The concept of moral distress was first described by Andrew Jameton in 1984. He described moral distress as the psychological disequilibrium associated with knowing the ethical/appropriate action to take but being unable to take the action. Jameton (1984) suggested that moral distress occurs when health professionals know, or believe they know the ethically appropriate course of action but are unable to carry it out because of obstacles that are present. What is needed in these situations is moral courage which Corley has defined as the willingness to take a difficult stance on a controversial issue (Corley, 2002).

Corley, using the moral distress scale she developed (Corley & Elswick, 2001), found that fifteen percent of staff nurses in one study and twenty-six percent of staff nurses in another study admitted to leaving the profession as a result of moral distress (Corley, 2002). Riley (n.d.) described moral distress among nurse executives. It is expected that all healthcare providers working in complex and constrained bureaucratic healthcare systems experience moral distress (Riley).

In this article I will describe a situation involving a chemically impaired nurse and examine how the senior leadership of a healthcare organization handled the situation, noting the distress experienced by the organization’s Nurse Executive as she tried to both discipline and obtain help for this nurse. I will also discuss the important role of the nurse executive as leader, the use of the American Association of Critical Care Nurses’ (AACN’s) framework for addressing moral distress, and the organizational outcome of this situation.

The Situation

This event occurred in a busy critical care unit within an inner-city, acute-care facility. Organizational policies and procedures clearly outlined the standards for safe and accurate medication administration and controlled substance management. However, no clear policy was in place to address the management of diverted narcotics or the management of an impaired healthcare provider. The nurses in this organization were represented by their Constituent Member Association of the American Nurses Association (ANA) for the purposes of collective bargaining. Due to fluctuating patient census and high acuity, agency nurses were utilized to supplement the required nurse staffing.

During a chart and record review, the Director of Pharmacy noted an increase of incomplete documentation of narcotic reconciliation forms coming from the Intensive Care Unit (ICU). Nurse supervisors and managers were asked to reinforce the policy of required narcotic documentation with both the permanent and the agency staff. Upon inquiry, nursing staff shared vague accounts of suspected staff diversion of narcotics and failure to follow policy. All indicators pointed to Peggy, one of the full-time nurses (the nurse’s name and clinical area have been changed to provide anonymity).

Peggy was an excellent clinician, and her performance evaluations had always been above average. However, now she had become the frequent target of the vague accusations from colleagues, as mentioned above. Her behavior was described as suspicious. Staff noted that she spent a great deal of time in the medication room alone and frequently disappeared from the clinical area. Peggy’s manager shared that her current work performance alternated between high and low productivity. This current performance deviated from her previous performance reviews. Peggy’s behavior and staff comments prompted an investigation into the administration of narcotics in the ICU. It was noted that an order obtained by Peggy appeared to have been altered. The charge nurse brought this matter to the attention of the night supervisor, noting that it appeared that the number of narcotic tablets had been altered from one tablet to two tablets.

This apparent deviation from standards required that an incident report be completed. The incident report is a legal document that is used to document an unusual occurrence and identify any patterns or trends in the care giving process. The report was brought to the attention of the organization’s Nurse Executive, who was ultimately responsible for the quality of nursing care provided and the welfare of both patients and staff within the organization. Per policy and practice, a meeting involving the Nursing Supervisor, Unit Manager, and Director of Nursing for Critical Care was called to discuss the evidence. At that time, it was unclear as to whether a medication error had occurred or if the physician order sheet had been altered. However, documentation indicated that the patient had received two tablets of the narcotic.

Given the altered appearance of the physician order and the suspected impairment of the nurse, the Nurse Executive called the ordering physician for clarification of the narcotic order. At first the physician was reluctant to comment. However, the Nurse Executive assured the physician that the intentions of the investigation were to provide help for a registered nurse who might be diverting narcotics and to assure patient safety. The physician then admitted that the order had indeed been changed from the original order. A comprehensive investigation ensued. This resulted in a suspension of the nurse, a review of all documentation regarding narcotic administration on that unit, and a review of the nurse’s past performance evaluations. Per state regulations the suspicions of drug diversion were reported to the Office of Professional Misconduct. During this process, the Nurse Executive began to experience moral distress because of the manner in which the entire situation was being handled by senior hospital administrators. She found the handling of the situation to be in conflict with her moral values and the ANA Code of Ethics for Nurses.

