“It’s a Burden You Carry”: Describing Moral Distress in Emergency Nursing

doi:10.1016/j.jen.2015.08.008

Journal of Emergency Nursing

Volume 42, Issue 1, January 2016, Pages 37-46

https://doi.org/10.1016/j.jen.2015.08.008 Get rights and content

Abstract

Introduction

Moral distress in nursing has been studied in many settings, but there is a paucity of research on moral distress as it manifests in the emergency department. One study suggests a correlation between moral distress and aspects of burnout, and other researchers report that nurses have considered leaving their position or even their profession because of moral distress. Further exploration of these issues may provide insight into their effects on ED patient care and the emergency nursing profession. The purpose of this study was to explore the nature of moral distress as it is experienced and described by emergency nurses.

Methods

A qualitative, exploratory design was employed using semi-structured focus groups for data collection. Using an iterative process, transcripts were analyzed for emerging themes by the research team. Six researchers analyzed the transcripts using a thematic analysis approach.

Results

Themes from the data included dysfunctional practice arena, being overwhelmed, and adaptive/maladaptive coping. Participants described, overall, a profound feeling of not being able to provide patient care as they wanted to.

Discussion

Causes of moral distress in emergency nurses are environment driven, not incident driven, as is described in other settings, and include a high-acuity, high-demand, technical environment with insufficient resources. Interventions should be targeted to improve environmental factors that contribute to the moral distress of emergency nurses. Future research should focus on the development and validation of an instrument to measure moral distress in this setting.

Section snippets

Methods

The study methodology was a qualitative, exploratory design consisting of semi-structured focus groups for data collection. Prior to the recruitment of study participants, this study was reviewed by Chesapeake Institutional Review Board (IRB; Columbia, MD) and determined to be exempt from IRB oversight. Participants were provided with a written description of the study at the time of online enrollment and again at the start of each focus group session. Prior to conducting the focus groups,

Results

Seventeen nurses participated in 2 focus groups held at the ENA 2014 Annual Conference. They had a mean of 24 ± 13 years of experience in nursing and 19 ± 11 years of experience as an emergency nurse. The majority (89.2%) held bachelors or masters degrees. The focus group participants were predominately female (94%) and mainly worked as staff nurses (58.8%) in general emergency departments (94%), in urban areas (47.1%), with fewer than 40,000 annual ED patient visits (52.9%). Geographic areas

Discussion

The concept of moral distress has been described among various nursing specialties, but there is a gap in research that describes this phenomenon specifically in the emergency care setting. We conducted this exploratory, descriptive study to contribute to the limited research on manifestations of moral distress or discordance among emergency nurses.

It is important to distinguish “moral discordance” or “moral distress” from other phenomena that reflect frustration but do not contain moral

Limitations

Because this exploratory study consisted of focus group participants who were a self-selecting sample of emergency nurses reporting personal experiences with the phenomenon of moral distress, transferability of the findings may be limited. Our sample was biased toward higher educational levels (89% were prepared at the baccalaureate or master’s level), which may have an effect on the understanding of moral decision making. Although this sample was otherwise demographically and geographically

Implications for Emergency Nursing

Focus group participants expressed a common desire to provide high-quality, compassionate care to their patients but also described dysfunctional and challenging aspects of the care environment that contribute to feelings of moral distress by impeding their ability to provide safe, effective patient care. The implications for emergency nurses as individuals, as well as for the profession, are significant and demand attention from ED and hospital administrators, but also from staff. While

Conclusion

Emergency nurses in this sample described a primary source of moral distress arising from conflicts between administrators’ and nurses’ expectations of the nursing role. In this high-acuity, high-demand, technical environment with insufficient resources (eg, time, staffing, technology, and administrative support), nurses felt continually challenged to provide safe, effective patient care. Successful interventions will most likely need to be targeted at the work environment and systemic

Acknowledgments

We thank the Institute for Emergency Nursing Research Advisory Council and Leslie Gates for their assistance with this study.

Lisa A. Wolf, Member, Pioneer Valley Chapter, is Director, Institute for Emergency Nursing Research, Emergency Nurses Association, Des Plaines, IL.

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Lisa A. Wolf, Member, Pioneer Valley Chapter, is Director, Institute for Emergency Nursing Research, Emergency Nurses Association, Des Plaines, IL.

Cydne Perhats is Senior Associate, Institute for Emergency Nursing Research, Emergency Nurses Association, Des Plaines, IL.

Altair M. Delao is Senior Associate, Institute for Emergency Nursing Research, Emergency Nurses Association, Des Plaines, IL.

Michael D. Moon, Member, San Antonio Chapter, is Associate Professor, University of the Incarnate Word, San Antonio, TX.

Paul R. Clark, Member, Kentuckiana Chapter, is Assistant Professor, University of Louisville School of Nursing, Louisville, KY, and System Educator, Norton Healthcare Institute for Nursing, Louisville, KY.

Kathleen E. Zavotsky, Member, West Central New Jersey Chapter, is Director, Nursing Research, Advanced Practice and Education, Robert Wood Johnson University Hospital, New Brunswick, NJ.

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Research“It’s a Burden You Carry”: Describing Moral Distress in Emergency Nursing

Abstract

Introduction

Methods

Results

Discussion

Section snippets

Methods

Results

Discussion

Limitations

Implications for Emergency Nursing

Conclusion

Acknowledgments

Crit Care Nurs Clin North Am

Australas Emerg Nurs J

J Emerg Nurs

J Emerg Nurs

J Emerg Nurs

Australas Emerg Nurs J

Nursing Practice: The Ethical Issues

Development and evaluation of a moral distress scale

J Adv Nurs

‘Moral distress’—time to abandon a flawed nursing construct?

Nurs Ethics

Nurses’ moral sensitivity and hospital ethical climate: a literature review

Nurs Ethics

Moral distress of staff nurses in a medical intensive care unit

Am J Crit Care

Emergency Medical Treatment and Labor Act (EMTALA)

Research
“It’s a Burden You Carry”: Describing Moral Distress in Emergency Nursing