Implications of moral distress on nurses and its similarities with Burnout

Abstracts

Realizou-se uma revisão integrativa, com o objetivo de identificar as implicações do sofrimento moral para os(as) enfermeiros(as), aproximações entre sofrimento moral e burnout, e estratégias de enfrentamento do sofrimento moral, na literatura científica nacional e internacional publicada nos últimos 10 anos. As bases de dados foram CINAHL, MEDLINE e SAGE, e as palavras-chave, sofrimento moral, burnout e enfermagem. Obtiveram-se 21 artigos para análise, realizada em quatro etapas: redução, visualização e comparação dos dados, e verificação e esboço da conclusão. Identificou-se que o sofrimento moral vivenciado pelos(as) enfermeiros(as) manifesta-se na dimensão pessoal, com alterações emocionais e físicas, e na dimensão profissional, com insatisfação no trabalho, burnout e abandono da profissão. Constataram-se estratégias de enfrentamento em três dimensões: educativa, comunicativa e organizacional. Considera-se necessário maior exploração dessa temática, contribuindo para a prevenção do sofrimento moral.

Moral; Ética; Burnout; Enfermagem

Fue realizada una revisión integradora, con objetivo de identificar las consecuencias del sufrimiento moral para enfermeros, similitudes entre sufrimiento moral y burnout, y estrategias de enfrentamiento del sufrimiento moral, en la literatura científica nacional e internacional publicada en los últimos 10 años. Las bases de datos fueron CINAHL, MEDLINE y SAGE, con las palabras clave sufrimiento moral, burnout y enfermería. Se obtuvieron 21 artículos para análisis, realizada en cuatro etapas: reducción, visualización y comparación de los datos, verificación y esbozo de la conclusión. El sufrimiento moral sufrido por enfermeros se manifiesta en dimensión personal, con cambios emocionales y físicos, en dimensión profesional, con insatisfacción en el trabajo, burnout y abandono de la profesión. Fue constatado estrategias de enfrentamiento en tres dimensiones: educativa, comunicativa y organizacional. Se considera necesaria mayor exploración de este tema, contribuyendo a prevención del sufrimiento moral.

Moral; Ética; Burnout; Enfermería

LITERATURE REVIEWS

Implications of moral distress on nurses and its similarities with Burnout

^IDoctoral student in Nursing, PPGEnf/FURG. Level-I Assistant Professor at Universidade Federal do Pampa. Rio Grande do Sul, Brazil. E-mail: [e-mail]

^IIPh.D in Nursing. Level-III Associate Professor, Escola de Enfermagem (EENF), FURG, CNPq fellow. Rio Grande do Sul, Brazil. E-mail: [e-mail]

^IIIDoctoral student in Nursing, PPGEnf/FURG. Level-I Assistant Professor, EENF/FURG. Rio Grande do Sul, Brazil. E-mail: [e-mail]

^IVPh.D in Nursing. Level-II Adjunct Professor, EENF/FURG. Rio Grande do Sul, Brazil. E-mail: [e-mail]

Correspondence

ABSTRACT

This integrative review was performed with the objective to identify, in national and international scientific literature over the last ten years, the implication that moral distress has on nurses, the similarities between moral distress and burnout, and the coping strategies for moral distress. The surveys were conducted on CINAHL, MEDLINE and SAGE databases, using the keywords: moral distress, burnout, and nursing. Twenty-one articles were obtained for the four-stage analysis: data reduction, visualization and comparison, and the verification and draft of the conclusion. It was found that the moral distress experienced by the nurses is manifested in the personal dimension, by emotional and physical alterations, and in the professional dimension, by job dissatisfaction, burnout and abandonment of the profession. The coping strategies are used in three dimensions: educational, communicative, and organizational. In conclusion, this theme should be further explored in order to contribute with the prevention of moral distress.

Descriptors: Moral. Ethic. Burnout. Nursing.

