Describe a distressing clinical experience you have had as a nurse when you either were involved in or witnessed care or behaviors that you would describe as unethical.
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Discussion 2: Moral Distress
Ethics education, including the ANA Code of Ethics (2001), is threaded throughout the
typical nursing curriculum at the Baccalaureate and Masters levels, yet students are not
universally instructed on how to proceed in circumstances where an ethical course of action
is ambiguous or when faced with troubling ethical dilemmas. There is a disconnect between
nursing education where students are taught the ideal and the real world of nursing where
compromises about what should be done and what can be done occur daily.
Research indicates practicing nurses are confronted with real-life barriers that make ethical
practice difficult (De Casterle, Izumi, Godfrey, & Denhaerynck, 2008). Such barriers include
pressure to conform, too few resources (human and financial), and little administrative
support. Practicing nurses confront dilemmas concerning the allocation of scarce resources
(e.g., organ donation), budget constraints and poor staffing ratios, horizontal workplace
violence (e.g., the emotional battering of a colleague), telling the truth about medication
errors, end-of-life decision-making, covering for a co-worker, and HIPAA violations.
One literature review describes that nurses’ ethical practice is a complex process of
reasoning, decision making, and implementation of the decision in practice. The process of
decision making is more than a pure cognitive process; it is influenced by personal and
contextual factors. In many instances the difficulties nurses encounter in their ethical
conduct are linked to their difficult work environment. As a result, nurses often capitulate to
the decisions made by others, which results in a conformist way of acting and less
individually adapted care (Goethals, Gastmans, de Casterle).
The experience of moral distress can be distinguished from the experience of moral
dilemmas. In moral distress, a nurse knows the morally right course of action to take, but
institutional structure and conflicts with colleagues create obstacles. A nurse who fails to act
in the face of obstacles also may have reactive distress in addition to the initial distress. Both
kinds of distress pose dilemmas about individual and collective moral responsibility. Coping
with these dilemmas effectively requires taking at least some successful actions to resolve
Possible Reference to use (1 of 3):
Westrick, S.J. (2014). Essentials of nursing law and ethics (2nd ed.). Burlington, MA:
Jones and Bartlett Learning
For this module discussion you are to reflect on a morally distressing clinical experience:
1. Describe a distressing clinical experience you have had as a nurse when you either were
involved in or witnessed care or behaviors that you would describe as unethical. Ensuring
confidentiality in your description of the event, place, and persons, include in your
a. the setting in which the conflict occurred (e.g., ICU, hospital inpatient unit, LTC, OR)
b. disease or patient group (e.g., geriatric, cancer, NICU, dementia) or healthcare team (e.g.,
c. the type of conflict (e.g., withdrawal of life support, nutrition, hydration; HIPAA
violation, pain management)
d. all those involved in the conflict (e.g., nurse, physician, patient, family member)
e. cultural factors identified as influencing the clinical experience (e.g., ethnicity, poverty)
2. How do you think this experience affected you as a nurse?
a. What emotions do you recall having in the aftermath of the situation (e.g., advocacy,
anger, career change, guilt, betrayal, and so on)?
b. How do you feel about it now?
3. How do you think these experiences affect the profession of nursing?
4. When confronted with a similar situation what do you imagine doing differently?
De Casterle, B.D.., Izumi, S., Godfrey, N.S., Denhaerynck, K. Nurse’s responses to ethical
dilemmas in nursing practice: meta-analysis. Journal of Advanced Nursing 2008 Sept 63 (6):
540-9 doi: 10.1111/j.1365-2648.2008.04702.x.
Goethals, S., Gastmans, C., de Casterle, B.D. Nurses’ ethical reasoning and behaviour: A
literature review. International Journal of Nursing Studies 2010 May 47 (5): 635:50. doi:
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