Moral Courage in Healthcare: Acting Ethically Even in the Presence of Risk

By Colonel John S. Murray, PhD, RN, USAF, NC

Abstract Healthcare professionals often face complex ethical dilemmas in the workplace. Some professionals confront the ethical issues directly while others turn away. Moral courage helps individuals to address ethical issues and take action when doing the right thing is not easy. In this article the author defines moral courage, describes ongoing discussions related to moral courage, explains how to recognize moral courage, and offers strategies for developing and demonstrating moral courage when faced with ethical challenges "Stand up for what is right even if you stand alone." Anonymous Examples of unethical behaviors are seen today in academia, politics, sports, entertainment, banking, and the legal system (Gallup, 2009; Kidder, 2005;Murray, 2007a; 2007b; Zangaro, Yager & Proulx, 2009). Healthcare professionals working in clinical practice, education, research, and administration are not immune to these unethical behaviors. They face ethical dilemmas on a regular basis. Shortages in the numbers of clinicians to deliver patient care, inadequate staffing levels, cost containment measures, consolidation of healthcare organizations, and ineffective leadership have resulted in the escalation of ethical dilemmas nurses face today in healthcare environments (Clancy, 2003; Einarsen, Aasland & Skogstad, 2007; Murray,

2008; 2007a; Zangaro et al., 2009). How individuals respond to these ethical dilemmas depends on their previous experiences with unethical behavior, their individual personality traits, and their ethical values, as well as their knowledge of ethical principles (Clancy, 2003). Moral courage is needed to confront unethical behaviors. The following exemplar demonstrates moral courage in clinical practice.

Emily was a novice nurse employed at an academic medical center. Her peers respected her and described her as an attentive and meticulous nurse with strong work values. Over time Emily noted a behavior in the work setting that concerned her and conflicted with her ethical principles. She had observed her supervisor falsifying training records of nurses still on orientation so that these new nurses could begin earlier to work independently, thus improving staffing levels. When Emily brought this behavior to the attention of the more senior nurses on the unit, they explained that they experienced retaliation if they even mentioned this misconduct. After much deliberation, Emily felt that she had an ethical responsibility to take action and bring this matter to the attention of the hospital administration. As soon as she did this, her supervisor began to berate her in staff meetings, change her work schedule unfairly and without notice, withhold needed information, set unreasonable deadlines, and prevent her opportunities for professional advancement. Recognizing that nurses have an obligation to always demonstrate the highest professional and ethical standards, Emily sought guidance from the medical center s nurse ethicist. This guidance and support helped her to stand firm and stay resolute in her determination to do what was right. There are few articles addressing moral courage in today s healthcare literature. What is available indicates a lack of moral courage on the part of healthcare professionals when they are faced with ethical challenges (Aultman, 2008). Sekerka and Bagozzi (2007) have encouraged healthcare organizations to promote ethical fitness so as to increase providers level of moral courage in daily organizational activities. Healthcare agencies and professional organizations need to articulate, encourage adherence to, and act on shared values as they provide an environment in which moral behaviors are welcomed and expected. The challenge in today s constantly changing healthcare environment is to be certain that professionals understand what moral courage is, why it is important for all settings in which they practice, teach, research, and/or lead, and how moral courage can be demonstrated when ethical challenges are confronted (Purtilo, 2000). In this article the author defines moral courage, describes ongoing discussions related to moral

courage, explains how to recognize moral courage, and offers strategies for developing and demonstrating moral courage when faced with ethical challenges. Citation: Murray, J.S., (Sept 30, 2010) "Moral Courage in Healthcare: Acting Ethically Even in the Presence of Risk" OJIN: The Online Journal of Issues in Nursing Vol. 15, No. 3, Manuscript 2.

Discussions Related to Moral Courage It is important not to confuse moral courage with moral arrogance and moral certitude (moral certainty). Moral arrogance involves truly believing that one s own moral stand or judgment is the only correct option regarding a controversial issue, even though others consider differing moral decisions or judgments to be morally acceptable (Gert, Culver, & Clouser, 2006). Morally arrogant individuals are condescending, dismissive of the thoughts of others, and primarily concerned with self (Baylis, 2007). Moral certitude (or certainty) is the term used to describe a very firm belief based on an inner conviction. Morally certain individuals believe that they are correct in their beliefs to the extent that they have no reservations whatsoever about the rightness of their beliefs. Moral arrogance and moral certitude inhibit the thoughtful assessment needed in ethical practice. These attitudes bring with them the risk of suppressing open dialogue and forthright deliberation regarding ethical issues. In contrast, professional and ethical principles, rather than personal preconceptions or unwavering preferences, should serve as the foundation of ethical decision making (Vaiani, 2009). The American Nurses Association (ANA) Code of Ethics for Nurses (2001) contains a common, shared set of ethical principles to guide nurses professional behavior. All nurses are encouraged to hold to these principles in their practice of professional nursing. While the Code of Ethics for Nurses encourages nurses to remain consistent with their own personal values, it also emphasizes the need for open discussion of differing ethical principles in a manner that does not consistently place one principle above another, thus avoiding the dangers of moral arrogance and moral certitude.

There is also much debate over the difference between public and private morals. TheCode of Ethics for Nurses (ANA, 2001) addresses the distinction between public and private morals. Provision Five of the Code discusses wholeness of character whereby, in the course of becoming a professional nurse, nurses accept the values of the profession integrating them with their personal value system (ANA, 2001). Additionally, Nursing s Social Policy Statement provides guidance regarding nursing s relationship with society as well as a nurse s professional obligation to the public (ANA, 2003). This statement notes that nurses are encouraged to use these guidelines to promote an awareness of their relationship with the public. Nursing is a critical component of the general public from which the profession has grown and continues to grow. Nurses are expected to conduct themselves in an ethical and responsible manner, mindful of the trust instilled upon them by society (ANA, 2003). Another discussion centers on the question of whether moral courage is a universal or a culturally dependent term. There is a paucity of literature addressing this question. Yet many have found that immigration to a new country poses unique challenges, including an adjustment to a variety of different customs. These challenges can be especially difficult for nurses who struggle both to become accepted into a new society and to exercise moral courage in an unfamiliar environment. Scholars of moral courage have addressed the question of whether there is a common moral framework that exists across cultures. While it is evident that values and principles vary worldwide, scholars point to ethical values that are shared across cultures, such as honesty, integrity, fairness, respect, responsibility, empathy, compassion, and courage. The scholars who study moral courage, however, have observed that diverse cultures place different priorities on these ethical principles. They call for additional research to address the manner in which these ethical principles are put into practice across various cultural settings (Bjarnason, Mick, Thompson, & Cloyd, 2009; Chatham-Carpenter, 2006; Miller, 2005). The ANA s 1991 Position Statement addressing cultural diversity in nursing practice helps health professionals understand how nurses cultural backgrounds can