INTRODUCTION

In the nursing practice environments, where disease often predominates, the workers are affected by several aspects, as they are exposed to a large array of stressors, which, on a daily basis, can put them in problematic situations and force them to experience moral dilemmas, thus leading to moral distress.¹

Moral issues usually occur when one same situation is perceived by different ways, which are not adequately disclosed, understood or resolved, thus leading to dilemmas and moral distress.² Moral dilemma refers to situations in which important moral values are in conflict, and the decision for one option rules out the other.³ Moral distress, on the other hand, refers to those painful feelings and psychological imbalance that occur when nurses are aware of the morally correct conduct to be followed, but are hindered to follow that course of action because of obstacles such as the lack of time, reluctance of supervisors, the inhibiting structure of medical power, institutional policies, or legal aspects.³

Studies have sought to understand how nurses deal with moral issues, moral dilemmas, and moral distress in their everyday practice in public and private hospitals, and it was found that nursing care becomes weakened and a source of moral distress because of problems related to the (dis)organization of work in terms of its humanization, involving the lack of material and human resources, interpersonal relationships,^4-5 institutional support for their autonomy, disrespect to patients' rights, and death by negligence.⁵

In this sense, the moral distress that nurses experience appears to have personal and professional effects on these individuals, which include the development of emotional symptoms, such as frustration, anxiety, anger, and guilt; as well as physical symptoms, such as shivering, sweating, headaches, diarrhea, and crying,^6-7 with possible risks of low self-esteem, loss of integrity and the inability to provide patients with good care.⁷ Furthermore, it can also result in a loss of job satisfaction, poorer patient relationships and even abandoning the job and the profession.⁸ This has caused great concern for the profession, due to the growing lack of nursing professionals, besides the possible problems related to the care and safety of patients and workers.⁹

Moral distress is mainly related to the conditions and conflicts in the workplace; factors that are equally connected to burnout, as the latter is associated with work overload and dissatisfaction and nurses abandoning the profession.¹⁰ The burnout syndrome is a process that results in physical, mental and emotional exhaustion due to being exposed to high levels of stress for a long period of time.¹¹ The chronic sourced of emotional and interpersonal stress at work are related to experiences of exhaustion, disappointment, and loss of interest for the professional activity, which emerges mainly among professionals that provide care to others, and involving personal characteristics as well as features of the workplace, comprising three dimensions, emotional exhaustion, depersonalization, and reduced personal fulfillment.¹²

Therefore, considering the relevance of moral distress for nursing professionals, in their personal life as well as in their relationship with work, the present study addressed the following question: "what implications does moral distress have on nurses?"; with the objective to identify, in national and international scientific literature over the last ten years, the implication that moral distress has on nurses, the similarities between moral distress and burnout, and the coping strategies for moral distress.

METHODOLOGY

This is an integrative review, a broad review method that summarized the empirical and theoretical literature data in a systemized and organized fashion, which permits a broader understanding of the studied phenomenon,¹³ by interconnecting the findings of existing studies,¹⁴ in this case, moral distress and its implications on nurses.

This study followed the five stages of an integrative review, which are: the formulation and identification of the problem, data collection, evaluation, analysis and interpretation, and presentation.^13,15

In the first stage, a theoretical study was performed about moral distress, and the study question was achieved. In the second stage, a bibliographic survey was performed on CINAHL (Cumulative Index to Nursing and Allied Health Literature), MEDLINE (Medical Literature Analysis and Retrieval System on-line) and SAGE Journals Online databases using the keywords moral distress, burnout, and nursing. Also in this stage, the selection criteria for the articles were defined, which included: be indexed on the referred databases under the mentioned keywords; be written in Portuguese, English, or Spanish; published between 1999 and 2009; include the abstract for a first analysis and provide access to the full text on the databases or by the CAPES Portal. The search on the referred databases, following the established criteria, yielded 32 articles, but eight did not provide access to the full text and three appeared repeatedly on the databases.

In the third stage, the surveyed articles were evaluated in terms of the quality of the data and their relation to the study problem. At completing this stage, a total 21 articles were obtained for the analysis among the three databases used for the collection.

The data analysis stage comprised the stages of data reduction, visualization and comparison, as well as the verification and draft of the conclusion.¹³ In the reduction stage the data were subdivided into subgroups according to the names of the authors, journal, title, objectives and approach, type of study, data collection method, target population; sample characteristics; type of analysis; language, origin, evidence, and year of publication. In the data visualization stage, these data were grouped into charts, containing the articles considered important according to the study problem. In the data comparison stage, the charts were analyzed, and the themes and relationships were identified. Finally, in the stage for verification and draft of the conclusion, gradual generalizations were elaborated for each analyzed subgroup, i.e., the data were categorized, summarized and integrated.

In the data presentation stage, the conclusions of the integrative review were presented, demonstrating its elaboration along with the authors' impressions and reflections.

