Moral Distress Takes Toll on Nurses

Moral distress is a serious problem among nurses that must be addressed for their sake as well as the sake of their patients.

According to the AACN, moral distress occurs when “you know the ethically appropriate action to take, but are unable to act upon it or you act in a manner contrary to your personal and professional values, which undermines your integrity and authenticity.”

“Critical care nurses work in a high stress environment, where they face daily challenges,” said Debra S. Wantz-Bucher, DNP, MSN, RN, CCNS, operations manager nursing education and adult ICU, Geisinger Medical Center, Danville, PA. “Moral distress can cause significant harm to caregivers and patients alike when left untreated.”

Factors & Impact

Several factors can contribute to moral distress including, but not limited to, intense patient situations (e.g. end of life care), lack of collaboration, and disrespectful communication.

“When caregivers do not feel safe in their work environment to do what they know is right, every member of the healthcare team and the patients they serve suffer,” stressed Wantz-Bucher. “If you become a victim of repeated moral distress it erodes at you as a person and can cause a variety of issues.”


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Untreated moral distress can result in emotional exhaustion, increased absenteeism, low morale, chronic discontent, and job dissatisfaction, according to Wantz-Bucher, which can lead to compassion fatigue and eventually burn out.

In turn, these symptoms can contribute to staff turnover.

“Recruitment and retention are big issues in nursing,” she noted. “We want to recruit nurses and more importantly we want to retain those nurses once we orient them.”

High staff turnover not only costs institutions financially, it also costs facilities in terms of unit morale and patient safety.

“When caregivers are not satisfied at work, the entire continuum of care feels the effects, which is why it is so important that leaders are aware of the signs,” said Wantz-Bucher.

Recognizing Distress

Nursing leaders must recognize the signs and symptoms of moral distress.

According to Wantz-Bucher, there are four domains of signs and symptoms: physical, emotional, behavioral and spiritual.

Nurses dealing with moral distress often show the signs of chronic overstress, such as fatigue, headaches and weight gain/loss. “You are more susceptible to illness because you are run down,” said Wantz-Bucher. “You aren’t sleeping well, which can impact your mental processes at work.”


“You may be more forgetful than usual,” she continued. “Critical care nurses are dealing with life and death. They must be at their best both mentally and physically.”

Emotional symptoms include anger, fear, guilt, depression and oftentimes resentment.

“An overreaction could be a warning sign for nurse leaders,” noted Wantz-Bucher. “I always become suspect when I see a nurse react in a way that I don’t feel is appropriate given the circumstances at hand.”

“When that happens I take a step back and ask myself, ‘what just happened here,'” she added. “In terms of behavioral signs and symptoms that’s a little more difficult.”

Behavioral signs require leaders to know their staff well. Nurses under moral distress may begin to show signs of addictive behavior and a lack of boundaries. Staff may overstep and become a little too close to patients or they may move in the opposite direction and become detached and indifferent.

“Spiritually nurses may feel disconnected from people and face a crisis of faith,” explained Wantz-Bucher. “Moral distress can cause caregivers to feel out of control and begin to question why they are doing what they are doing.”

“You should never dread going to work,” she emphasized. “When a nurses tells me she cries on her way to work every day there is something seriously wrong.”

Combating Distress

Once leaders identify moral distress in their unit, it is important to not only find the solution, but also the cause.

“Every individual is different,” said Wantz-Bucher. “As leaders we must help them identify what is wrong and see how it ties to moral distress and workplace events.”

At Geisinger, employees have five free counseling sessions at their disposal. In addition, the ICU has champions that watch out for the signs of moral distress among their colleagues.

“These nurses have a particular interest in a healthy work environment and have been trained in identifying moral distress,” said Wantz-Bucher. “The staff knows they can go to these people when they need help coping with an event or issue.”

Whether it is a workplace bully or the death of a patient these nurses are always available to help. “When a fellow nurse shares a concern, if necessary, the champions will make leadership aware of the problem.”

Wantz-Bucher recalls a recent example. “A young pregnant woman was admitted to the ICU and fetal demise occurred,” she said. “This event had a huge impact on the staff, especially new nurses on the unit.”

“They were very distressed by what they had observed and were feeling extremely bad, so they went to their champions, who in turn, came to me.”

Wantz-Bucher’s team can also find relief and support through a peer protected program known as “the circle.” Nurses can sit with the chaplain and talk about all that happened. She then provides a debriefing and strategies to cope.

“Sometimes all a nurse needs is the opportunity to talk to one another and validate that they aren’t the only one’s feeling this way,” Wantz-Bucher said. “The circle provides them this chance.”

“If the spiritual care provider believes that there is a nurse or nurses in this meeting that are really having a hard time, they come to me,” she added. “I then confidentially help them get whatever it is they need to get back on the path of good health.”


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Prevention the Priority

While nursing leaders play an important role in identifying with moral distress, they also have the power to make a difference before incidents occur.

“Preventing moral distress depends on communication, positivity and respect,” stressed Wantz-Bucher. “Leaders must recognize the situations that could potentially lead to moral distress while fostering an environment where staff members feel comfortable communicating within their unit and beyond.”

Situations will occur that can negatively impact the team, but as long as those concerns are expressed in a timely, respectful manner the issues can be resolved and the unit will move on stronger than ever.

“Early intervention is important for everyone,” concluded Wantz-Bucher. “Nurses are not the only ones at risk for moral distress. Caregivers of all specialties and disciplines are welcome to join us and talk about an issue.”

“Challenges and differences will arise, but as long as there is honest communication they can be overcome.”

Catlin Nalley is assistant editor at ADVANCE. Contact: [email protected]

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