influence the care they give. This position statement has noted that nurses who bring varying cultural customs, philosophical views, and ethical principles to the professional setting can strengthen and broaden healthcare delivery as they help their colleagues understand differing perspectives regarding illness and treatment modalities (ANA, 1991). As nurses increase their understanding of differing perspectives regarding health, illness, and ethical values, they can better respect and work to integrate these perspectives into the care they provide (ANA, 2001; Bjarnason, Mick, Thompson, & Cloyd, 2009).

Recognizing Moral Courage Moral courage is seen in individuals who, when they uncover an ethical dilemma, explore a course of action based on their ethical values, and follow through with a decision as to the right course of action regardless of the possible consequences this course of action might present. Moral courage generally occurs when individuals with high ethical standards face acute or recurring pressures to act in a way that conflicts with their values (Clancy, 2003; Miller, 2005). Moral courage can be seen in a staff nurse such as Emily (described above), who, when under pressure from administration, refuses to document patient care that wasn't provided; in a researcher who declines to engage in scientific misconduct for the purpose of receiving funding to help the organization enjoy better standing in the research community; or in an academician who rejects unrelenting demands to pass failing students despite threats to tenure (Murray, 2007a). All of these healthcare professionals exemplify moral courage in doing what they believe is ethically correct.

Developing Moral Courage in the Face of Ethical Challenges The lack of moral courage seen today across many sectors of society provides evidence as to why this virtue requires development (Aultman, 2008; Sekerka & Bagozzi, 2007). Scholars have questioned whether or not moral courage is instinctive or a trait that is learned. Aristotle in particular argued that moral virtues are teachable (Day, 2007;Miller, 2005). Most scholars who study ethics agree with Aristotle that everyone,

regardless of profession, can benefit from education and training in the area of moral courage (Kidder, 2005). Strategies for developing moral courage include open dialogue about ethical principles and systems, case studies, role modeling by real-life exemplars, and rehearsals in which learners practice what they have learned in order to build their skills related to moral decision making (Aultman, 2008; Kidder, 2005; Purtilo, 2000). This requires a continuous commitment to, and reflection upon personal values and moral behaviors that influence ethical decision making (Clancy, 2003; Kidder, 2005). Moral courage can only be developed and strengthened through regular application (Miller, 2005). Healthcare professionals need to recognize their responsibility to address unethical behaviors in the workplace (Murray, 2007; Saver, 2009). When nurses are mentored in developing moral courage, they come to learn and take-hold-of new behaviors, such as taking action when unethical behaviors are observed. Ethics consultants, healthcare educators, and researchers are encouraged to provide guidance and pedagogical tools that enable professional providers to understand and implement morally courageous behaviors and demonstrate exemplary personal and professional standards of ethical behavior (Purtilo, 2000; Sekerka & Bagozzi, 2007). Academic programs at the undergraduate and graduate levels, internships, fellowships, and continuing education programs in which participants dialogue about ethical dilemmas can serve to develop moral courage. Healthcare organizations that acknowledge the importance of following ethical principles can create an expectation that morally courageous behavior will occur when personnel face ethical dilemmas that threaten deeply held values pertinent to the work environment (Purtilo, 2000). Furthermore, hospitals, academic institutions, research centers, and professional organizations are encouraged to make resources related to moral courage available to all healthcare providers. Valuable resources include professional journal articles, textbooks, and continuing educational offerings, along with institutional policies that support an ethical environment (Aultman, 2008; Murray, 2008; 2007a). Table 1 lists a number of websites offering resources to strengthen moral courage among healthcare professionals.

Conclusion This article has highlighted the critical need for healthcare professionals who both understand the importance of moral courage in the workplace and are willing to take action when ethical values are being compromised. An awareness of the importance of moral courage and factors that support/inhibit moral courage can help clinicians, educators, researchers, and leaders in healthcare demonstrate moral courage when they face ethical challenges and uphold ethical environments (Murray, 2007a;Sekerka & Bagozzi, 2007). It is important that all healthcare professionals value and support their peers who have the courage to stand up and speak out against unethical behavior even when others are silent or differ in opinion. Professional nursing organizations should encourage members to take actions that create and sustain ethical environments and support protections for those who choose to confront unethical behaviors in the workplace (Murray, 2007a; 2010; Sekerka & Bagozzi, 2007). All levels of educational programs, and also continuing education programs are encouraged to address the need for moral courage and to teach strategies that enable healthcare providers to act courageously when ethical standards are compromised. Healthcare institutions can address moral courage and ethical principles in their position descriptions, performance appraisals, and strategic planning sessions. It is essential that the healthcare industry develop leaders with strong ethical values, leaders who are willing to live these values with integrity and courage, even when doing so risks their professional relationships and their position in their organizations (Murray, 2010).

References American Nurses Association. (1991). Position statement: Cultural diversity in nursing practice. Retrieved February 17, 2010. American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Retrieved December 20, 2009. American Nurses Association. (2003). Nursing s social policy statement (2nd Ed). Silver Spring, MD: American Nurses Association.

Aultman, J. (2008). Moral courage through a collective voice. The American Journal of Bioethics, 8(4), 67 69. Bjarnason, D., Mick, J., Thompson, J., & Cloyd, E. (2009). Perspectives on transcultural care. Nursing Clinics of North America, 44, 495 503.

Baylis, F. (2007). Of courage, honor and integrity. In L.A. Eckenwiler & F.G. Cohn (Eds.), the Ethics of Bioethics: Mapping the Moral Landscape. Baltimore, MD: The Johns Hopkins University Press.