RESULTS

In this integrative review, 32 studies were found, after crossing the keywords, however, 21 articles were selected for analysis, because three were repeated, and eight did not have access to the full text. The articles selected for the analysis are described in chart 1.

Based on the analysis of the articles described in chart 1, it was identified that moral distress that nurses experience at the workplace has implications on the personal and professional dimensions of their lives. It was also possible to identify the coping strategies used for moral distress, elucidated in the analysis categories "Implications of moral distress on nurses and its similarities with burnout" and "Prevention and coping strategies for moral distress", which are presented below.

Implications of moral distress on nurses and its similarities with burnout

The moral distress that nurses experience causes successive changes in their lives, in the personal dimension, manifested by emotional and physical alterations, as well as in the professional dimension, with repercussions in their own performance at work. By analyzing the texts, it is considered that the implications that moral distress has on these two dimensions are similar to burnout.

Regarding the emotional manifestations, they appear along with the initial moral distress, which is seen as a psychological imbalance that nurses experience when facing barriers and being impeded to perform interventions and behaviors they consider adequate (I). Among the stated manifestations, the most recurrent were frustration and feelings of powerlessness, due to their perception of a lack of power in making decisions.^16-23 The feeling of powerlessness can be increased with the development of a feeling of guilt in nurses, because it appears to be associated with their professional ideals, limiting their self-efficacy.^20,24-25

The feeling of frustration can be associated to the moral distress experienced by the nurses in different situations and due to the singularities of each workplace. In the case of emergency units, it appears that moral distress is manifested because of conditions of overcrowding, lack of space and privacy for patients, which can contribute to the development of burnout among nurses, because they realize that they are failing to provide quality care (IV). Among nurses working with telehealth, on the other hand, the frustration is caused by conflicts involving organizational policies and patients, in view of the prescription of nursing care, which can also cause burnout among these professionals, because of the difficulty they face to solve moral challenges such as dilemmas, suffering and uncertainties (VI).²¹ For nurses, it appears that burnout is also associated with feelings of frustration and powerlessness, and can, thus, compromise patient care with manifestations in three dimensions: emotional exhaustion, reduced personal fulfillment, and depersonalization.^17,26

Other emotional manifestations resulting from moral distress are highlighted in the analyzed texts, including feelings of guilt, resentment, anger, humiliations, embarrassment, sadness, misery, anxiety, fear, insecurity, a non-appreciation of work, depression, differences of opinion, and job dissatisfaction.^{16-21,23,27-28}

Physical manifestations appear to occur in a second stage of moral distress, i.e., in the reactive moral distress, resulting from the continuous moral distress that nurses experience when unable to overcome the barriers for interventions and moral behaviors they identify as necessary since the initial moral distress, which can also cause the development of symptoms similar to those of burnout.¹⁶ The most common physical symptoms include: crying spells, loss of sleep, loss of appetite, nightmares, feelings of uselessness, tachycardia, headaches, muscle pain, sweating, shivering, gastrointestinal disorders, and stress.^16,18,20,23

Although this condition requires further investigation, it can be stated that there appears to be similarities between the phenomena of moral distress and burnout, despite being possible to differentiate moral distress for its unique characteristics and its development process, i.e., when nurses feel responsible for a moral action and experience obstacles to implement the desired intervention, developing negative feelings when not accomplished.¹⁶ The physical and emotional manifestations of moral distress, experienced over many years, can result in the abandonment of the profession or in burnout.^16,20,23,25 The frequency of situations that can cause moral distress has been significantly associated with the experience of emotional exhaustion and burnout.¹⁸

It appears that when moral distress is associated with an ethically poor organizational ambiance, it can have a negative impact on nurses' job satisfaction.²⁹ Job dissatisfaction is associated with the abandonment of the profession and a feeling of not wanting to return to work after each shift, because nurses question the purpose of the care they are providing to patients and the ethics of the hospital.²⁹ Associated with the perception of moral distress, it appears there is also a reduction in the interactions with patients and relatives, promoting a less individualized care, as an attempt to avoid pain and a greater suffering.¹⁸

The desire to change jobs or abandon the profession can be related to the nurses' incapacity to avoid and cope with moral distress, decisions that acre followed by feelings of low self-esteem and powerlessness in view of the triggering situation²⁹. The abandonment of the profession has comprised a source of concern due to the high costs for the institutions, related to hiring and training professionals, and the costs with contract terminations, besides the worry about loosing staff, thus requiring the creation of a culture for the retention of nursing professsionals.³⁰

