Moral Distress: Call for Stories

Moraldistress is the psychological disequilibrium when a person believes he or

Moral Compass
Moral Compass (Photo credit: psd)

she knows the right course of action to take but cannot carry out that action because of an obstacle, such as institutional constraints or lack of power. (source: Arizona Bioethics Network). Moral distress has been studied in nurses—mainly acute care nurses—since the 1980s. Although imperfectly defined and measured, moral distress appears to be strongly related to professional burnout and patient safety issues in a variety of health care professionals including doctors. (see NYT article “When Doctors and Nurses Can’t Do the Right Thing” Pauline Chen, 2-5-09).

A 2010 symposium focused on moral distress was held at the University of Victoria on Vancouver Island. As reported recently by Bernadette Pauly and her colleagues in the journal Healthcare Ethics Committee Forum (2012, issue 24) interventions targeting moral distress have focused on individual coping skills of nurses and other providers. (I’ve mainly seen interventions such as deep breathing, meditation and journaling.) Most research has focused on acute care nurses and has reinforced the notion of “nurse as victim” in the hierarchical hospital system. Pauly and colleagues called for greater attention to structural issues involved with moral distress, including the ethical climate of the hospital administration. In addition, they questioned the current emphasis in nursing education on teaching ethical frameworks instead of specific guidance and skills in how to navigate increasingly complex ethical terrain in everyday practice. They also recommended interprofessional education—bringing together nursing, medical and other health professions students for this sort of ethics education.

The journal Narrative Inquiry in Bioethicshas a call for stories about moral distress from nurses and other health care clinicians. It would be great to see submissions from nurses working in schools, public health, home health, community-based clinics, and occupational health sites, as well as from acute care settings. This is your chance to contribute to a forum that could contribute to some positive structural changes in our health care system—and not just more deep breathing and meditation trainings.

Here’s the information: Narrative Inquiry in Bioethics Call for Stories

Narrative Symposium: The Many Faces of Moral Distress Among Clinicians

Edited by Cynda Hylton Rushton, PhD, RN, F.A.A.N. and Renee Boss, MD, MHS

Narrative Inquiry in Bioethics will publish an issue devoted to personal stories from clinicians regarding situations that cause moral distress and how they have responded to them. Moral distress arises when professionals find that they are unable to act in accordance with their moral convictions. The focus of this inquiry is on the personal and professional short- and long-term impact of moral distress and the ways that clinicians respond to and make meaning from that distress. Appropriate contributors might include nurses, physicians, social workers, nursing assistants, clinical ethicists, occupational and physical therapists, and professionals in training. We want true, personal stories in a form that is easy to read.

In writing your story, you might want to think about:

·         Which specific clinical situations give rise to moral distress? Why?

  • How do you experience moral distress—physically, psychologically, socially or spiritually?
  • How do you deal with moral distress? In past distressing situations

o   Did you take actions that allowed you to uphold your deepest values?

o   What conditions within yourself, the people involved, and the external environment allowed you to do this?

o   How did you made sense of the situation?

  • What have been the short or long term consequences?

o   Have you ever been professionally disciplined for acting upon your moral conviction?

o   How has moral distress affected your job performance or your commitment to your job?

o   What has been left undone or been the residual impact?

o   How have your own values evolved as a result of moral distress?

  • How would you change the system (e.g., policies, hierarchies, processes) to alleviate moral distress within your position? Do you think it can be alleviated, or is it inevitable?

You do not need to address all of these questions—write on the issues that you think are most important to share with others. You do not need to be a writer, just tell your story in your own words. We plan to publish 12 stories (800 – 2000 words) on this topic. Additional stories may be published as online-only supplemental material. We also publish two to four commentary articles that discuss the stories in the journal.

If you are interested in submitting a story, we ask you first to submit a 300-word proposal—a short 
description of the story you want to tell. Please include a statement about what type of clinician you are and what kind of environment you work in (no institutional names are needed). Inquiries or proposals should be sent to the editorial office via email: We will give preference to story proposals received by Oct 31st. For more information about the journal Narrative Inquiry in Bioethics, the guidelines for authors, and privacy policies, visit our webpage with Johns Hopkins University Press at:


HIPAA at 30,000 feet/ October 22, 2010

At 30,000 feet cruising altitude on a four-hour direct flight between Seattle and NYC, my seatmate pulled out a two-inch sheath of papers, put them on her seat tray table and started writing on them. I was knitting and had my headphones on, trying to relax. I glanced down to see what she was working on and saw that they were patient charts. Individual progress notes complete with full names, dates of birth, addresses, insurance carriers, presenting complaints, physical exam findings, medications, diagnoses and treatments. I discovered all of that by small furtive glances past my knitting project. I tried not to look, but it is like trying not to look at an attractive person starting to undress in public. You know you shouldn’t be looking but it impossible not to.

My seatmate’s progress notes (along with the familiar blue and white billing/encounter forms) also had her name on them and the name and address of the clinic where she worked. From the range of patients she had seen, she must be a family physician. The clinic is outside of Seattle—sort of in the country. But still, I am fairly sure that she is aware of HIPAA and that it is rather odd (and I’d say unethical) behavior to be charting on an airplane. She worked on these charts for three hours, after which she laid her head back to rest, thought better of it and turned the top page over to cover the information. As if that took care of the patient confidentiality part of having just waived patient information under my nose for the past three hours? Oh yes. The other thing that I found fascinating is that all of the patient progress notes she worked on were from over a month ago. And it wasn’t like she had even made short notes already on the progress notes from (presumably) the day she had seen these patients. They were all blank except for the patient’s information and presenting complaint. Perhaps she has a good memory. Perhaps she was making it all up. Maybe she had had some sort of family emergency and hadn’t been able to chart on these people closer to the time she had seen them. But really, on an airplane?

I thought about saying something. I wondered if it’s possible to make a HIPAA citizen’s arrest at 30,000 feet. I did neither of course, and instead kept knitting and composing this blog post in my head. I kept wondering what all of those patients would think/say/do if they knew their personal health information—psoriasis, acne, domestic violence injuries among others—was being displayed on an airplane. I also thought about how it was likely her patients were from a low-income community clinic of some sort, since many of them had no insurance. Would a family doctor from a more upscale clinic be charting on paper progress notes on an airplane? I doubt it. So this leads me to wonder about the inequity even in the application of HIPAA and patient privacy in the US. HIPAA seems to be more about protecting the health care system than protecting individual patients—at least how it has been interpreted and applied. For instance, at a community clinic I recently worked at, the clinic administration decreed that we as providers could not provide patients or parents of children copies of their immunization record. At least we couldn’t give it to them the day they asked for it. Instead, they had to fill out/sign a record request form that went to medical records and presumably several weeks later they could come back to clinic and get their immunization record. When we questioned this, the clinic administration said it was “HIPAA rules.” As if.