Understanding and Addressing Moral Distress

Abstract Moral distress occurs when one knows the ethically correct action to take but feels powerless to take that action. Research on moral distress among nurses has identified that the sources of moral distress are many and varied and that the experience of moral distress leads some nurses to leave their jobs, or the profession altogether. This article considers both moral distress and moral residue, a consequence of unresolved moral distress. First, we will explain the phenomenon of moral and distress by providing describing strategies

an historical

overview,

identifying

common sources,

for recognizing moral distress. Next we will address moral residue and the crescendo effect associated with moral residue. We will conclude by considering ways to address moral distressand the benefits of a moral distress consult service. Ethical debate in clinical settings can be productive and positive, a sign that healthcare providers are engaged in collaborative relationships and concerned about the quality of care for their patients. The presence of moral distress, however, signals a different issue altogether. Moral distress, in fact, is a sign that ethical challenges are not being addressed adequately. What is moral distress? Who is vulnerable? How is it recognized? What can be done about it? This article begins to answer these questions in

order to provide a deeper understanding of this difficult, but persistent, problem in healthcare. The Phenomenon of Moral Distress In 1984, Andrew Jameton (1984) defined moral distress as a phenomenon in which one knows the right action to take, but is constrained from taking it. Moral distress is different from the classical ethical dilemma in which one recognizes that a problem exists, and that two or more ethically justifiable but mutually opposing actions can be taken. Often, in an ethical dilemma, there are significant downsides to each potential solution. Consider the following case: Mr. Anderson, a 92 year old man living in a nursing home and suffering with Alzheimer s disease for over 10 years, reaches the stage where he is no longer able to swallow food effectively. He has been hospitalized with aspiration pneumonia four times in the last year. The man s eldest child, who lives in the same town, has a durable power of attorney, and visits regularly, insists that a feeding tube be inserted. He has the support of his two siblings. The staff feels that a feeding tube would be distressing to the patient. Besides, they say, He swats away our hands when we try to hold him down to insert the tube, and he always pulls the tube out. The dilemma here is that the family, legally authorized to make medical decisions for the patient, desires one action (inserting the feeding tube) and the staff, who manage the patient daily and who have the clinical knowledge of the ultimate outcome, desire an opposing action (not inserting the tube, rather providing comfort care). Thus there are two mutually exclusive courses of action both of which are ethically justifiable, and neither of which is optimal. If the family s desires are followed, Mr. Anderson will endure having a feeding tube placed and his life will be prolonged. Yet one may ask how beneficial is a longer life for Mr. Anderson, and what are the social, familial, and financial costs of this action? On the other hand, if the staff s desires are followed, Mr. Anderson will surely die sooner, and the family will likely feel abandoned and angry an end-of-life

situation all would desire to avoid. Again one must consider the social, familial, and financial costs of the action. In contrast, moral distress occurs when an individual identifies the ethically appropriate action but feels unable to take that action Consider this case: Mr. Jones is an 82 year old nursing home resident who has multiple co-morbidities including significant dementia. He is combative and often kicks or punches those who attempt to care for him. In fact, three members of the staff (two nurses and a nursing assistant) have been treated in the emergency room for injuries that occurred during the course of caring for him. The man s wife refuses medications to sedate him, saying that she is concerned about the side effects. Communicating the consistency and severity of the problem to the doctors, some of whom are there as consultants and all of whom only see Mr. Jones for brief intervals, is challenging. While the nursing staff are not willing to abandon Mr. Jones, they are afraid for their safety and are morally distressed because they feel forced to endure physical violence without any power to change the situation. They know that caring for Mr. Jones safely requires giving him medication, but they are constrained by the fact that the doctors, who must write the prescription, do not understand the extent of the problem and Mrs. Jones, the patient s power of attorney, opposes any form of sedation. They feel trapped. In this situation, there is not an ethical dilemma; the nurses are confident that the ethically appropriate action is to provide enough medication to Mr. Jones so as to permit safe care by the nursing staff, but not so much that he is obtunded and unable to respond to his environment. They are not torn between two opposing actions. However, they may feel powerless to take the right action and unable to communicate effectively with those who have the power to implement the ethically appropriate course of action. This is moral distress. Historical Overview In his early work defining moral distress, Jameton noted that the field of bioethics has placed greater emphasis on ethical dilemmas than on moral distress (Jameton, 1993). Because dilemmas involve weighing the ethical justification for alternative courses of

action, they are ideal teaching tools, encouraging identification and discussion of ethical principles. In situations that engender moral distress, the ethically appropriate action is likely to have been identified. Thus, discussion of the ethical elements is less critical. Instead, addressing moral distress requires identification of social and organizational issues, and questions of accountability and responsibility. Moral distress was first recognized among nurses, and certainly the majority of studies have focused on this population. Although this article focuses on moral distress among nurses, it is important to note that moral distress is not solely a nursing problem. It has been identified among nearly all healthcare professionals, including physicians (Austin, Kagan, Rankel, & Bergum, 2008; Chen, 2009; Forde & Aasland, 2008;Hamric & Blackhall, 2007; Lee & Dupree, 2008;Lomis, Carpenter, & Miller, 2009), respiratory therapists (Schwenzer & Wang, 2006), pharmacists (Sporrong, Hoglund, Hansson, Westerholm, & Arnetz, 2005), psychologists (Austin, Rankel, Kagan, Bergum, & Lemermeyer, 2005), social workers (Chen, 2009), nutritionists (Chen, 2009), and chaplains (Chen, 2009). Between the professions, there appear to be differences in what causes moral distress and in how it is manifested (Austin, Rankel et al., 2005; Austin et al., 2008; Forde & Aasland, 2008; Hamric, Davis, & Childress, 2006;Hamric & Blackhall, 2007; Lee & Dupree, 2008; Lomis et al., 2009; Schwenzer & Wang, 2006; Sporrong et al., 2005). These differences are beyond the scope of this article, but it is critical that nurses understand that this is a multi-disciplinary problem. Corley (2002) theorized that moral distress among nurses occurs when the nurse knows what is best for the patient but that course of action conflicts with what is best for the organization, other providers, other patients, the family, or society as a whole. Thus, moral distress occurs when the internal environment of nurses -- their values and perceived obligations -- are incompatible with the needs and prevailing views of the external work environment. Traditional ethics education that focuses on ethical dilemmas and underlying principles is inadequate to address situations involving moral distress. Values clarification, communication skills, and an understanding of the system in which healthcare is delivered are the tools necessary to address conflicts between the

