Better communication key to mitigating moral distress for nurses, say researchers

Study of conditions in pediatric intensive care units aims to stem the flow of nurses leaving the profession.


Moral distress can take a serious physical and mental toll on health-care professionals, according to a U of A nursing researcher who interviewed pediatric ICU nurses about their experiences for a study aimed at keeping them from quitting the profession. (Photo: Getty Images)

Diane Kunyk quit just months into her first nursing job. The cause was moral distress — a growing problem for Canada’s health-care system — although she didn’t have the words to describe it that way at the time. 

Kunyk was working in a neonatal intensive care unit, with worried parents at the cribside day and night. Yet she wasn’t allowed to speak with them.

“The policy was that nurses should not talk to the parents about the child’s care because you might say something wrong,” remembers Kunyk who, more than 40 years later, is now acting dean of Canada’s top nursing program at the University of Alberta.

“I couldn’t deal with that,” she says. “It was so disconnected from family-centred nursing care, so I resigned. I got the job in May and left in December.” 

Moral distress is the ethical crisis that occurs when you believe you know the right thing to do but can’t carry through because of circumstances beyond your control. Nurses who face this repeated compromise of their values go through a range of physical and emotional symptoms including heart palpitations, nausea, headaches, sleeplessness and anxiety, says Sadie Deschenes, one of Kunyk’s students and principal investigator for newly published research on moral distress in pediatric critical care. Some nurses end up leaving nursing altogether.

Even before the COVID-19 pandemic, the Canadian Federation of Nurses predicted a shortage of nearly 120,000 nurses by 2030, with 37 per cent saying their mental health was suffering and 60 per cent saying they wanted to quit nursing. When nurses go on extended sick leave or resign, the resulting staff shortages lead to a decrease in the quality of patient care and further stress for the nurses who remain.

“Almost 50 per cent of nurses who experience moral distress will leave their position or the profession,” says Deschenes, now a postdoctoral fellow who starts as an assistant professor of nursing at the University of Alberta in January. 

Compromised values

Moral distress among health-care professionals has been acknowledged, studied and defined since Diane Kunyk’s first experience with it. Much of that work was contributed by U of A professor emeritus Wendy Austin, who was Canada Research Chair in Relational Ethics in Health Care from 2003 to 2013.

Most health-care professionals experience some moral distress, but levels for pediatric ICU nurses are among the highest, according to Deschenes and Kunyk.

“One of the nurses I interviewed spoke of the pediatric ICU like a war zone. They said, ‘I didn’t want to leave anybody behind,’” Deschenes recalls. “They said they’re surprised that no one has committed suicide.”

“I suspect a part of the high level of moral distress for pediatric ICU nurses is because they’re working with seriously ill children experiencing pain and suffering, and sometimes loss of life,” says Kunyk. “Nurses are at the bedside so witness children’s experiences and parents’ suffering as well. Their personal agency to alleviate suffering can be limited.”

That may be due to a lack of information about the overall care plan for a patient, a difference of opinion with other care team members, restrictive hospital policies or a lack of resources, usually personnel shortages, according to Deschenes.

Deschenes went through it herself when she left a job in a pediatric ICU without really knowing why it made her so unhappy. It wasn’t until she had enrolled in a PhD program that she realized the cause was moral distress. She decided to dig into the academic literature and learn more. She was surprised and disappointed when her review of previous studies on the topic revealed plenty of descriptions but few evidence-based solutions that had been tested and implemented. And nurses’ voices were missing. 

“We couldn’t find data asking nurses what they wanted, and they’re the ones experiencing it,” she says. “How could we better support them? What would they need? What would they want? And what would they offer as advice to new nurses?” 

Strategies to better support patients, families and staff

For her latest paper, Deschenes asked those questions of 10 pediatric ICU nurses during in-depth interviews. 

“They spoke about how they loved taking care of babies and families. They were proud of their work,” she found. “They said the individuals they worked with were highly competent, and yet they often said the team was broken, because you can’t ask for help from somebody who’s also burnt out.”

Deschenes identified four main themes for proposed solutions, all of which came down to better communication: 

  • Increasing supports for patients and families, for example with social workers and other professionals, to supplement care by the nurses;
  • Improving direct supports for nurses, so they know who to turn to during a mental health crisis;
  • Improving communication about patient care with the entire care team so that everyone knows what the plan is and why, and how that plan has been relayed to families;
  • And better education for nurses so they know how to mitigate moral distress as they are experiencing it.

Deschenes teaches ethics to U of A nursing students and covers moral distress as part of the course. She’s excited that young nurses are developing a common language to talk about moral distress and anticipating strategies for coping before they are in real-life situations. 

Based on the data from her research, Deschenes has proposed an intervention that she plans to test in an urban hospital: setting up an interdisciplinary meeting for pediatric ICU team members where they discuss not only goals and plans of care for patients but also what supports are available for patients, families and the team. Deschenes is working on a feasibility study with Sean Bagshaw, professor and chair of critical care medicine, and Shannon Scott, professor and vice-dean of nursing, who also co-supervised Deschenes’ PhD research with Kunyk. 

“We hope our intervention could help because it’s allowing team members to ask questions like, ‘What else can be done’ and ‘Who else should be involved in the situation?’” Deschenes says. “We want everybody on the same page, understanding what’s been done and where we’re going, even if not everybody agrees.” 

Kunyk returns to the war analogy to underscore how important she feels it is for the health-care system to do a better job of dealing with moral distress.

“It’s such a loss to have a highly trained nurse leave the profession because of unresolved despair,” she says. “It’s like abandoning soldiers who are wounded in the field.”