An Experience with Moral Distress and its Resolution

ethical issuesSeveral weeks ago I attended a lecture given by a nurse midwife. She reviewed important information about how nurses support the health and wellbeing of patients who are incarcerated during pregnancy. The speaker was very engaging and provided clinically relevant, useful material.  At one point the speaker described the problems resulting from routine use of custody restraints to transport pregnant women.  She noted that the policy of the correctional organization where she provided services was that women were shackled even while in labor.  The speaker being familiar with the experience of women in labor, further commented that risk of escape or assault during this time was not likely.  She also indicated that she found it futile to try and change the correctional system’s practice regarding use of restraint during pregnancy. There are several organizations that recommend against routine use of shackles during labor and delivery. These include the American Corrections Association, the National Commission on Correctional Health Care, the American Congress of Obstetricians and Gynecologists, and the American Civil Liberties Union. No one contributed this information during the presentation. I could have but did not and my failure to act has since haunted me.

This is an example of moral distress, a condition experienced by many correctional nurses. Moral distress occurs when correctional nurses find themselves in situations where nursing values are jeopardized.  In correctional settings where shackles are used routinely in the transport and security of pregnant women nurses are witness to treatment that is not consistent with recommended standards of care and is therefore inhumane. To resolve the distress associated with ethical conflict correctional nurses can use moral reasoning to re-align their actions with professional nursing values. Here is a description of the steps discussed in Chapter 2 Ethical Principles for Correctional Nursing to resolve moral distress and how I used them to address the distress I experienced recently:

1. Assess the Situation: In a presentation made at a national conference an authority on the health care of pregnant women described a correctional system’s routine practice of using shackles during pregnancy, labor and delivery. This practice is not consistent with recommendations of several authoritative organizations. No one in the audience provided information about recommended practices. As a result, participants left the session ill-informed and therefore unable to advocate for change that will reduce risk of injury and prevent re-traumatization of women.

2. Identify Moral Problems: Two moral problems were identified. First, there is a prevailing body of literature that management of women during incarceration should be “trauma-informed” and not include use of custody restraint unless necessary. Therefore routine use of shackles causes harm to the patient and is not consistent with the value of human dignity. Second, the principle of social justice is that in the absence of evidence that that there is imminent risk to the safety of the patient, the infant or the public the criminal justice requirements should not outweigh considerations of human dignity.

3. Set Moral Goals and Plan Moral Actions: My goal is to speak up so that nurses and others in correctional health care and the criminal justice system know that limiting the use of shackles during pregnancy, labor and delivery is recommended.

4. Implement Moral Plan of Action: So far I have had two opportunities to speak up. Because I have identified the problem and set a goal I am also more aware of opportunities to share this information, advocate for and support efforts to change policy and practice.

5. Evaluate Moral Outcomes: The best outcome would bethat no system uses shackles on pregnant women unless there is some evidence of imminent danger to the mother, child or other people. Until then, one outcome is to bring the issue up whenever it is relevant to do so and to generate discussion about steps to implement practices that are more consistent with the recommendations.

Have you experienced moral distress?  I found the discussion of nursing values and ethics in Chapter 2 Ethical Principles for Correctional Nursing very helpful in identifying what bothered me so much about this experience. Even more valuable, though, was developing the action plan because taking thoughtful steps to do something different guarantees that it will not happen to me again. What steps have you found useful in resolving moral distress? Please tell about your experience by responding in the comments section of this post. To read more about how to resolve moral distress order your copy of the Essentials of Correctional Nursing directly from the publisher. Use promotional code AF1209 for $15 off and free shipping. Photo Credit: © Marek –

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