internal and external environments. Corley (2002) has noted that while moral distress can be devastating, leading nurses to consider leaving the profession, it can also have a positive impact by increasing nurses awareness of ethical problems. Some broadening of the definition of moral distress has occurred in recent years. For example, Hanna s (2004) analysis of small qualitative studies of moral distress revealed that although nurses do not consistently identify constraints on their behavior or conflicts with the work environment, they are consistent in describing symptoms of emotional distress and a sense of isolation because others do not grasp the moral elements they see. McCarthy and Deady (2008) cautioned researchers and authors to differentiate moral distress from emotional distress which is more generic and may occur in a stressful work environment but may not have an ethical element. In the case of Mr. Jones, nurses are certainly emotionally distressed, when they experience fear, frustration, and anger as they attempt to manage his care appropriately. However, there is more to this case than emotional distress. The nurses feel devalued and unheard. Thus, a moral element, not characteristic of emotional distress, is present. This moral element differentiates emotional distress from moral distress. Although implied but not explicitly stated in the earlier definition, moral distress involves a threat to one s moral integrity. Moral integrity is the sense of wholeness and self-worth that comes from having clearly defined values that are congruent with one s actions and perceptions (Hardingham, 2004). For the nurses caring for Mr. Jones, entering his room despite concerns for their own safety threatens not only their physical integrity, but their moral integrity as well. Sources of Moral Distress Situations that cause moral distress vary among individual providers just as values and obligations are individually interpreted. While nursing research has identified common sources of moral distress, not every nurse will experience distress when faced with these situations, and some nurses will experience distress from other circumstances. The following are commonly cited sources of moral distress among nurses, as noted by Corley (2002):

 Continued life support even though it is not in the best interest of the patient.  Inadequate communication about end of life care between providers and patients and families.  Inappropriate use of healthcare resources.  Inadequate staffing or staff who are not adequately trained to provide the required care.  Inadequate pain relief provided to patients.  False hope given to patients and families. As described by Jameton (1993) and also Corley, Elswick, Gorman, and Clor (2001), a key element in moral distress is the individual s sense of powerlessness, the inability to carry out the action perceived as ethically appropriate. Jameton (1993) described this as occurring because of constraints on a nurse s behavior. Constraints can be internal, such as fear of losing one s job, self-doubt, anxiety about creating conflict, or lack of confidence (Hamric, Davis, & Childress, 2006). External constraints that contribute to moral distress include power imbalances between members of the healthcare team, poor

communication between team members, pressure to reduce costs, fear of legal action, lack of administrative support, and hospital policies that conflict with patient care needs (Jameton, 1993). In the case above, the nurses providing care for Mr. Jones face an external constraint in that the documentation system did not effectively communicate the severity of Mr. Jones behavior to medical providers. Recognizing Moral Distress Moral distress often involves feelings of frustration and anger (Elpern, Covert, & Kleinpell, 2005; Wilkinson, 1988), which are fairly easy to recognize. Under the surface, and more difficult to identify, are the feelings that threaten one s moral integrity feeling belittled, unimportant, or unintelligent. Unfortunately, these feelings are often borne alone as professionals are often hesitant to speak openly about their impotence. As a result, morally distressed individuals may also feel isolated, an additional threat to their integrity.

One complicating factor which adds to the feeling of isolation is that in any given situation, not everyone will be morally distressed. Because values and obligations are perceived differently by various members of the healthcare team, moral distress is an experience of the individual rather than an experience of the situation. In the case of Mr. Jones, for instance, there are likely to be nurses who are quite morally distressed. There are equally likely to be nurses who are not morally distressed. The nurses who do not feel moral distress are not morally insensitive or deficient persons. In other situations, they may experience significant moral distress. Thus far, we have described how moral distress is defined, when it is likely to occur, and how to recognize it. Many argue that moral distress in healthcare comes with the territory. While some moral distress may be inevitable, it must be attended to or the effects will be damaging. In fact, there is increasing evidence that repeated exposure to moral distress can devastate one s moral sensitivity to problematic clinical situations, as well as to one s career. The damage occurs as levels of moral residue increase as described below. Moral Residue Jameton noted that moral distress tended to linger, and called this lingering moral distress reactive distress (1993). Today, this lingering distress is recognized as a concept that is different from, yet related to, moral distress. It is called moral residue. This phenomenon has been described best by Webster and Bayliss who said that moral residue is that which each of us carries with us from those times in our lives when in the face of moral distress we have seriously compromised ourselves or allowed ourselves to be compromised (2000, p. 208). In situations of moral distress, one s moral values have been violated due to constraints beyond one s control. After these morally distressing situations, the moral wound of having had to act against one s values remains. Moral residue is long-lasting and powerfully integrated into one s thoughts and views of the self. It is this aspect of moral distress the residue that remains that can be damaging to the self and one s career, particularly when morally distressing episodes repeat over time.

Addressing Moral Distress Recently, several approaches to reducing moral distress (and moral residue) have been published. Although further research is necessary to determine the degree of effectiveness of these approaches, their foundations are solid and they are, at least in part, useful to nurses at the bedside. The nurses can tailor the strategies described below to an individual, unit, or organizational setting as appropriate. American Association of Critical Care Nurses 4 A s The American Association of Critical Care Nurses (AACN, 2005) has targeted moral distress as a priority area and has developed the 4 A s approach to address and reduce moral distress (AACN, n.d.; Rushton, 2006). Although designed initially for the critical care setting, the 4 A s are adaptable and applicable in many non-critical care settings. The 4 A s are: ASK, AFFIRM, ASSESS, and ACT. They are summarized below. Readers are encouraged to see AACN (n.d.) for a rich, full description of the 4 A s. ASK: Review the definition and symptoms of moral distress and ask yourself whether what you are feeling is moral distress. Are your colleagues exhibiting signs of moral distress as well? AFFIRM: Affirm your feelings about the issue. What aspect of your moral integrity is being threatened? What role could you (and should you) play? ASSESS: Begin to put some facts together. What is the source of your moral distress? What do you think is the right action and why is it so? What is being done currently and why? Who are the players in this situation? Are you ready to act? ACT: Create a plan for action and implement it. Think about potential pitfalls and strategies to get around these pitfalls. Conclusion Moral distress and moral residue are issues of concern for different reasons. Moral distress occurs in the day-to-day setting and involves situations in which one acts against one s better judgment due to internal or external constraints. Putting aside one's values and carrying out an action one believes is wrong threatens the authenticity of the moral self. Unfortunately, situations of moral distress are common in healthcare, and