The Nurse Executive believed she should work with the impaired nurse within the organization, providing help and safety to both the nurse and the organization. However, the senior leadership of the hospital directed that the nurse be terminated.Moral values are those values held to be right or wrong, desirable or undesirable. The Nurse Executive valued Watson’s Theory of Caring (Watson, 2006) which recognizes caring as the core of nursing and the moral ideal of preserving human dignity. The Nurse Executive believed she should work with the impaired nurse within the organization, providing help and safety to both the nurse and the organization. However, the senior leadership of the hospital directed that the nurse be terminated. This decision was incongruent with the nurse executive’s own moral values and beliefs. The Nurse Executive struggled to ensure safe quality patient care, to help the nurse who was clearly in trouble and about to lose her license and professional career, and to maintain the smooth functioning within the organization.

The ANA Code of Ethics for Nurses (ANA, 2001) notes that the Nurse Executive has the obligation "... to protect the patient, the public and the profession from potential harm when a colleague's practice, in any setting, appears to be impaired" (section 3.5). A nurse executive is likely to experience moral distress when the organization does not address impaired practice in a compassionate way, and instead terminates the nurse.

The Nurse Executive in this situation completed an investigation, interviewed involved staff, sought information from experts in the field, and came to a well-thought-thought-out conclusion and plan. Her recommendations were based on a comprehensive analysis of the situation, and a desire to demonstrate respect for the nurse while ensuring patient safety. She wanted to counsel the nurse with compassion, in a fair and impartial manner. She wanted to do what was best for both the nurse and the patients by referring the impaired nurse for professional treatment.

The Nurse Executive as the Leader

Nurse executives need to recognize the numerous political influences
...at any point in time and to understand the impact of all decisions on the organization. Nurse executives need to recognize the numerous political influences that are in operation at any point in time and to understand the impact of all decisions on the organization. Additionally, the nurse executive, as the leader of the nursing department, must be the role model for ethical conduct. Nurse leaders need a strong personal commitment to personal moral integrity when organizational factors and goals are in direct opposition to their moral values (Curtin, 2007). This is especially important when the CEO may fear potential litigation and the impact of negative publicity and hence consider employee termination as the path of least resistance. Nurse executives need to be prepared to make difficult choices between the desires of the organizational leaders and the needs of the nursing staff.

AACN Framework

Promoting a healthy work environment is a priority initiative of the AACN. To give nurses the tools to recognize and address moral distress in their work environment, the AACN Ethics Workgroup developed the 4 A’s to Rise Above Moral Distress (AACN, 2004). This framework has been used successfully in a variety of situations (Cox, 2008; Pendry, 2007; Rushton, 2006). This AACN framework is a useful resource for addressing both clinical and administrative ethical issues (AACN, 2004). Organizational leaders are encouraged to use this framework themselves and guide the staff in using it to decrease moral distress in the workplace. The Table provides an overview of this framework.

...the Nurse Executive, new in her executive position, struggled to admit that she was experiencing moral distress. The first step in this framework is to ask, to become aware of the moral distress one is experiencing. In the situation above, the Nurse Executive, new in her executive position, struggled to admit that she was experiencing moral distress. She recognized her frustration with and resentment toward the CEO’s position. She resented the negative comments regarding this situation made by other members of the senior management team. She also began to experience sleep difficulties and self doubt. Yet it took her some time to finally recognize that she was indeed experiencing moral distress.

The purpose of the next step, to affirm, is to recognize one’s moral distress and one’s professional responsibility to address this distress. The recognition of her moral distress provided an opportunity for the Nurse Executive to both reappraise her own moral values and adopt a position of respect for the views of the CEO. The experience of moral distress and its potential for emotional depletion provided the motivation to move forward in resolving the situation, both for her sake and that of her colleagues.

The third step is that of assessing and analyzing the risks of doing what one believes is the right thing to do. The Nurse Executive needed to address this situation from the perspectives of patients, organizational staff, directly involved RNs, and the organizational hierarchy. She recognized that safety for all patients was the most important priority. While attempting to stay true to her own personal values, the Nurse Executive weighed the risks of taking action, considering all those who might be involved in the situation. This assessment included, among other considerations, patient safety, compliance with legal and statutory requirements, and compliance with the nursing union labor contract. The Nurse Executive knew she needed to avoid a fractured relationship with the CEO in order to appropriately and effectively represent the nursing department. She needed to identify both the barriers to, and the benefits of achieving her goal of assuring patient safety while showing care and compassion for the impaired nurse.

