Better Mitigation Tools, Research Needed for Caregiver Moral Distress

Management of ethical challenges has an impact on the nursing experience

stressed out nurse

For nearly 40 years, researchers have been shining a light on the challenge of moral distress among nurses and other healthcare professionals, but progress has been slow when it comes to developing interventions to help them face ethically challenging situations.

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 “Interventions to Mitigate Moral Distress: A Systematic Review of the Literature,” recently published in the International Journal of Nursing Studies, outlines research on the topic and recommends that educational tools be designed to empower nurses to manage the different types of moral distress they encounter at work.

“Researchers have been studying moral distress since it was first described in the nursing literature in 1984, but most of the research has been focused on understanding what moral distress is, its causes and impact,” says Georgina Morley, PhD, Director of the Nursing Ethics Program at Cleveland Clinic and first author on the review. “We wanted to look at whether there is actually anything that has an evidence base as an intervention to help us address moral distress.”


Morley worked with Rosemary Field, MS, APRN-AOCNS, Cristie Cole Horsburgh, JD, and Christian Burchill, PhD, RN, CEN, to identify and assess mitigation efforts for moral distress, which is the psychological distress that occurs because of a moral event.

Situations that can ignite moral distress include: when caregivers believe they know the right thing to do but aren’t able to carry it out; when caregivers believe they are exacerbating a patient’s suffering; when caregivers don’t know the right course of action; when two or more options feel equally bad; and when there is disagreement between care team members. The effects of the COVID-19 pandemic on caregiver experiences has increased the likelihood that nurses will experience moral distress.

Effects of moral distress are wide ranging

There is still much to be learned about how to address the negative effects of moral distress on caregivers. The phenomenon has been linked to intentions to leave healthcare or leave positions within high acuity environments such as intensive care units.

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The presence of moral distress is not entirely negative.

“It shows that people have ethical awareness and they can see when there’s an ethical issue at stake. It shows that they care and that they’re connected to their patient,” Dr. Morley says. “The experience of moral distress is probably a good thing, but there are all these negative outcomes and emotions that can result because of the distress, including feelings of frustration and disempowerment.”

The authors reviewed interventional studies through Medline, Embase, PsycINFO, CINAHL and Cochrane from July through September 2019 as well as bioethics databases.

The authors found a variety of approaches to mitigate moral distress, including facilitated discussions, specialist consultation, multidisciplinary rounds, self-reflection and narrative writing.

While statistically significant reductions in moral distress were reported in seven of the 16 included papers, Morley and her team found design and methods limitations that suggest the need for more rigorous assessment. One of  the struggles of building tools to help address moral distress, and developing reliable ways to measure them, lies in the “unwieldiness and the subjectivity of moral distress itself,” Dr. Morley says.

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“How do you design an intervention that could be successful at mitigating the impact of an ethical issue? It’s just such a big problem because we can think about ethical issues in different ways. And it is necessarily value-laden,” she says.

Similarly, interventional studies are difficult to design and to implement, Dr. Morley says.

The ideal kind of educational program might consist of developing ethics competencies through both classroom teaching and hands-on experience.

“An example that springs to mind is you have a nurse that’s experiencing, let’s say, moral-uncertainty distress because they don’t understand why a patient is receiving certain treatments or the plan of care is not clear,” Dr. Morley says. “For nurses who may be new or don’t have as much confidence, or simply work in settings where it’s challenging to have these discussions with providers, can we teach them skills to navigate this issue?

“One of the things we’ve been doing at Cleveland Clinic is plan-of-care rounds, and it’s meant to be a purposeful way for nurses to have these conversations,” she adds. “Caregivers still need to possess communication skills to articulate concerns in a way that can be heard by others to promote open dialogue. That might not immediately seem like an ethics skill, but it really is vital for addressing an ethical issue.” Among the takeaways from the authors’ systematic review, Dr. Morley says, is that cross-disciplinary research expertise can make an important contribution to quality. “Collaboration from researchers, ethicists and philosophers can really produce high quality research, because then you have the experts that are able to engage with the conceptual theoretical work and make sure the research is conducted in a really robust way.”