damage to providers moral integrity occurs with alarming frequency. Some moral distress is likely inevitable. However, the strategies summarized above, as well as other strategies, can reduce the level of moral distress, or circumvent commonly occurring situations of moral distress, to maintain the moral integrity of staff and the unit as a whole, and prevent progression of the moral residue crescendo. Moral residue is not a day-to-day issue. Instead, it grows quietly after each exposure to moral distress. It is the sum of the nicks in one s moral integrity and the selfpunishment inflicted when one does not do the right thing. Moral residue can lead to withdrawal, conscientious objection, or burnout, none of which is optimal or even acceptable for highly skilled, highly caring healthcare providers. Intervening to address moral distress achieves several goals. First, it gives a name to a phenomenon that has, until recently, been an unrecognized hazard in the healthcare arena. Second, it reduces the threat to providers moral integrity. Even if moral distress cannot be completely removed, at least the angle of the moral distress crescendo can be flattened so that the level of moral distress does not climb so high. Third, it provides an avenue for those who are without power in certain circumstances to voice their opinion and to be heard. This does not necessarily mean that this voice will be the final voice or that the opinion will be followed. That is not the goal. The goal is to preserve moral sensitivity and integrity by being recognized, valued, and heard. Fourth, it allows moral distress to be recognized as a multi-disciplinary problem. Moral distress is not a nursing problem. Other providers are known to experience moral distress as well. Regardless of where a provider is in the healthcare hierarchy, there is always someone above and there is always someone below. As a result, there is always potential for powerlessness, for being trapped, and for being morally upended. This must be acknowledged if we are to move forward as ethically grounded, healthcare professionals. Finally, addressing moral distress reduces the crescendo of moral residue. Addressing moral distress and working to reduce the crescendo may slow the exodus of healthcare professionals from their professions, preserve moral sensitivity and integrity among skilled staff, and increase

awareness of powerlessness in healthcare settings, ultimately benefitting providers and patients alike. References AACN. (2005). AACN standards for establishing and sustaining healthy work

environments. Austin, W., Lemermeyer, G., Goldberg, L., Bergum, V., & Johnson, M. S. (2005). Moral distress in healthcare practice: The situation of nurses. HEC Forum, 17(1), 33-48. Austin, W., Rankel, M., Kagan, L., Bergum, V., & Lemermeyer, G. (2005). To stay or to go, to speak or stay silent, to act or not to act: Moral distress as experienced by psychologists. Ethics & Behavior, 15(3), 197-212. Austin, W. J., Kagan, L., Rankel, M., & Bergum, V. (2008). The balancing act: Psychiatrists' experience of moral distress. Medicine, Health Care & Philosophy, 11(1), 89-97.

Why Emotions Matter: Age, Agitation, and Burnout Among Registered Nurses
By Rebecca J. Erickson, PhD Wendy J. C. Grove, PhD

Abstract Knowledge of the emotional demands facing today s nurses is critical for explaining how work stressors translate into burnout and turnover. Following a brief discussion of how the experience of burnout relates to the nursing shortage, we examine the scope of nurses emotional experiences and demonstrate that these experiences may be particularly consequential for understanding the higher levels of burnout reported by younger nurses. Using survey data collected from 843 direct care hospital nurses, we show that, compared to their older counterparts, nurses under 30 years of age were more likely to experience feelings of agitation and less likely to engage in techniques to manage these feelings. Younger nurses also reported significantly higher rates of burnout and this was particularly true among those experiencing higher levels of agitation at work. We conclude by suggesting the need for increased awareness of the emotional demands

facing today s nursing workforce as well as the need for more experienced nurses to serve as emotional mentors to those just entering the profession. You can recruit till the cows come home, and that s what we see nurse recruiters in hospitals doing. Pull out all the stops, do the sign-on bonuses, basically bribe them in some way to get them in the door. But until you can stop the bleeding, they re coming in the front door and leaving out the back door (Bozell, 2004). In 2002, the Bureau of Labor Statistics (BLS) projected that the United States would be 800,000 registered nurses (RNs) short of the national need by the year 2020. Recently, this number has increased to over one million RNs short of the need by 2012 (BLS, 2004). Although there has been some indication that the entry of older nurses into the profession, along with efforts to recruit foreign-born nurses, have helped to ease the shortage, scholars project that the predicted trends are likely to continue (Auerbach, Buerhaus, & Steiger, 2007; Buerhaus, Donelan, Ulrich, Norman, & Dittus, 2006; Larkin, 2007). As such, the need for understanding the factors contributing to the nationwide shortage has never been greater. The current shortage is a problem of both supply and demand (American Hospital Association, 2006). As the population ages, there is increasing demand for nursing care both in hospitals and nursing homes (Hecker, 2001). At the same time, fewer individuals are choosing nursing as a career, the most experienced nurses are quickly approaching retirement age, and others have been leaving the profession before they reach retirement age citing poor working conditions as their reason for doing so (Buerhaus et al. 2006; Gordon, 2005; Hecker, 2001; Pinkham, 2003; van Betten, 2005). These trends have led many to speculate about the causes and solutions to the current shortage of registered nurses. In what follows, we show how attending to the emotional dimensions of nurses work environments provides new insight into the experience of burnout and why younger nurses may be particularly at risk for experiencing high levels of burnout and, potentially, lower rates of retention.

