Our hearts are wrong

"New Zealand Herald" on the moral�distress nurses face

 
August 14, 2012 -- Today the New Zealand Herald ran a fairly good report by Hayden Donnell about a new Massey University study that found high rates of serious "moral distress" among Kiwi nurses. The study of more than 400 nurses nationwide found that 48 percent had considered leaving a job, and 16 percent were considering leaving their current job, because of issues "beyond their control." These included delivering poor care because of management pressure to cut costs; doing things that "unnecessarily prolonged the dying process"; and carrying out "physician's orders" for what the nurses believed were unnecessary treatments and tests. The use of the word "orders" in this context is always unfortunate since it wrongly suggests that nurses report to physicians and must do whatever they want. In fact, nurses are ethically bound to decline to carry out physician prescriptions if the nurses believe they are not in a patient's interest. Of course physicians do (wrongly) have more power, so this is a factor in the distress under consideration. On the upside, the piece quotes lead researcher Martin Woods, identifying him as "a nursing ethics and education expert," though oddly not as the lead researcher. It does refer to him as "Dr. Woods," and we hope that readers will understand that refers to his PhD in nursing rather than a medical doctorate. In any case, Dr. Woods explains that some nurses consider leaving not just one job but the entire profession, and he does a good job of emphasizing the gravity of the findings, which can lead to "depression, burnout and stress." The piece rightly (if minimally) notes that "results were similar to overseas studies." The article might have benefited from a little more detail on that, as well as from some information about the causes of and potential solutions to the nurses' moral distress. On the whole, though, the piece provides a helpful look at serious issues in New Zealand nursing today.

The piece leads by noting that nearly half of New Zealand nurses have considered quitting because of moral distress, though at the end of the sentence it tacks on the phrase, "a new study claims," which may suggest there is some reason to doubt the findings. But the piece never gives any reason for doubt. Instead, it presents helpful basic information on the study, which was based on survey results from 412 nurses from around New Zealand. After giving the key findings about how many respondents had considered leaving their jobs, the piece consults Woods, "a nursing ethics and education expert," who explains the "widespread impact" of the problem:

It's very disturbing; half the nursing workforce at some stage have had such moral disquiet that they wanted to leave. This survey uncovers the ethical issues and constraints affecting nurses. It shows moral distress is a reality nurses are struggling with - and they are really struggling. Stories of burnout and leaving not just a given position but nursing itself must be taken seriously.

The piece explains that nurses may have experienced moral distress when "internal or external constraints clashed with what they believed to be ethically appropriate actions." The study found that could occur in five key areas, which the Herald offers in bullet points:

• Concerns they were not delivering good care due to pressures from management to reduce costs.

• Watching patient care suffer because of a lack of continuity in who was providing treatment.

• Working with other professionals who were not competent enough to provide the care needed.

• Carrying out physician's orders for what was considered to be unnecessary tests and treatments.

• Carrying out extensive life-saving actions when the nurse thought they were unnecessarily prolonging the dying process.

"Dr Woods" (right) notes that any one of these situations could cause nurses to consider quitting, since they could lead to (in the piece's words) "feelings of depression, burnout and stress." Woods adds that moral distress occurs more often "and often with more devastating effects" than anticipated. The piece closes by noting that "results were similar to overseas studies."

The piece would have benefited from a little more detail on that last point, because there certainly have been other studies in the last decade showing that the disempowerment of nursing practice, as manifested in things like understaffing or the inability to prevent poor treatment by colleagues, can indeed lead to moral distress, nursing burnout and turnover--and poor care, a point this piece does not make. The piece also does not explain why nurses today might experience so much moral distress, nor does it offer any potential solutions, such as better staffing, altering workplace power and economic dynamics, or re-thinking traditional approaches to end-of-life care. In fact, one positive step might be to stop referring to physician care plans as "orders," when in fact nurses are ethically bound to work for better plans when they believe the current ones are not in the patient's best interests, an ethical duty that is itself difficult and stressful given the greater practical power physicians now have. These are issues on which we assume Woods himself might have had something to say. However, in fairness, it is a short report whose goal seems to be to convey the basic results of the study and give some context, and of course it's very helpful for the public to learn about these distressing issues in nursing practice. And at the same time, the piece's treatment of Woods is generally good, since it presents him as a nursing "expert" with a doctorate and gives him space to underline the importance of the problem.

We thank Hayden Donnell and the New Zealand Herald for this generally helpful report.

Also see a piece we did on moral distress regarding a New York Times piece in February 2009.

The research was presented by: Woods M., La Grow S., & Rodgers V. (2011). "Researching moral distress amongst New Zealand nurses." Paper presented at 12th International ICNE Conference (Researching Nursing Ethics and the Ethics of Research), The International Centre for Nursing Ethics, Continuing Education Centre (CEC), University of Surrey, Guildford, UK., 07 Sep 2011 - 08 Sep 2011. The research is scheduled to be published in 2013.

See the article "NZ nurses battling 'moral distress' - study" by Hayden Donnell posted August 14, 2012 on the New Zealand Herald website. You can reach Mr. Donnell by clicking here and putting "Attention Hayden Donnell" in the subject line. Please also email us a copy of your letter to letters@truthaboutnursing.org. Thank you!