As a nurse, you’ve likely been caught in the moral distress crosshairs. Your training, instincts, and values are telling you the right thing to do, but you’re anguished because other factions are preventing you from doing it.

Indeed, there are enough grey areas in medicine to cause anxiety for even the most seasoned nurses, particularly those dealing with chronic conditions and end-of-life choices. A physician dismisses your opinions. . .Hospital policy doesn’t permit your suggestions. . .Or you’re at odds with family members over choices. You’re certain the treatment will be suffering without benefit while they hang on to hope.

So, how do you diminish the moral distress that ethical dilemmas trigger? By planning strategically and acting boldly, you can change the dynamic and open the conversation so that you and others aren’t going it alone.

“Silence is extraordinarily harmful when it comes to moral distress,” says Katherine Brown-Saltzman, RN, MA, co-director of the UCLA Health System Ethics Center and an assistant professor at the UCLA School of Nursing. “It creates isolation, which creates a sense that ‘I’m in this alone. No one else understands or appreciates it.’ It also doesn’t allow for the creative potential of coming together and working things through.”

Plan Strategically

Whatever situation is fueling your angst, creating a self-care plan that maximizes your strengths and minimizes potential pitfalls is essential. Since moral distress can trigger physical, emotional, behavioral, and even spiritual responses, recognizing the cues is a no-brainer. But steeling your resolve also involves other proactive steps.

Respect Values—Yours and Others

Being comfortable with your values and those of others is fundamental for navigating any ethical issue. Your moral compass is based largely on a belief system rooted in culture, family, ethnicity, and religion. They set the tone for your responses even though your training and specialty choice influence, too. Caring for patients with chronic illnesses, relentless pain, and/or end-of-life challenges, for instance, can skew your viewpoint. The same holds true for being part of a minority group historically rebuffed by the health care system. “That’s going to profoundly affect your perspective and perhaps even level of advocacy to vulnerable patients,” Brown-Saltzman says.

Whatever influences you, however, being curious about what motivates others matters as well. Understanding someone else’s priorities and goals is crucial in finding common ground. But it also may determine what you do next. Even though your responsibility is to set aside your belief system for a patient, you may need to step away eventually. “We all have the right to our deeply held values, but we can’t force them on other people,” says Donna Casey, BSN, MA, RN, NE-BC, FABC, vice president of patient care services and co-chair of the ethics committee at Christiana Care Health System in Newark, Delaware . “So when we’re asked to do something professionally that goes against our beliefs, it’s our obligation to ask to be removed from the situation.”

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Identify Sympathetic Colleagues

Even though the response to any ethical dilemma is personal—not everyone will share your sensitivities—moral distress has to do with the environment, too. Hopefully, you’ve selected a workplace where you’re empowered to speak up because nursing leaders listen. Even if you draw a line in the sand, they’ll honor your values—and the conscience clause protecting your rights.

But you also want trusted colleagues in your corner. With empowerment research showing that two people standing up for something are more likely to stay the course than one person going it alone, there’s reason to lasso a workplace colleague with similar misgivings about an ethical situation. It adds credence to your voice. “There are times,” says Casey, “when you may be off base because you only have partial information. By sharing your concerns with peers, you can validate them.”

Likewise, a mentor not only can help clarify events, but also broaden your skills. For instance, Melissa Batchelor-Murphy, PhD, RN-BC, FNP-BC, assistant professor at Duke University School of Nursing, had little advanced training early in her geriatric nurse practitioner career to be a death and dying expert. But since counseling was part of her job, she not only read copiously about aging patient issues, but also tapped a mentor to model difficult end-of-life discussions. By listening intently, Batchelor-Murphy not only survived an initial rough patch but also sharpened her geriatric communication skills.

Today, she advises other nurses, particularly in high burnout specialties, to do the same. “You need to seek out that mentor and then ask to sit in and watch how it’s done,” she says. “Also notice when someone else isn’t doing it well so you’ll know where you want to be.”

Act Boldly

You may reach a critical juncture whereby you undergo what Alvita K. Nathaniel, PhD, and Margaret A. Burkhardt, PhD, authors of Ethics and Issues in Contemporary Nursing refer to as moral reckoning. That is, something so compelling occurs that you’re finally willing to take a stand, whether that means engaging your supervisor, going up the chain of command, or even blowing the whistle. Even if the situation doesn’t demand dramatic tactics, there are other effective ways to move forward.