Burnout and the Nursing Shortage Burnout is a unique type of stress syndrome that is fundamentally characterized by emotional exhaustion (Cordes & Dougherty, 1993; Maslach, Schaufeli, & Leiter, 2001). Because of the nature of their work, health care professionals are at especially high risk for experiencing the emotional exhaustion component of burnout. This is problematic because, as Lafer (2005, p. 36) observed, the stress, danger, exhaustion, and frustration that have become built into the normal daily routine of hospital nurses constitute [the] single biggest factor driving nurses out of the industry. Others have echoed this link between current work conditions and high rates of turnover (Peterson 2001; Vahey et al., 2004), noting the close connection between feelings of burnout and intentions to leave one s job. In an international study on hospital care, Aiken and her colleagues have demonstrated, for example, that nurses experience burnout at significantly higher rates than expected for medical workers based on national norms (Aiken et al., 2001). In another study, 43% of surgical nurses who reported high levels of burnout said that they intended to leave their jobs within the next 12 months. In comparison, only 11% of nurses who were not burned out stated that they intended to leave their jobs (Aiken et al., 2002). Exhausted, discouraged, saddened, powerless, frightened these are the

emotions experienced by nurses on a daily basis. Nurses negative feelings about their jobs, including their feelings of burnout, tend to be influenced more by the organizational practices governing the workplace than by the challenges inherent in caring for others (Aiken et al., 2001, 2002; Aiken & Sloane, 1997). Supporting this view, a report based on the National Sample Survey of Registered Nurses indicated that it was the structure of the job, rather than the composition of the work that influenced nurses job satisfaction (Spratley, et al. 2000, p. 31). Despite the prominent role that feeling and emotion play in nurses self-reflections about their work (Payne, 2001; Savett,

2000; Ufema, 2000), few researchers have systematically examined the emotional components of nurses work experiences and their relationship to the experience of burnout.

Such neglect is particularly surprising given the results reported by the ANA (2002) concerning how nurses felt as they left their jobs each day. The ANA reported that the four most frequent responses were: Exhausted and discouraged (50%); discouraged and saddened by what I couldn t provide for my patients (44%); powerless to affect change necessary for safe, quality patient care (40%); and frightened for patients (26%). Exhausted, discouraged, saddened, powerless, frightened these are the emotions

experienced by nurses on a daily basis. Recognizing that burnout is rooted in such intense emotional experiences is integral to specifying the facets of the work environment that are directly affecting nurses well-being and to effectively managing the hospital work environment in ways that can improve nursing outcomes. As others have shown, having a healthy and satisfied workforce is consistently associated with higher rates of patient satisfaction (Leiter et al., 1998; Vahey et al., 2004). This is especially true in the case of nursing, a profession whose ethic of care is central to its claim for professional distinctiveness and in which the ability to effectively manage one s own and others emotions is critical to the provision of excellent patient care (Sumner & TownsendRocchiccioli, 2003). Despite the central place that emotion holds in the conceptualization of burnout (Aiken et al., 2001), and studies indicating that the experience and management of emotion are critical to nursing practice (Henderson, 2001; Bolton, 2000; Smith, 1992), scholars know relatively little about how emotional experiences may differ among nurses or whether such experiences correlate directly with job burnout. ...scholars know relatively little about how emotional experiences may differ among nurses or whether such experiences correlate directly with job burnout.As an initial step toward increased understanding, this paper explores the types of emotional experiences reported by direct care hospital nurses and how these are related to burnout. In what follows, we examine the prevalence with which direct care hospital nurses experienced and managed their emotions at work, and the extent to which these occupational experiences were associated with reports of job burnout. Because turnover has been shown to be particularly high among registered nurses who are under the age of 30

(Barron & West, 2005;Bowles & Candela, 2005; Kiyak et al., 1997), we further explore how these emotional experiences and their effects on burnout may vary by age. In the final section of the paper, we discuss the importance of emotional mentorship for novice nurses and the need to increase awareness of the emotional context of nursing care. Study Method Registered nurses employed within two acute care hospitals in an urban midwestern city were provided with a questionnaire at their place of employment. Eightyone percent of the eligible registered nurses returned completed surveys. Although data were collected from both direct-care nurses and nurse managers, in this paper we limit the sample to the 829 registered nurses who provided direct care to hospital patients and for whom complete data were available. Sample. Of these 829 registered nurses, 96% were female and 95% were Caucasian. In regard to education, approximately 30% had, as their highest level of preparation, graduation from a diploma program, 13% were prepared at the Associate Degree level, 53% were prepared at the Baccalaureate level, and 4% had earned graduate degrees in nursing. Seventy-five percent of the sample was married and sixty-five percent had children living at home at the time of the survey. The mean age of respondents was 41.5 years old with an average having about 16 years experience as a registered nurse. Our sample included 110 RNs under age 30 (13%) and 719 RNs over age 30 (87%). In regard to work characteristics, 63% of the sample worked at least 30 hours a week and 59% worked the day shift. Among clinical areas of employment, 22% of the sample was employed in medical-surgical units, 36% in critical care, 15% in operating or recovery units, 19% worked in maternity with the remaining 8% in psychiatric or other units. Measures. In this study we examined the emotional exhaustion dimension of burnout, emotional experiences, and emotional labor both generally and by age. For the purposes of this study, nurses age was measured in years and then dichotomized to create a variable identifying those under the age of thirty (Over 30 = 0; Under 30 = 1). The emotional exhaustion dimension of the Maslach Burnout Inventory (MBI) was used to assess job burnout (Maslach, Jackson, & Leiter, 1996). Emotional experiences were

