Managing moral distress

By Cynthia Saver, MS, RN

The COVID-19 pandemic has added to the burden of nurses’ daily work in many areas, including forcing them into situations where they feel moral distress. Failure to manage this distress appropriately can affect nurses’ wellbeing and cause them to leave the profession. But applying strategies to help prevent moral destress or resolving moral distress in a positive way can benefit both nurses and organizations by promoting optimal patient care and reducing staff turnover and the risk of litigation from clinical errors.

What is moral distress?

According to the American Association of Critical-Care Nurses (AACN) tool “Recognize & Address Moral Distress”, moral distress occurs when someone “knows the right thing to do, but constraints, conflicts, dilemmas, or uncertainty make it nearly impossible to pursue the right course of action.” Moral distress differs from burnout, which refers to physical, mental, and emotional exhaustion caused by workplace stress, and it differs from compassion fatigue, which is physical, mental, and emotional weariness related to caring for those in significant pain or emotional distress.

Causes of moral distress

Various situations, usually related to values conflicts, trigger moral distress. Examples of these situations include continuing what the nurse feels is unnecessary treatment for a patient or witnessing inadequate pain relief because a provider fails to order adequate medication.

Many external factors can constrain or stop nurses from acting in the way they wish, thus contributing to moral distress. According to the AACN tool, unit-level factors include inadequate staffing, ineffective communication, working with incompetent colleague(s), bullying, and lack of a healthy work environment. Organization factors include inadequate staffing, lack of resources, pressures to decrease costs, hospital policies, hierarchy of power, ineffective communication, and financial limitations. If not addressed, these factors can lead to the disturbing effects of moral distress.

Effects of moral distress

Moral distress affects both individuals and organizations. In individuals, it can produce symptoms that are emotional (frustration, anger, anxiety, guilt, sadness powerlessness, withdrawal), physical (muscle aches, headaches, heart palpitations, neck pain, diarrhea, vomiting), and psychological (depression, emotional exhaustion, loss of self-worth, nightmares, reduced job satisfaction, depersonalization of patients) in nature. Repeated episodes of moral distress that aren’t resolved can accumulate as “moral residue,” with nurses ultimately experiencing burnout and leaving their jobs—or even their careers.

Job attrition causes organizations to incur turnover costs. More importantly, unresolved moral distress can negatively impact the quality of patient care, potentially leading to adverse patient events. This not only affects an organization’s reputation in the community, but it could result in greater liability exposure from errors.

Taking action

What should you do if you are experiencing moral distress?

Identify the source. The source may be a patient care issue, a policy problem (such as how family member meetings related to end-of-life issues are held), a lack of collaboration among team members, or something else.

Conduct a self-assessment. Self-assessment begins with determining the severity of the distress. The Moral Distress Thermometer, developed by Wocial and Weaver, is used for research, but also can be helpful for clinicians. The thermometer asks you to rate your distress on a scale from 1 to 10 and includes descriptions (mild, uncomfortable, distressing, intense, and worst possible) to help with the process. The results will give you a sense of how urgently you need to act, and you can use the tool to track changes in your distress over time.

The second component of self-assessment is determining your readiness to act. The “4A’s to Rise Above Moral Distress,” published by AACN, suggests asking yourself these questions:

  • How important is it to you to try to change the situation?
  • How important would it be to your colleagues/unit to have the situation changed?
  • How important would a change be to the patients/families on your unit?
  • How strongly do you feel about trying to change the situation?
  • How confident are you in your ability to make changes occur?
  • How determined are you to work toward making this change?

The AACN publication contains a rating scale, but you also can simply reflect on whether you feel you are ready to act. Listing the risks and benefits of taking action may be helpful in making your decision.

Keep in mind that in some cases the law will compel you to take action. For example, your state likely has laws requiring you to report child or elder abuse. Failure to do so leaves you open to legal liability. You’ll also need to consider if the standard of care is being violated. In these cases, failure to speak up can make you the target of a state licensing board complaint, or a target in any a lawsuit related to patient harm that occurs as a result.

Develop a plan. Once you decide to take action, consider when you will act, who will be involved, and what resources are available to you. For example, you may want to gather facts and share your concerns with a trusted colleague to ensure you have a sound plan. Your plan should include self-care, as this will be a stressful time. Resources to help you in assessing the situation and developing a plan include the ANA Code of Ethics with Interpretive Statements, your state board of nursing (when a practice issue is involved), the ethics consulting service in your hospital, and your organization’s employee assistance program.

Make the case. Share your concerns with the appropriate person(s). Present the facts in a calm, respectful way. Consider timing and location—unless the situation is urgent, you’ll want to bring up the issue privately. Following the chain of command is important, particularly if your concerns aren’t being acknowledged. For example, if a physician isn’t listening to your concerns about lack of sufficient pain medication, you’ll want to involve your immediate supervisor. If your supervisor does not take action, move up to the next level. In the case of non-clinical issues related to an individual team member, you may need to speak to a human resources representative.

Document. Document your conversations, including whom you spoke with, the information conveyed, and the response. If related to a patient situation, record the information in the patient’s health record. If you are dealing with a problem with a team member or organizational policy, you should keep a personal record, so you can trace the steps you took.


Nurses, units, and organizations play a role in preventing moral distress and addressing it effectively should it occur. Nurses can enhance their moral resilience (see Moral distress strategy: The 4 Rs) and participate in professional development activities such as continuing education programs on ethics.

The AACN tool identifies strategies for units and organizations. Units can identify ethics champions for peer support, create a committee to address common areas that cause distress, and establish a mentoring program for new staff.

Organizations can provide resources to support staff (for example, an ethics consulting service), provide education on topics such as debriefing, adopt zero-tolerance policies for all forms of violence, and offer programs that improve staff well-being. Ultimately, the goal should be to create a healthy work environment.

AACN has identified six standards for a healthy work environment: skilled communication, true collaboration, effective decision-making, meaningful recognition, appropriate staffing, and authentic leadership. A healthy work environment improves nurses’ psychological health, job satisfaction, and job retention; it also results in reduced patient errors and patient mortality.

A partnership

Ideally, nurses and leaders should work together to establish a health work environment that supports nurses in many ways, including providing adequate staffing and a mechanism for dealing with ethical dilemmas, so moral distress is reduced. Nurses and leaders should also partner to ensure that those experiencing moral distress have the resources needed to address the situation.


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American Association of Critical-Care Nurses Ethics Work Group. The 4 A’s to Rise Above Moral Distress. Aliso Viejo, CA: American Association of Critical-Care Nurses; 2004.

American Nurses Association. Code of Ethics with Interpretive Statements. 2015.

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University of Kentucky Moral Distress Project. 2020.

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Cynthia Saver is president of CLS Development, Inc., in Columbia, Md.

Disclaimer: The information offered within this article reflects general principles only and does not constitute legal advice by Nurses Service Organization (NSO) or establish appropriate or acceptable standards of professional conduct. Readers should consult with an attorney if they have specific concerns. Neither Affinity Insurance Services, Inc. nor NSO assumes any liability for how this information is applied in practice or for the accuracy of this information.

This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. The individual professional liability insurance policy administered through NSO is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to or call 1-800-247-1500.