Moral Distress in the Emergency Department
This guest post is written by Lisa Wolf PhD, RN, CEN, director, Institute for Emergency Nursing Research, Emergency Nurses Association
Moral distress as it is currently understood in nursing has been studied in many settings, but there is a lack of research on the nature and content of moral distress as it manifests in the emergency department (ED).
Moral distress has been described by Corley and colleagues1 as "the painful psychological disequilibrium that results from recognizing the ethically-appropriate action, yet not taking it, because of such obstacles as lack of time, supervisory reluctance, an inhibiting medical power structure, institution policy or legal considerations." Because researchers find a relationship between moral distress and aspects of burnout, nursing retention and job satisfaction, this is an important area of study.
To investigate moral distress among emergency nurses, we conducted a qualitative exploratory study in which 17 nurses participated in two focus groups held at the Emergency Nurses Association's 2014 Annual Conference. The nurses had an an average of 24 years of experience in nursing and 19 years of experience in emergency nursing.
Overall, nurses in the study described a profound feeling of not being able to provide the quality of care they believed patients deserved. They told us about "challenges of the emergency care environment" that included staffing levels, quality and safety of patient care, the use of technology and conflicting expectations of the nursing role. "Being overwhelmed" included categories concerning frequent users, time pressures and patient volume and flow. "Maladaptive/Adaptive/Coping" included categories referring to emotional fallout, physical symptoms and stress management strategies.
What we found was that unlike in the ICU and other care areas, where sources of moral distress were interaction-based (ie, conflicts between particular nurses and patients, or nurses and families, or nurses and physicians), feelings of moral distress in the ED centered on the practice environment itself.
Nurses reported physical manifestations of moral distress that included disturbances in sleep, food intake, and complaints of gastrointestinal (GI) distress, fatigue and high blood pressure. The emotional repercussions of moral distress were reported as helplessness, despair, complacency, burnout, emotional withdrawal, anger, depression/anxiety and desire to leave the job. Nurses reported coping with this distress by using "positive" mechanisms such as training for a triathlon, or unit support groups, but also reported using less positive coping mechanisms such as alcohol and food to mitigate the feelings of moral distress.
There are two really important implications of this study, for both emergency nursing specifically as well as nursing as a discipline: the first is that for emergency nurses, the cause of moral distress is an inability to provide care to the standard they see as a disciplinary obligation, stemming from a lack of resources and support. In short, the factors in moral distress are environmental, and therefore the solutions must also address the work environment.
The second implication is that nurses describe high levels of "moral residue," or lingering moral distress, from what appears to be an almost continuous series of compromising events and lack of external support, or capacity, to remedy the way in which care is provided. This leads to burnout and compassion fatigue, and ultimately patient care suffers.
The issue of moral distress affects both nurses and their patients. Addressing the individual and environmental factors of moral distress may lead to a healthier work environment and better patient care.
1. Corley MC, Elswick RK, Gorman M, Clor T. Development and evaluation of a moral distress scale. J Adv Nurs. 2001;33(2):250-256.