assessed using a question that asked nurses how strongly or intensely they felt twelve different emotions while they were at work during the past week. Consistent with Erickson and Ritter (2001), factor analyses indicated that positive emotions and agitated emotions were the most commonly reported and, as a result, they serve as the focus for this paper. The positive emotions scale was created by summing the responses for happy, proud, excited, calm, and relaxed (Cronbach s alpha reliability = .78). The agitated emotions scale summed responses for the feelings of frustration, anger, and irritation (Cronbach s alpha reliability = .89). Hochschild (1983) reported that surface acting and deep acting represent two distinct techniques to manage emotion. When emotion management is part of what it takes to perform a job effectively, as it is in nursing, the task is referred to as emotional labor (de Castro, 2004; Mann & Cowburn, 2005; Sumner & Townsend-Rocchiccioli, 2003). Surface acting involves managing the outward expression of feelings in the hope that authentic emotion will follow. In contrast, deep acting involves the attempt to actually feel the emotions one is expected to display. We examine both emotional labor techniques here. Consistent with the methodological approach introduced used by Brotheridge and Lee (2003), we asked nurses to what extent they managed their emotions in interactions with others by covering up (surface acting), pretending to have unfelt emotions (surface acting), and making an effort to actually feel emotions that were expected at work (deep acting). However, where Brotheridge and Lee asked only about interactions with customers, we asked the nurses about their interactions with patients, patient families, doctors or residents, their unit manager or director, nursing co-workers, and non-RN staff. As with other measures, the results were summed to create an overall index for each form of emotional labor. For burnout, emotional experience, and emotional labor, t-tests were used with each of the scales to assess the extent to which the results reported for each age group (e.g., under and over age 30) were significantly different from one another. In presenting descriptive information regarding these outcomes, dichotomous categories were created. Those reporting high burnout scored greater than 24 on the standard MBI scale that

ranges from 0-42. This operationalization of being burned out is the same as that used by Aiken et al. (2001). For reports of emotional experience and emotion management, nurses identified as experiencing high levels of these phenomena are those whose scale scores were higher than the mean, or average, score reported for the entire sample. Protection of Subjects . This study was approved by both the university s and the participating hospitals Institutional Review Boards. Letters inviting participation

informed the potential participants of the study s objectives. Written consent was not obtained from participants in order to allow participants responses to remain confidential. Instead, voluntarily returning a completed survey was viewed as an indication of a respondent s consent. Surveys were returned to the researchers via the United States mail system in a previously addressed, stamped envelope. We further protected the confidentiality of the participants by using numerical codes to identify the completed questionnaires. Results Before we could assess the extent to which the role of emotion might provide new insights into nurses experience of job burnout, we needed to determine the levels of burnout experienced by the nurses in our sample. Using the standard measure of the emotional exhaustion component of burnout, we followed Aiken et al. (2001) in assessing the rate of high or problematic burnout. This level of burnout reflects scores that are significantly higher than those normally expected among medical workers (24 or higher on a scale ranging from 0-42; Aiken et al. 2001; Maslach et al. 1996) and that are most commonly associated with other negative outcomes such as lower job satisfaction, turnover intentions, depression, and decreased physical health (Janssen et al., 1999; Kalliath & Morris, 2002; Shamian et al., 2002). Although fewer nurses in our sample experienced this problematic form of burnout than those studied by nurses in the Aiken et al. (2001) study 38.4% compared with 43.2% -

the rate is still high enough to be of concern. Our concern was reinforced once we compared the results for nurses under and over age 30. Our analyses indicated that more nurses under the age of 30 experienced this problematic form of burnout (43.6%) than did

nurses who were over age 30 (37.5%). A t-test comparing the mean rates of burnout between the two groups confirmed that younger nurses were experiencing significantly higher levels of burnout than their older counterparts (t = -2.06, df = 827, p< .05). This difference in the rate of burnout by age might be explained by the fact that ...younger nurses experience more stress than their older, more experienced counterparts.As noted above, although it has long been recognized that burnout is fundamentally characterized by the experience of emotional exhaustion, few researchers have examined how the emotional context of the nursing work environment might be related to this outcome. For example, one of the central occupational stressors associated with burnout that might explain the age difference is the need to cover up or evoke emotions that are appropriate for the particular interactional context. In her case study of three nurses, Staden (1998, p. 153) quotes one nurse as saying she not only has to be able to block out her own feelings but must be able to drag up new ones from somewhere to take their place. Nurses, as well as other health professionals, perform emotional labor in order to provide effective patient care. Successfully suppressing and evoking emotions can be experienced as stressful. Could it be that nurses under 30 experience higher levels of burnout because they are more likely to perform surface and deep acting than their older counterparts? To explore this possibility, we examined the extent to which these two forms of emotional labor were associated with burnout and then how the performance of surface and deep acting varied across age groups. As indicated in Figure 1, 69% of those who experienced high levels of burnout also reported performing higher than average amounts of surface acting. This difference was confirmed through a t-test which indicated that the burnout rate was significantly higher among those reporting frequent masking of emotion than for those who tended not to engage in this form of emotional labor (t = -9.75, df = 827, p < .001). Similar results were found for pretending to have feelings that were expected but not actually felt. Sixty-four percent of those pretending at higher than average rates also reported they were burned out (t = -11.65, df = 827, p < .001). No significant difference in burnout was found for the deep acting technique of making an effort to actually feel the expected emotion.

The results presented in Figure 1supported our expectation that performing surface acting would be related to the experience of burnout. However, contrary to our expectations, we did not find that nurses under age 30 performed this form of emotional labor more frequently. Instead, as shown in Figure 2, we found that younger nurses were significantly less likely than those over 30 to cover up their true feelings (t = 2.38, df = 827, p < .05) and to pretend that they had feelings that were expected but that they did not really experience (t = 2.38, df = 827, p < .05). No such age differences were found in regard to deep acting. Finding that younger nurses report higher levels of burnout but lower levels of surface acting is surprising given that emotional labor has been identified as a central occupational stressor influencing burnout, retention, and other dimensions of well-being (Erickson & Wharton, 1997; Hochschild, 1983; Mann & Cowburn, 2005; Smith,

1992;Sumner & Townsend-Ricchiccioli, 2003). In sum, the findings presented thus far indicate that nurses under the age of 30 and those who perform two surface acting types of emotional labor (i.e., covering up emotions and pretending to feel emotions) are more burned out. However, contrary to what these results might suggest, younger nurses are not performing more emotional labor than nurses over 30. In fact, we find the opposite: among those who are burned out, 57% of nurses over 30 report high levels of covering up compared to only 38% of nurses under age 30 (see Figure 3). Similarly, 40% of older nurses who are burned out frequently pretend to have emotions that are expected but that they do not feel. In comparison, only 23% of burned out younger nurses are frequently performing this type of surface acting. These results thus suggest that emotional labor does a better job accounting for the burnout experienced by nurses over age 30 than it does for their younger counterparts. These anomalous results led us to the possibility that perhaps it is not themanagement of emotional experience that is problematic for younger nurses but the emotional experiences themselves. Because little is known about the distribution of emotional experiences or their management among nurses, our next goal was to examine the prevalence of these experiences.