Therefore, it is also relevant to identify the coping and prevention strategies for moral distress in nursing, in order to increase job satisfaction, and, consequently, reduce the abandonment of the profession.³⁰

Prevention and coping strategies for moral distress

According to the analyzed texts, it can be stated that the search for literature regarding the prevention and coping strategies for moral distress deserves special attention to avoid the naturalization of this phenomenon in nursing. These strategies refer mainly to the educational dimension, including the process of permanent education and training; the communicative dimension, which include multiprofessional communication, structured communication, ethical rounds, forums, simulations and lectures; and the organizational dimension.

Regarding the educational dimension, it is suggested that nursing educators should strengthen the discussions and reflections about the ethical issues involved in the professional education process by teaching strategies to encourage the nurses' use of power, using adequate behavior models to cope with situations that involve dilemmas and moral distress, as well as to establish effective interpersonal relationships at work, i.e., that would prepare them to maintain ethical dialogues with other professionals.^25,31 Also regarding the educational dimension, emphasis is given to permanent education programs, with informative interventions about moral distress, such as offering ethical workshops and literature updates and courses about ethics, along with the work of ethics committees, providing opportunities for discussion, coping and seeking answers to the ethical conflicts existing in the everyday health care practice at institutions.^{20, 22, 25,30-33} The interdisciplinary education of health care professionals is also seen as an essential strategy, because it helps to strengthen the collaboration between the health team members, thus promoting socialization and discussions about the care provided to patients; also to help in this process, it suggested that philosophers and psychologists participate.^18,34-35

The prevention and coping strategies for moral distress, in the communicative dimension, include multiprofessional communication, structured communication, the ethical rounds, group discussion forums, the simulation of conflicting situations, and lectures on patient care. Except for the lectures on patient care, all the other strategies are aimed at improving the communication between health team members.^{18,20,22,31,33,35} Multiprofessional communication is seen as essential particularly regarding the nurses' knowledge regarding the manifestations and alterations presented by the patients, considering they work close to them. Structured communication, on the other hand, contributes with multiprofessional communication by establishing an order of discussion, in other words, first there is a description of the situation, followed by the presentation of its background, i.e., of what is found regarding the present situation, then, an evaluation is performed, and, finally, the recommendations are made.³⁵

The ethical rounds, group discussion forums and simulations of conflicting situations are important in order to discuss, from a moral and ethical perspective, issues related to the patient treatment goals, as well as case studies, encouraging intervention strategies.^{18, 22,31-32,35} And, finally, lectures are mainly used to promote the development of communication between health team members and relatives, also providing nurses with opportunities to talk with other professionals on the team, and expose their beliefs and address ethical dilemmas related to health care.^20,31,33,35

Therefore, it is realized that communication is an essential element in nursing practice, which can involve the team itself, nurses, or between nurses and the medical team, so as to avoid conflicts and maintain their job satisfaction.^{20,22,25,33,35}

Coping with moral distress, in an organizational dimension, includes strategies such as the inclusion of nurses and nursing leaders in the process of creating organizational policies and decisions, and incorporating safety measures,^18,21,32 as well as hiring more nurses to reduce the overload and increase their available time to invest in health education interventions and prevention measures to avoid harms.³³ It is also important to improve the working conditions, such as distributing material resources and promoting sustainable environments, with nurses being closer to the patients.^20,36 Therefore, when the administration of the hospital provides the necessary support, nursing leadership can be improved, because, sometimes, they are described as invisible, as they do not advocate for the staff and not even for the clients.^20,22

Moral distress and the challenges of the nurses' working environment should, therefore, be valued so that coping and prevention strategies can be developed and socialized, thus avoiding the abandonment of the profession, job dissatisfaction, the possible development of burnout and, consequently, the scarcity of nurses to work in health institutions.^26,35

DISCUSSION

Based on the implemented integrative review, it was possible to realize the implications that moral distress has on nurses in several aspects, in the personal as well as professional dimensions. In the personal dimension, nurses can present emotional and physical manifestations, while in the professional dimension, the nurses' manifestations result from their own work performance, with interferences on their satisfaction, which can lead to the abandonment of the profession.

