Critical care nurses who believe their patients have access to palliative care tend to feel less moral distress than nurses who don’t believe that type of resource is available, according to a survey.
The survey, published in the October issue of Critical Care Nurse, discussed how palliative care focuses on enhancing the lives of seriously ill patients and their families. Moral distress is common among nurses in many settings and can lead to nurses’ burning out — leaving their jobs and careers.
Moral distress is different from a moral dilemma, said study author Alexander Wolf, DNP, RN, APRN, CCRN, an advanced practice nurse in palliative care at TriHealth in Cincinnati, Ohio.
A moral dilemma suggests a nurse is unsure about the most ethical action to take. Moral distress is a situation in which a nurse has identified the morally correct action to take using his or her own professional integrity. But the nurse feels unable to take the action because of some type of perceived constraint, according to Wolf.
“I think just about any nurse you talk to will describe some situation in which they felt moral distress,” Wolf said. “I was an ICU nurse for about three years in Denver. For me the personal experiences with moral distress were in situations where I felt we were just causing suffering for people who had incurable illnesses. There were situations where I felt all I did that day was prolong someone from dying or basically made their final days, weeks or months very painful and debilitating.”
That was before palliative care was a recognized specialty, Wolf said. It was up to nurses to provide what have become essential palliative care competencies, according to Wolf. Those competencies include the ability to sit down and communicate effectively with a patient, elicit a patient’s goals and understanding of an illness, determine what the patient wants to accomplish in the time they have left, and more.
“My experience with moral distress was in situations where I felt like I couldn’t do that,” Wolf said. “I felt like either I wasn’t being listened to by the team, the patient and family were unrealistic or something was keeping me from being able to do what I felt was the right thing to do.”
Today’s critical care nurses agree
Researchers surveyed more than 500 critical care nurses in critical care units at the University of Virginia Medical Center, Charlottesville. In total, 167 completed the questionnaires about their perceptions of palliative care in practice and recent experiences in moral distress.
Nearly all of the nurses — about 95% — indicated they thought it was very or extremely important to have palliative care training and education. The remaining 5% said it was somewhat important. Yet, Wolf and colleagues found fewer than 40% of nurses felt highly competent in any palliative care domain.
“Of the 10 competency domains assessed, the team communication domain had the highest proportion of respondents self-rating as highly competent (38%), while only 11% of respondents rated themselves as highly competent in their knowledge of advance directives, living wills and do-not-resuscitate order,” according to a press release on the study.
Thirty-eight percent of nurses responding reported receiving no palliative care training in the last two years.
In essence, according to Wolf, nurses in the study believe palliative care is an important part of their practice but they don’t feel highly competent to provide it.
Most nurses said they experienced recent moral distress, particularly when they felt they were prolonging the dying process or when treatment goals were unclear. The level of moral distress nurses felt increased or decreased depending on nurses’ perceived access to palliative care.
“Basically, we found nurses who felt palliative care had been used more frequently when appropriate, they experienced less moral distress,” Wolf said.“Conversely, those who felt it was used less frequently when appropriate tended to experience more moral distress, Wolf said. “One of the big things previous research has shown is moral distress doesn’t really go away. When you experience an episode of moral distress, it reminds you of previous episodes of moral distress. You carry that with you and it turns into moral residue.”
The moral residue can accumulate to a point a nurse withdraws from the ethical aspects of nursing, leaves a position or leaves the profession, according to Wolf.
“About 7% said they had previously left a position and 39% had previously thought about leaving a position,” he said. “About 18% were currently thinking about leaving their position at least in part due to moral distress.”
What to do?
The study’s results suggest health system leaders and educators should prioritize palliative care education for critical care nurses and their interprofessional colleagues. Nurse leaders, nurse educators and others need to be thinking about what opportunities exist at their facilities and institutions for ICU nurses, including nursing students who are going into the acute or critical care setting. They also need to think about potential ways to improve on those opportunities, according to Wolf.
Wolf outlined a few programs that provide palliative care training for nurses. These include:
The American Association of Critical-Care Nurses resources for ethics and more distress
The 4A’s — a simple graphic and framework that helps nurses identify moral distress and arms them with information about how to rise above it
Another potential solution is a moral distress consult service, a facility-based intervention including specially trained interdisciplinary ethics consultants who are available to a facility’s or system’s nurses and other providers when they need to discuss moral distress and how to deal with it.
Although the study didn’t address moral distress outside critical care nursing, many other studies have looked at moral distress in oncology, hospice and palliative care, emergency room and other healthcare settings.
“This study is probably not generalizable beyond the critical care world,” Wolf said. “But in general we do know that moral distress is not unique to critical care and is probably not unique to healthcare. Anytime you feel constrained from being able to act morally that can induce distress. And I think it’s particularly distressing if you don’t know how to escape it — if you don’t know how to rise above it.”
Take these courses to learn more about palliative care and end-of-life issues:
(1 contact hr)
Nurses have an obligation to address end-of-life issues with patients and families by addressing concerns, such as fear of abandonment, losing control of bodily functions, and being overwhelmed with pain or distress. This module will provide an overview for clinicians who provide comfort and support to dying patients and their families, regardless of the setting in which care is provided.
Advance Directives: Conversations Matter
(2.2 contact hrs)
Healthcare professionals have an important role in helping patients and families formulate advance directives. As patient advocates, clinicians are in a strong position to work with patients and other healthcare professionals to make these important changes occur.
Lessons From the Dying Patient, Part 1: The Fear of Death and Symbolic Language
(1 contact hr)
Using real-life examples from her personal experience, Elisabeth K’bler-Ross, MD, explains the use and meaning of end-of-life symbolic language and how clinicians can engage and support patients at this difficult time. Dianne Gray, president of the Elisabeth K’bler-Ross Foundation, provides an introduction to this three-part webinar series.