I remember distinctly my transition from emergency nursing to correctional nursing. It was only after I was not in the emergency department for a few weeks that I realized the heavy burden of stress I had been carrying. I recognized that my stress level baseline was at a point where others would consider it to be at a critical level and I vowed that I would be more self-aware moving forward. However, after a while, I found myself again in the throes of developing stress, but of a different nature. In the correctional environment, nurses are often faced with ethical dilemmas in their day-to-day practice, that, left unaddressed, may result in moral distress.

What’s in a Name?

The first step in addressing moral distress is to identify it. Moral distress has been defined as knowing the right action to take, but being constrained from taking it. In its simplest form, then, moral distress in correctional nursing may be knowing that a patient should be able to make a health decision autonomously, but seeing that they are limited in the choices offered.

However, researchers in moral distress among nurses add to this definition in important ways. Nurses are often confronted with an ethical dilemma where the course of action best for the patient is in conflict with what would be best for others; whether it is the organization, other providers, other patients, or society. So, the interior world of the nurse that identifies who they are as a professional is in conflict with the exterior world of the work environment and work team. This is what leads to the distress that can be strongly felt by a nurse.

Moral distress is when:

1. A nurse is involved in or aware of a situation that calls for a moral action.
2. Is obstructed from taking that moral action.
3. Experiences negative feelings because that action was not taken.

I hear about many examples of moral distress among correctional nurses in my various interactions. Intentional bias, poorly staffed medical units, or obstruction from officers or leadership can cause treatment delays, unrelieved pain, or gaps in care management. Conscientious nurses absorb the stress of longstanding unethical treatment.

Absorbing Moral Distress

Absorbing moral stress over time affects our emotional, psychological and physical well-being. This has been defined as ‘moral residue’ and is particularly intense when injury to a nurse’s moral integrity is repeated over time. In a correctional setting, a nurse may see the ‘take down’ of a mentally ill inmate multiple times over months of practice and have a ‘here we go again’ response to the moral wound caused by seeing this action and feeling unable to do anything about it.

Identifying Moral Distress

Although nurses cannot always name the feeling, most of us know what it is like to be in moral distress. We feel powerless, anxious, and unhappy. Moral residue can lead to typical stress-related symptoms such as nausea, insomnia, and headaches. It can cause us to seek other employment or even leave the profession. When these feelings are present, it is important to seek the source of discontent. It may be the weight of long-standing moral distress.

Seeking a Good Response

Nurses can also feel belittled or unimportant in morally distressing situations. It is easy to experience isolation if we do not feel supported in talking about the morally injuring situations around us. Talking to a supportive colleague is an important action to help identify and clarify moral distress.

Critical care nurses also often find themselves in a morally distressing situation. The American Association of Critical Care Nurses (AACN) developed a 4 step process to help nurses address and reduce moral distress.

STEP	ACTION
ASK	Ask yourself if what you are feeling is moral distress. Are others exhibiting signs of moral distress, as well?
AFFIRM	Affirm your feelings and consider what aspect of your moral integrity is being threatened.
ASSESS	Objectively analyze the situation and what the ‘right’ action would be. Consider what is currently being done, who the players are, and your readiness for action.
ACT	Create a plan of action considering any pitfalls and strategies to overcome them.

Have you had to deal with moral distress in your correctional nursing practice? Share your experience with our readers using the comments section of this post.