The emotional implications caused by moral distress appear to be strongly related to the nurses' lack of power in making decisions, which often drives them towards making interventions that are against their beliefs and values, and denying their knowledge, which results in feelings of frustration, powerlessness and guilt, related to the organizational and ethical conflicts. The physical implications, on the other hand, emerge in the reactive stage of moral distress, which is more advanced and can also result in burnout.

In this sense, some consequences of moral distress on nurses can be differentiated between the individual and institutional level. In the former, suffering appears due to the submission in conflicting situations, with the development of burnout and the abandonment of the profession; in the latter, the high rates of turnover appear among nurses, with difficulties in hiring professionals, which causes a reduction in the quality of care and a reduced patient satisfaction, which compromises the reputation of the institution,³⁷ which appears to be associated with the usual lack of protection and care that nurses need to perform their activities, avoiding work-related accidents and diseases.³⁸

Emotional exhaustion, on of the dimensions of burnout, also appears to be strongly associated with moral distress. The causes for emotional exhaustion include work overload and personal conflicts in the relationships, i.e., a distress um that originates from the affective attachment created in the individuals' relationships with work.^38-39

It is also considered that poor working conditions, fragile interpersonal relationships, and management models that are not very participative contribute for the nurses' distress.⁴⁰ Work, therefore, can often be a source of moral distress and burnout for nurses, due to the conditions in which it is performed, and may thus interfere on their personal and professional decisions, with possible negative influences on their work results and in the lives of these workers. Hence the relevance of the nurses' seeking a meaning for their work, in the sense of valuing it and, therefore, avoiding or coping better with the professional exhaustion and moral distress in the workplace. Nurses become emotionally involved with their work to achieve a better performance of care, but they often have to deny their emotions and beliefs in order to work according to the recommendations of the institution.^41-42 In this sense, it is important to search strategies to promote nurses' autonomy and recognition, thus avoiding job dissatisfaction, burnout and the abandonment of the profession.⁴²

Prevention and coping strategies for moral distress are essential considering job satisfaction as well as to retain the nurses in the workplace, an issue that should be addressed in their education process and in health institutions, in order to also contribute with the recognition and cooing of this problem. Therefore, it is important for health institutions to create ethical environments in which nurses can express themselves, recognizing their liberty to discuss about what they consider to be the bets patient care interventions, valuing their knowledge and their role in the health team, encouraging respectful practices and collaboration in the multiprofessional team, with a view to provide greater benefits in the development of the work, reflecting as a better service to patients.

FINAL CONSIDERATIONS

In view if the finding regarding the implication that moral distress has on the nurses' lives, with emotional and physical manifestations in the personal dimension, and job dissatisfaction, burnout and abandonment of the profession in the professional dimensions, in addition to the negative effects for health institutions and patient care, it is fundamental to perform studies that focus on how this problem develops. Furthermore, it is necessary to implement strategies that strengthen the ethical environment in the organization, the valorization and recognition of the nurses' work in the institution, thus contributing with their well being and the adequate provision of health services to clients, as well as the improvement of the collaborative dialogue with the other health care professionals.

In this sense, it is also essential to address and explore the moral distress issue both in the educational process of nurses as well as in health institutions, in order to contribute with the prevention and coping of this feeling and the resulting implications, which include the nurses' abandonment of the ideals of the profession. Job dissatisfaction and the abandonment of the profession among nurses are serious problems that must be highlighted. However, the abandonment of the professional ideals by nurses while practicing their profession is an urgent problem that must be dealt with immediately, in order to assure the continuity of the nursing identity as a profession whose essence is care.

Finally, we outline that all the articles analyzed in the present study were published outside Brazil and written in English, which could, therefore, be a better reflection of the international rather than the national condition. However, studies addressing moral distress and their implications on nurses, due to moral problems and dilemmas present in the everyday nursing practice, remain scarce despite being a current and common issue. Furthermore, the issue is not well recognized by nurses, who are often affected by their manifestations, but do not know how to react to them, which thus reinforces the need to value the ethical dimension in their field of practice.

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¹

Graziele de Lima Dalmolin^I; Valéria Lerch Lunardi^II; Edison Luiz Devos Barlem^III; Rosemary Silva da Silveira^IV

Publication Dates

• Publication in this collection
  28 Mar 2012
• Date of issue
  Mar 2012

History

• Received
  04 Oct 2010
• Accepted
  08 July 2011