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MORAL DISTRESS Nursing Care Plan

Moral Distress

Response to the inability to carry out one’s chosen ethical/moral

The state in which a person experiences psychological disequilibrium,
physical discomforts, anxiety, and/or anguish that results
when a person makes a moral decision but does not follow
through with the moral behavior**
Defining Characteristics*
Expresses anguish (e.g., powerlessness, guilt, frustration, anxiety,
self-doubt, fear) over difficulty acting on one’s moral choice
Related Factors
When Moral Distress is used to describe a response in nurses, as
explained in this section, related factors are not useful. These
are not documented but rather represent a response
that requires actions by the nurse, unit, and/or institution.
The related factors listed below represent a variety of situations
that can precipitate Moral Distress.
Situational (Personal, Environmental)
End-of-Life Decisions*
Related to providing treatments that were perceived as futile for
ill client (e.g., blood transfusions, chemotherapy, organ
transplants, mechanical ventilation)
Related to conflicting attitudes toward advanced directives
Related to participation of life-saving actions when they only prolong
Treatment Decisions
Related to the client’s/family’s refusal of treatments deemed appropriate
by the health care team
Related to inability of the family to make the decision to stop ventilator
treatment of terminally ill client
Related to a family’s wishes to continue life support even though it is
not in the best interest of the client
Related to performing a procedure that increases the client’s suffering
Related to providing care that does not relieve the client’s suffering
Related to conflicts between wanting to disclose poor medical practice
and wanting to maintain trust in the physician
Professional Conflicts
Related to insufficient resources for care (e.g., time, staff)
Related to failure to be included in the decision-making process
Related to more emphasis on technical skills and tasks than relationships
and caring
Cultural Conflicts
Related to decisions made for women by male family members
Related to cultural conflicts with the American health care system

Author's Notes
This NANDA-I nursing diagnosis, accepted in 2006, has application in all
settings where nurses practice. The literature to support this diagnosis
when submitted was focused primarily on moral distress in nursing.
If moral distress occurs in a client or family, this author suggests a
to a professional expert in this area; for example, a counselor,
therapist, or nurse spiritual advisor. Refer also to Spiritual Distress. Nurses
should expect to experience moral distress as they struggle to make clinical
decisions involving conflicting ethical principles (Zuzelo, 2007).
This author will present Moral Distress as a Department of
Nursing—Standard of Practice. This standard addresses prevention
of moral distress with specific individual nurse, unit, and department
interventions. Strategies for addressing moral distress for individual
nurses, on units, in the department of nursing and in the institution will
be presented.
In this 14th edition, this author has developed and included Risk for
Moral Distress.
Moral Distress represents proactive strategies for individuals, groups,
and institutions to prevent moral distress in nurses. This diagnosis has
not yet been submitted to NANDA-I.
Most Americans fear how they will die than death itself (Beckstrand,
Callister, Kirchhoff, 2006). Eighty-six percent of Americans polled
nurses have very high or high ethical standards, ranking nurses
at the top of other professions

The nurse will relate strategies to address moral distress as evidenced
by the following indicators:
• Identify source(s) of moral distress.
• Share their distress with a colleague.
• Identify two strategies to enhance decision-making with clients
and family.
• Identify two strategies to enhance discussion of the situation
with the physician.

Identify Sources of Moral Stress (AACN, 2004)
• Staffing
• Competency of nurses, physicians
• Nurse–physician communication
• Futile care
• Needless pain and suffering
• End-of-life conflicts
• Deception/incomplete information
• Inadequate symptom management
• Disrespectful interactions
• Violence in the workplace
Determine Actions or Strategy Options
• Evaluate the risks and benefits of options.
• Consider the worse possible outcome to your action.
• Consider the risks of doing nothing (personal, client, family,
• Avoid rationalization.
Do Not Try to Avoid or Shrug Off Moral Distress
• Acknowledge your distress.
• Affirm your professional obligation to act.
• Ask for help and clarification.
“Use the Chain of Command to Share and Discuss Issues That
Have Escalated Beyond the Problem-Solving Ability and/or Scope
of Those Immediately Involved” (LaSala & Bjarnason, 2010)
Explore Moral Work and Action
• Educate yourself about moral distress. Refer to articles on the
• Share your stories of moral distress. Elicit stories from coworkers.
• Read stories of moral action. Refer to Gordon’s Life Support:
Three Nurses on the Front Lines and Kritek’s Reflections on
Healing: A Central Construct (see the Bibliography).
Investigate How Clinical Situations That Are Morally Problematic
Are Managed in the Institution; If an Ethics Committee Exists,
Determine Its Mission and Procedures
Initiate Dialogue With the Client, If Possible, and Family
• Explore what the perception of the situation is (e.g., How do
you think your ___ is doing?)
• Pose questions (e.g., “What options do you have in this
Elicit feelings about the present situation. Does the
family know that the client is terminal? Is the client improving?
• Access the physician to clarify misinformation. Stay in the
room to promote sharing.
• Encourage the client/family to write down questions for the
• Be present during physician’s round to ensure client’s/family’s
• Avoid deception or supporting deception.
Gently Explore Client/Family End-of-Life Decisions
• Explain the options (e.g., “If you or your loved one’s heart/
breathing stops...”)
• Give medications, oxygen
• Cardio defibrillation (shock)
• Cardiopulmonary resuscitation
• Intubation and use of respirator
• Advise the client/family that they can choose all, some, or none
of the above.
• Differentiate between prolonging life versus prolonging dying.
• Document the discussion and decisions according to institute
on policy.
If Indicated, Explain “No Code” Status and Explain the Focus of
Palliative Care That Replaces Aggressive and Futile Care (e.g., Pain
Management, Symptom Management, Less or No Intrusive/Painful
Seek To Transfer Individual From Intensive Care Unit, If Possible
Dialogue With Unit Colleagues About the Situation That Causes
Moral Distress
Seek support and Information From Nurse Manager
Enlist a Colleague as a Coach or Engage as a Coach for a Coworker
• For advice, seek out colleagues who implement actions when
they are distressed.
Start With an Approach to Address an Unsatisfactory Moral Clinical
Situation That Has a Low Risk; Evaluate the Risks Before Taking
Action; Be Realistic
Engage in Open Communication With Involved Physicians or
Nurse Manager; Start the Conversation With Your Concern, for
Example, “I Am Not Comfortable With...,” “The Family Is Asking/
Questioning/Feeling...,” “Mr. X Is Asking/Questioning/Feeling...”
Dialogue With Other Professionals: Chaplains, Social Workers,
or Ethics Committee
Advocate for End-of-Life Decision Dialogues With All Clients
and Their Families, Especially When the Situation Is Not Critical;
Direct the Client to Create Written Documents of Their Decisions,
and Advise Family About the Document
Integrate Health Promotion and Stress Reduction in Your Lifestyle
(e.g. Smoking Cessation, Weight Management, Regular Exercise,
Meaningful Leisure Activities)

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