Addressing Moral Distress

The importance of Peer Group in recognizing Moral Distress:  The ‘4 A’s’ Model

The following prominent model called ‘The 4A’s to Rise Above Moral Distress’ 3, was proposed by The American Association of Critical Care Nurses to help those who experience moral distress. The aim of this approach is to identify and reduce moral distress by responding through the following four steps (AACN, 2005; Rushton, 2006).4,5

 

  1. Ask: Help individuals to ask and identify whether the symptoms they are experiencing are associated with moral distress. The objective of this step is to enable the individual to become aware that moral distress is present, if it is indeed present.

  2. Affirm: Following the identification step, the individual is encouraged to affirm his/her distress and proceed with the commitment of taking care of his/herself. This commitment involves validating the individual’s perceptions and feelings with others; while affirming their professional duty to act. The objective of this step is to enable the individual to make a commitment to address moral distress.

  3. Assess: Once the commitment is made by the individual to address moral distress, they can begin to assess the sources of their experience and determine whether it is personal or environmental. The goal of this step is to encourage the individual and confirm that ‘you are ready to make an action plan’.

  4. Act: This step prepares the individual to take the action set out in their action plan and to begin implementing strategies that result in the desired changes while also expecting some set-backs.  The goal of this step is to help the individual preserve their authenticity and moral integrity. 

First-Aid Strategies

During times of intense crisis such as the pandemic, we are challenged to discern the ethically justified response and to maintain a sense of professional integrity.  Applying E-PAUSE to ethical challenges is an opportunity to pause, reflect and empower ethical competence and resilience.

E- Ethical Context – Name the ethical challenge or issue

P- Perspective Taking – Who is involved and what are their perspectives, biases, and assumptions?

A- Ask Questions

U- Utilize Resources

S- Stand up and Speak

E- Empower My Practice

Short-Term Strategies

1. Acknowledge the suffering.

Name it, giving voice to it and bearing witness to it are important steps toward creating an environment of professional integrity.   

2. Offer support.

Those experiencing moral distress should be encouraged to seek informal support from trained peer supporters, managers, colleagues, chaplains, or other support provided by their employers.

3. Be a leader.

Those in leadership roles should proactively check in with their teams and facilitate effective team cohesion, informal support, or professional support, when needed.

Long-Term Strategies

1. Education.

Improved understanding of and developing coping strategies for moral distress are key. Focusing on individual practitioners and strengthening ethical skills—including the ability to recognize and interpret a situation that contains ethical content—may lessen the intensity and frequency of moral distress.

2. Collaboration. 

Education with a focus on fostering and participation in an interprofessional environment to facilitate greater understanding of the perspectives of other health practitioners and to improve collaboration and consequently interdisciplinary dialogue.

3. Implementation of moral distress rounds or ethics rounds. 

When team members can share their feelings with colleagues, this helps to create a work environment that’s more likely to support moral agency.

The Moral Distress Education Project from the University of Kentucky is a self guided web documentary that offers more information and possible techniques for addressing moral distress

References:

(1)  Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice-Hall.

(2)  Hardingham, L. B. (2004). Integrity and moral residue: Nurses as participants in a moral community. Nursing Philosophy, 5(2), 127-134.

(3)  http://www.emergingrnleader.com/wp-content/uploads/2012/06/4As_to_Rise_Above_Moral_Distress.pdf

(4)  American Association of Critical Care Nurses (AACN). (2005). AACN standards for establishing and sustaining healthy work environments. Retrieved from https://www.aacn.org/nursing-excellence/standards/aacn-standards-for-establishing-and-sustaining-healthy-work-environments

(5)  Rushton, C. H. (2006). Defining and addressing moral distress: Tools for critical care nursing leaders. AACN Advanced Critical Care, 17(2), 161-168.

(6)  Jameton, A. (1993). Dilemmas of moral distress: Moral responsibility and nursing practice.AWHONNS Clinical Issues in Perinatal & Womens Health Nursing, 4(4), 542-551.

(7)   Webster, G., & Bayliss, F. (2000). Moral residue. In S. Rubin, & L. Zoloth (Eds.), Margin of error: The ethics of mistakes in the practice of medicine. Hagerstown, MD: University Publishing Group, Inc.

(8)  Epstein, E. G., & Hamric, A. B. (2009). Moral distress, moral residue, and the crescendo effect. Journal of Clinical Ethics, 20(4), 330-342.

(9)  Corley, M. C. (1995). Moral distress of critical care nurses. American Journal of Critical Care, 4(4), 280-285.

(10) Hamric, A. B., & Blackhall, L. J. (2007). Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate. Critical Care Medicine, 35(2), 422-429.

(11) Epstein, E. G. (2008). End-of-life experiences of nurses and physicians in the newborn intensive care unit. Journal of Perinatology, 28, 771-778.