She needed to identify both the barriers to, and the benefits of achieving her goal of assuring patient safety while showing care and compassion for the impaired nurse. A number of skilled professionals helped the Nurse Executive evaluate her goal. Early in the investigation, the Vice President of Human Resources advised her whom she should contact to ensure compliance with state regulatory standards. This Human Resources leader also provided support for her at the senior executive meetings. The local Drug Enforcement Administration (DEA) staff member guided her assessment of the situation by helping her increase her awareness of the magnitude of substance abuse in the healthcare environment. In addition, the local representative of the State Peer Assistance Program for Nurses (SPAN) offered seminars describing addiction as a disease, behavioral clues for identifying addiction, and support and legal protection services for those involved in addiction cases.

Colleagues can be another valuable source of support and experiential knowledge. The Nurse Executive consulted with her mentor, the former Nurse Executive. This experienced nursing leader emphasized the importance of establishing a close collaboration with the labor union representative during this investigation and developing a plan of action. She emphasized that all parties shared the same priority of patient safety.

The guidance of these professionals assisted the nurse leader to display moral courage in presenting her plan to help the impaired nurse. However, the CEO and Risk Manager were reluctant to allow the return of the RN upon completion of her treatment. Both of these senior administrators questioned ‘why’ such efforts should be made and expressed concern for possible legal exposure for the organization.

However, now the Nurse Executive was ready for the fourth step, namely, to act. She utilized her newly acquired knowledge to allay the apprehensions of the senior management team and strengthen her resolve to assist the staff nurse, a valued member of the organization, while ensuring quality patient care. The CEO did eventually approve the plan but made it clear that he would have preferred an alternate option.

Throughout the investigative process the Nurse Executive had collaborated closely with the nursing bargaining union representative. Accompanied by the union representative, the nurse was invited to meet with the Nurse Executive to discuss the situation. Options for interventions were provided. The Nurse Executive utilized suggestions from the State Peer Assistance Program for Nurses and Drug Enforcement Administration. After a non-threatening, yet candid meeting, the RN admitted her problem, surrendered her license, and enrolled in the State Peer Assistance Program.

Once these 4 steps have been completed, and the goal has been achieved, it is important to maintain the desired behavior(s). A plan was developed that included DEA recommended changes to the existing policies for handling controlled substances. These changes included provisions for more frequent reconciliation of narcotic counts and for strict enforcement of ‘observing the wasting of narcotics.' The nurse was granted a leave of absence, completed an inpatient substance abuse program as prescribed, and participated in follow-up outpatient counseling and attendance at group meetings. A 'Return to Work Agreement’ was developed specifically for this RN. The agreement included necessary restrictions, such as no access to narcotics, no overtime, day shift only, and oversight by a work place monitor. The role of this work place monitor, usually another nurse, was to provide emotional support and guidance while also communicating with the substance assistance program director about the nurse’s work performance and progress in recovery. With these provisions in place, Peggy successfully completed her transition and assimilation back into the workforce.

Organizational Outcomes

Nurse leaders are in a unique position to focus attention on the issue of moral distress and the changes needed to resolve this distress. Peggy successfully returned to work and over the last five years has assumed a management position. Three other RNs, in other clinical areas, have been identified as being impaired and are currently in various stages of recovery from chemical dependency. Termination of these competent nurses would have been costly to the individual nurses, the organization, and the profession.

Attention to moral distress is vital to ensure the provision of quality patient outcomes in the existing healthcare environment. Nurse leaders are in a unique position to focus attention on the issue of moral distress and the changes needed to resolve this distress. The AACN’s 4A’s framework enables nurse leaders and professionals throughout the organization to reduce moral distress in the work environment. The nurse executive can play a pivotal role in providing leadership that demonstrates human caring values and advocates for both patients and nursing staff.

Reprinted with permission American Association of Critical Care Nurses (AACN) from AACN Work Group. (2004)

Letter to the Editor by Howard

• Reply by Author

Author

Carole McCue, MS, RN, CNE
E-mail: CMcCue@riversidehealth.org

Carole McCue received her nursing diploma from the Cochran School of Nursing in Yonkers, NY, and her BS and MS degrees from Pace University in Pleasantville, NY.  Throughout her career as a nurse, she has achieved certifications in critical care nursing, quality improvement, and nursing education (both in academia and in staff development). She has served as a Chief Nursing Officer in an acute care facility and has presented at national conferences. Areas of expertise include quality improvement, staffing model initiatives, regulatory compliance, leadership, and management. Ms. McCue currently holds a faculty position in an associate degree nursing program and an adjunct faculty position in a baccalaureate nursing program.