Affirm Your Role

Whatever the setting, your perspective as a nurse is uniquely important given the intimate time you likely spend with patients and families. You may have a view about someone’s suffering, beliefs, and family positions that other providers haven’t heard and need to know. Unfortunately, that doesn’t necessarily buy leverage. In fact, physicians don’t always appreciate the moral burden nurses experience.

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There are ways to let others know your value, however. Being respectfully inquisitive of other viewpoints even as you use your listening and questioning skills to determine the rationale behind a medical decision can create inroads. “Many times nurses blame physicians for what they perceive as lacking the moral courage to refuse the aggressive care a family is demanding,” says Casey. “But they’re not our adversaries. We’re all in this together.”

Still, the linchpin in getting your voice heard is to know your ethical responsibilities and refer to them liberally. The American Nurses Association’s Code of Ethics for Nurses, for instance, not only outlines what you can and can’t do, but also yields a framework for discussion and ammunition for making your case. By being able to say “I have an obligation as a nurse to raise and explore this issue with you,” your opinion and advocacy gain new weight. As Mary K. Walton, MSN, MBE, RN, director of patient and family-centered care and nurse ethicist at the Hospital of the University of Pennsylvania, notes:If we can anchor our questions and concerns in the framework of our obligations as nurses, we’ll have a guide to help mitigate distress and/or clarify when we need to hold fast to our professional code and speak up.”

Engage Early

Whatever you do to advocate for your patient, bringing everyone to the table for an ethical discussion is critical. You may involve other resources—chaplains, social workers, and palliative or hospice care specialists — separately at times for their unique perspectives. But you’ll likely need the structure of an ethics consult to sort out those value-laden uncertainties tied to end-of-life or other high stakes care. Such a meeting facilitates common ground by encouraging patients and their surrogates to express their goals—and providers equal time to reframe them into feasible objectives and care.

“Reasonable people can disagree on important matters,” Walton says. “So you want to understand before you try to convince others that your perspective is the correct one.”

To achieve your objectives, you need patience, curiosity, and what Walton refers to as “cultural humility” and “exquisite communication skills” to uncover what’s relevant to others. It’s critical to ask, listen, and reflect so you know how someone else views the situation or sees what you’re not seeing. Whatever the give-and-take, ensuring that everyone has a realistic, coherent picture of the situation—and is comfortable with the next steps—can break the isolation for you and others. “If you engage in an ethical dialogue right from the beginning by inviting everyone to the table,” says Brown-Saltzman, “you have the potential for greater understanding. That paves the way for reduced moral distress.”

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Encourage Family Participation

Since family members are important players, obviously you want their input to build consensus and avoid any unsettling surprises. But sometimes you need to go even further than keeping relatives informed by specifically asking for their participation.

For instance, citing her research about end–stage dementia and eating, Batchelor-Murphy suggests that teaching family members supportive hand feeding as an alternative to tube feeding not only gives family members a role, but also affirms that the health care team is in sync with their quality end-of-life goals. “Sometimes when we have these conversations the only thing families hear is that we’re taking something away from the patient,” she says. “But as soon as we tell them what we can’t do, we also need to say, ‘Let’s talk about how we’re going to take care of your family member.’”

Final Thoughts

With new technologies recasting the diagnostic and treatment landscape in every which way, health care providers have more effective tools now than ever to help patients. But they also have to grapple with the fine line ethics of when to use them. Since the same options that improve and lengthen life may also prolong discomfort and extend dying, there are ample ethical challenges for everyone. And even if you’re not on the high stakes care front line, you may experience other conflicts.

Whatever the source, you have a vested interest in being proactive since moral distress may eventually hurt your ability to provide quality care and shorten your professional longevity. But by boosting your skills, you’re protecting yourself and even changing the dynamic with colleagues. More importantly, you may also stiffen your resolve for helping patients and families make very difficult ethical choices. “We sometimes need to help families understand that life is a limited circumstance,” says Casey. “Medicine has done some wonderful things, but we can’t cure the fact that we’re all going to die.”

Chris Hinz
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