenz, R. A. (2018). Ethical conundrums in nursing: An integrative analysis Clinical nursing journal, 27(19-20), 3446-3461. https://doi.org/10.1111/jocn.14542
Tverskoi, D., Guido, A., Andrighetto, G., Sánchez, A., & Gavrilets, S. (2022). Disentangling material, social, and cognitive determinants of human behavior and beliefs.
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Study Notes:
The MORAL model (Moral Distress, Outcomes, Role, And Loyalties) can be used to analyze and resolve the dilemma presented in the case study described in EXERCISE 4-3. The nurses in this scenario may respond to the physician’s request by first identifying their moral distress and then exploring their own values, beliefs, and loyalties related to the situation. They may then begin to take positive actions to prevent moral distress by seeking guidance from colleagues, seeking additional information, and advocating for the best possible outcome for the patient.
In the case study entitled You be the Ethicist, the compelling rights that are addressed include the right to autonomy and self-determination, the right to life and health, and the right to informed consent. The rights of the 14-year-old patient should take precedence, as he is a competent individual who should have the right to determine what will happen to him. However, it is also important to consider the potential harm to the patient and the consequences of his decision on his health.
From the perspective of health care policy, it would be necessary to evaluate the need for the policy and the possible support or lack of support from peers, nursing management, and others who might be affected by the policy. The 10 framework questions outlined by Malone in chapter 4 of the Guido textbook can Help in this process. A process proposal for the organization could include guidelines, procedures, and policies that address the ethical issues identified in the case study, such as informed consent and autonomy.

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