By Stacey Kusterbeck
As a critical care nurse, Vanessa Amos, PhD, RN, CNL, has participated in many moral distress consultations, and has seen the benefits firsthand. Amos wanted to know more about how others were affected by the consults and how healthcare leaders viewed the service. Amos and colleagues collected data on 52 participants in 20 moral distress consultations at two academic medical centers.1 Participants reported a mean moral distress score of 5.9 (with scores ranging from 0 to 10) before the consult and 5.3 after the consult. The researchers also interviewed eight unit and organizational leaders about the moral distress consultation service. The leaders viewed moral distress consultation as valuable to the organization and empowering to unit staff. One stated, “I think, at a very basic level, it’s just that people talk about how they feel. They get that opportunity. They need to be able to say what bothered them, how it impacted them.”
“It was helpful to hear how powerful the lived stories of those experiencing moral distress were to leadership teams,” says Amos. Leaders spoke about the consult service providing safe spaces for clinicians to communicate after morally distressing cases. One commented, “I’ve never been somewhere that had something like this. So, it’s remarkable.”
Leaders suggested there was a need to include healthcare providers other than nurses as moral distress consultants. Leaders also saw a need for improved marketing of the consult service. Five leaders said that the moral distress consult service was not well-known among unit staff. Leaders suggested that the service be promoted by putting contact information on computer screensavers or by creating an electronic medical record order for clinicians to request a consult.
The causes of moral distress mainly were team-level-focused before the consult. Participants identified causes such as witnessing poor team communication, for instance. However, after the consult, participants indicated that causes of moral distress mainly were system-level-focused. Participants talked about lack of support from managers or caring for more patients than is safe.
Leaders saw a need to gauge the success of the moral distress consult service. They suggested tracking trends in who makes requests and following up with participants to find out if any changes or improvements occurred. “It is important to keep a record of how ethics services and/or moral distress consult services are making impacts, no matter how small they could feel at the moment,” says Amos. Such documentation could identify patterns in consult requests and provide clinicians with guidance for recurring issues. Surveys also could provide insights on whether participants thought the service was helpful.
“Interviews of consult participants on a regular basis could determine how the service is doing and how it could be improved,” suggests Amos.
Hilary Mabel, JD, HEC-C, core faculty and healthcare ethicist at Emory University Center for Ethics, has facilitated many formal moral distress conversations with teams experiencing high levels of moral distress. Usually, someone in nursing leadership from the unit or floor reaches out to the ethics consultation service for support. “My sense is that bedside caregivers often feel more taken care of, knowing that their leadership reached out to the ethics team to help support them in this way,” says Mabel. When facilitating discussions on moral distress, Mabel has these goals:
- to provide validation that moral distress is normal;
- to empower caregivers to express their perspectives (including inviting differing moral perspectives);
- to give ethics language to the perspectives expressed by tying them into relevant ethical frameworks (using layperson language when possible).
“I find a lot of professional fulfillment in structuring and facilitating these discussions. Caregivers are often yearning to share their feelings on a really challenging patient case that sticks with them,” reports Mabel.
Not all moral distress discussions happen because someone on the team recognizes the issue. Sometimes an ethics consult is requested for an unrelated issue, and it becomes apparent that an individual or team is experiencing moral distress. “In these situations, I try to engage folks one-on-one, talking about moral distress explicitly — what it is, and that it’s common and normal. And I usually try to stop by at least every other day to see how these folks are doing and to demonstrate my care for them,” says Mabel.
Simply validating moral distress can be a game-changer in moving an ethics consult forward. In one case, a physician declined to perform a tracheostomy for a patient. The physician thought it was futile because, in the physician’s estimation, the patient would have a poor quality of life. However, the primary care team thought that a tracheostomy was appropriate. Clinicians came to this conclusion based on the family’s understanding of the patient’s values and the fact that the family was not agreeable to discontinuing ventilation.
“An ethicist in a case like this could try to explain the difference between physiologic futility and potentially inappropriate care, which would be relevant and accurate. But this approach misses an opportunity to recognize the moral distress underlying the physician’s objection,” says Mabel. Instead, Mabel framed the issue as one of moral distress, arising from a difference in values between the physician and the family regarding acceptable quality of life. The possibility of the physician conscientiously stepping back from the case was explored. Ultimately, the physician decided to perform the procedure. “If I hadn’t taken the time to validate his moral distress, I don’t think he would have come to that decision,” says Mabel. “We would have gone down the route of finding another provider and all that entails — and the physician may have been left feeling like the ethics consultation service didn’t try to really hear him.”
Reference
1. Amos V, Whitehead P, Epstein B. Moral distress consultation services: Insights from unit- and organizational-level leaders. J Healthc Manag. 2025;70(1):32-48.
As a critical care nurse, Vanessa Amos, PhD, RN, CNL, has participated in many moral distress consultations, and has seen the benefits firsthand. Amos wanted to know more about how others were affected by the consults and how healthcare leaders viewed the service.
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