Moral distress and moral strength among clinicians in health care systems

Nurse burnout impacts both nurses and patients, and significantly influences the retention of nurses in the healthcare setting, research shows. But could burnout be a symptom of something larger?

A commentary by a University of Pennsylvania School of Nursing (Penn Nursing) nurse-bioethicist explores the effects of ethical issues faced by clinicians in practice and how moral distress may play a larger role in the loss of clinicians in the workplace.

"Moral distress may be inevitable in the multifaceted and ethically complicated arena of meeting the healthcare needs and preferences of diverse patients, but such distress need not inevitably lead to negative outcomes," wrote Connie M. Ulrich, Ph.D., RN, FAAN, the Lillian S. Brunner Chair in Medical and Surgical Nursing and Professor of Bioethics and Nursing , co-author of the commentary.

Moral distress results from managing the complex ethical issues in healthcare practice and patient care. Those morally stressing situations can make clinicians feel unable to provide the care they think is best based on their professional standards of practice and their values. While the confidence, moral clarity, and self-efficacy that come with moral strength can help clinicians make difficult ethical decisions, moral strength can likewise be eroded in the healthcare environment.

While support and training efforts to help clinicians develop coping skills, resiliency, and enhanced moral strength are important, the authors caution that it is imperative to also address organizational and systemic factors that contribute to moral distress and ways to support clinicians' capacity to act with moral strength.

"More research into the subject is needed in order to prioritize educational and institutional change that address the ethical complexities in healthcare institutions, as well as interventions to prevent the experience of moral distress from leading to self-doubt and to the erosion of moral strength," said Ulrich.

The commentary is set for upcoming publication in the National Academy of Medicine's NAM Perspectives and is co-authored by Christine Grady, PhD, RN, Chief of the Department of Bioethics, Clinical Center, National Institutes of Health.