Our analyses confirmed that emotions are a pervasive feature of nurses daily occupational experiences. Among our sample, 99.9% of nurses reported experiencing positive emotions (e.g., happiness, pride) during the past week at work, with 95.5% also reporting that they experienced feelings of agitation (e.g., frustration, anger). When we examined the frequency of emotions experienced at work by age, however, differences did emerge (see Figure 4). In examining whether low levels of positive emotion and high levels of agitation were more related to burnout for younger versus older nurses, we found different trends based on the emotion being experienced. As indicated in Figure 5, low levels of positive emotion were more commonly associated with burnout among older nurses while the experience of agitation was more frequently related to burnout among nurses under 30. The t-tests indicated that the mean levels of burnout did not differ significantly by age when emotional experience was taken into consideration. However, these trends do suggest that well-being among older nurses may be somewhat more sensitive to their experience of positive emotions on-the-job while younger nurses feelings of agitation may be the most problematic. Further descriptive analyses lend support to the idea that feelings of frustration, anger, and irritation may be disproportionately problematic for the well-being of nurses under 30 in that thirty-three percent of younger nurses reported experiencing high levels of agitation and high burnout compared to only 26% of older nurses who reported this combination of experiences. In contrast, the results for positive emotions and burnout do not differ much by age in that 28% of younger nurses and 27% of older nurses reported experiencing low levels of positive emotion and high levels of burnout. Conclusions In this paper we have suggested that the emotional demands and effects of caring work should be considered when examining the sources of burnout among registered nurses. As our results suggest, understanding the emotional experiences of younger nurses may be particularly important for understanding why their burnout levels are disproportionately higher than those of their older counterparts.

As expected, the data show that nurses under the age of 30 are more highly burned out than their older counterparts, a result that supports what other researchers have previously shown (Aiken et al., 2001). In an attempt to explain this result, we explored how different forms of emotional labor might be contributing to job burnout. Through surface and deep acting techniques, nurses strive to appear as though they feel the emotions that are expected of them within their jobs and profession. Our data demonstrate that surface acting is indeed associated with higher levels of job burnout among nurses. Nurses who pretended to have unfelt feelings were more burned out than nurses who did not pretend to have unfelt emotions. And, nurses who covered up their true feelings were more burned out than nurses who did not cover up such emotional experiences. Given that the data showed an association between job burnout and age of the RN, we then wondered what role age played in the relationship between emotional labor and burnout. Our analyses indicated that age of the RN was associated with the extent to which one engages in surface acting techniques to manage emotions at work. However, it was not the younger nurses who covered up their feelings or pretended to have unfelt emotions, it was the nurses over age 30 who were more likely to employ these emotion management techniques. Therefore, contrary to our expectation, engaging in emotional labor did not explain the higher burnout we saw in younger nurses. Recalling research by Fredrickson (2000) who reported that positive emotions felt at work may insulate workers from job burnout, we decided to examine the types of emotion nurses report feeling at work. While there were no age differences in the experiences of positive emotions at work, nurses under age 30 reported significantly more experiences of agitated emotions (frustration, irritation, and anger) than nurses over age 30. Thus, the younger nurses sampled experienced more agitation and tended to be more burned out. Although our results are inconclusive as to the strength and direction of this relationship, these preliminary results suggest that the relationship between agitation and job burnout among younger nurses should be considered in future research as well as among nurse administrators seeking to lower levels of burnout and turnover among

younger nurses. This suggested trend is also important because it shows that what is felt at work relates to burnout in ways that may be just as important than what nurses dowith what they feel (i.e., perform emotional labor). Given that older nurses were less likely to experience agitation or to be burned out, creating roles for older, more experienced nurses to provide emotional mentorship to younger nurses may be one way to help novice RNs cope with the emotional demands of the profession. Such roles would also be consistent with one of Buerhaus et al. s (2006, p. 11) primary recommendations for reducing the nursing shortage. As these authors note, employers must look beyond recruiting initiatives and be unrelenting in their attempts to improve the work environment so that nurses entering the profession remain and those who are expected to retire choose to postpone that decision. Given that an estimated 40% of the RN workforce will be over age 50 by the year 2010, employers must work to develop roles that take advantage of older nurses years of clinical experience and knowledge of the nursing profession. Although nursing mentors are not new, our findings indicate that such mentorship must include an explicitlyemotional component. Having more experienced nurses recognize and attend to the emotional experiences facing those new to the profession may go a long way toward improving the retention rates among both groups of nurses. In sum, our research indicates that there is a link between being younger than 30, feelings of agitation at work, and job burnout among nurses. Recognizing both the emotional experiences that are an integral but often invisible part of the nursing work environment, and the impact that such experiences and their management have on job burnout, are central to efforts aimed at increasing nurse retention. We encourage nurse managers and administrators to work toward the development of systems of care delivery that support nurses ability to experience and manage emotion in ways that improve the quality of patient care at the same time that they reduce the incidence of burnout. As one nurse suggested, it may be particularly crucial, in these days of increasing patient acuity, nursing shortages, declining enrollments, and an aging nurse population, to recognize the impact of emotional work on nurses (Henderson, 2001). Although more research is

needed to confirm these relationships across a wider sample of registered nurses, our preliminary evidence suggests a role for older RNs to provide explicitly emotional mentorship to younger nurses. Increasing recognition of the emotional experiences and demands that constitute an essential facet of the nursing work environment is the first step to providing younger nurses with the support they need to reduce their feelings of agitation and job burnout, and ultimately, reduce their rates of turnover. References Aiken, L. H. & D. M. Sloane. (1997). Effects of organizational interventions in aids care on burnout among urban hospital nurses. Work & Occupations, 24, 453-477. Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association, 288, 1987-1993. Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J. A., Busse, R., Clarke, H., Giovannetti, P., Hunt, J., Rafferty, A. M., & Shamian, J. (2001). Nurses reports on hospital care in five countries. Health Affairs, May/June, 43-53. American Hospital Association. (April 2006). Trends affecting hospitals and health systems. TrendWatch. Retrieved August 17, 2006.