Emergency nurses know what it’s like to suffer pangs of moral distress

Like the emergency physicians they work alongside, ER nurses experience moral distress in substantial numbers and multifaceted ways, according to a new study published in the Journal of Clinical Nursing.

The researchers behind the investigation note their findings also align with those from previous probes into moral distress in nurses working in ICU and critical care settings. 

The new study similarly echoes prior recent research into moral distress among ER doctors and, in fact, physicians in general.

For the present inquiry, PhD candidate Clare Walters and colleagues at Murdoch University in Australia conducted a scoping review of the relevant scientific literature. 

The team defines moral distress as the unsettled psychological state experienced “when a nurse knows the right course of action but is constrained from acting upon it due to institutional or systemic barriers.”

This definition adapts wording from the late Andrew Jameton, PhD, who first used the term in 1984 and refined the concept in subsequent years. 

Narrowing the literature to 12 representative studies from a raw cohort of more than 180 with some relevance, the Aussie team found most research concentrated on the experience of moral distress. 

Largely left out to date have been evaluations of interventions, organizational supports and long-term effects, Walters and co-authors report. 

Painful compromises to care quality 

That said, the present study offers some instructive insights into the nature and character of moral distress. 

Across the studies analyzed by Walters et al., for example, moral distress was consistently described as “a significant and multifaceted experience” for emergency nurses. 

Also: 

• Moral distress was often triggered when ER nurses “perceived a conflict between their professional values and the care they were required to deliver.”
   
• Consistent with prior research into the experience among ICU and critical care nurses, Walters and colleagues report, moral distress in ER nurses is a risk when providing care perceived as futile.
   
• Another commonly described scenario is nurses thwarted from “acting in accordance with ethical standards” by organizational constraints like inadequate staffing and low-skilled co-workers. 
   
• Across methodological approaches, moral distress was consistently described as a multifaceted phenomenon associated with emotional exhaustion, reduced job satisfaction, increased intent to leave and perceived compromises to care quality.

Emergency professionals don’t work in a vacuum 

In their discussion, Walters and co-researchers remark that emergency RNs represent a particularly vulnerable cohort for moral distress. 

“The ED environment is distinguished by its need for rapid decision making, patient acuity, unpredictable workloads and limited continuity of care,” they write.

The team adds that the present findings “underscore the need for further conceptual and empirical work to refine definitions of moral distress and related constructs, strengthen measurement consistency and support the development of targeted, context-responsive interventions.”

In coverage of the study by Murdoch University’s in-house news operation, Walters warns healthcare leaders that, if hospitals are to retain experienced emergency nurses, “we need to stop thinking of resilience as an individual responsibility.”

“We cannot keep asking nurses to become more resilient,” she adds, “while simultaneously expecting them to work in systems that repeatedly place them in ethically impossible situations.”

The study is posted in full for free.