Correctional Nurse Self-Care: Are You Carrying the Heavy Burden of Moral Distress?

Kiko con cajaRecently I traded in my clunky 2009 laptop for a new streamlined model. It wasn’t until my first journey with this new laptop that I realized just how heavy my old version was. Now I have a good idea why my shoulders ached after a long day of traversing airports for gate changes while running to make the connection with computer bag in tow.

Moral distress can be like that – a heavy weight on your shoulders that has been slowly building as you work in the criminal justice system. You may not even notice the developing distress until something snaps. Correctional nurses need to monitor moral distress and seek morally satisfying solutions to the ethical dilemmas encountered in day-to-day practice.

What’s in a Name?

The first step in solving moral distress is to identify it. Moral distress has been defined as knowing the right action to take, but being constrained from taking it. In its simplest form, then, moral distress in correctional nursing may be knowing that a patient should be able to make a health decision autonomously but seeing that they are being forced to make that decision against their will.

However, researchers in moral distress among nurses add to this definition in important ways. Nurses are often confronted with an ethical dilemma where the course of action best for the patient is in conflict with what would be best for others; whether it is the organization, other providers, other patients, or society. So, the interior world of the nurse that identifies who they are as a professional is in conflict with the exterior world of the work environment and work team. This is what leads to the distress that can be strongly felt by a nurse.

Moral distress is when:

  1. A nurse is involved in or aware of a situation that calls for a moral action.
  2. Is obstructed from taking that moral action.
  3. Experiences negative feelings because that action was not taken.

I hear of many examples of moral distress among correctional nurses in my various interactions. Intentional bias, poorly staffed medical units, or obstruction from officers or leadership can lead to treatment delays, unrelieved pain, or gaps in care management. Conscientious nurses absorb the stress of longstanding unethical treatment.

The Grimy Build Up of Moral Distress

Absorbing moral stress over time leads to a grubby film that builds up in our nursing souls and affects our emotional, psychological and physical well-being. This has been defined as ‘moral residue’ and is particularly intense when injury to a nurse’s moral integrity is repeated over time. In a correctional setting, a nurse may see the ‘take down’ of mentally ill inmate multiple times over months of practice and have a ‘here we go again’ response to the moral wound caused by seeing this action and feeling unable to do anything about it.

Identifying Moral Distress

Although nurses cannot always name the feeling, most of us know what it is like to be in moral distress. We feel powerless, anxious, and unhappy. Moral residue can lead to typical stress-related symptoms such as nausea, insomnia, and headaches. It can cause us to seek other employment or even leave the profession. When these feelings are present, it is important to seek the source of discontent. It may be the weight of long-standing moral distress.

Seeking a Good Response

Nurses can also feel belittled or unimportant in morally distressing situations. It is easy to experience isolation if we do not feel supported in talking about the morally injuring situations around us. Yet, talking to a supportive colleague is an important action to help identify and clarify moral distress.

Critical care nurses also often find themselves in a morally distressing situation. The American Association of Critical Care Nurses (AACN) developed a 4 step process to help nurses address and reduce moral distress.

ASK Ask yourself if what you are feeling is moral distress. Are others exhibiting signs of moral distress, as well?
AFFIRM Affirm your feelings and consider what aspect of your moral integrity is being threatened.
ASSESS Objectively analyze the situation and what the ‘right’ action would be. Consider what is currently being done, who the players are, and your readiness for action.
ACT Create a plan of action considering any pitfalls and strategies to overcome them.

Have you had to deal with moral distress in your correctional nursing practice? Share your experience with our readers using the comments section of this post.

Photo Credit: © KostaKostov –

Moral Courage: Do You Have What It Takes?

Courage And RiskA recent news story describes an investigation into 148 female inmate sterilizations in the California Prison System between 2006 and 2010. Inmates report being coerced into tubal ligation surgery following in-custody births. Although the situation is still under investigation, this news story reveals one of many moral situations encountered in correctional health care. One wonders if others in the facilities questioned the actions of the physicians performing these procedures in violation of prison healthcare policy which requires administrative approval of any elective procedure.

Possibly more than any other nursing specialty, correctional nurses confront moral dilemmas in the clinical setting. Clashing worldviews of security and healthcare along with the political and social implications of healthcare delivery to criminals create a quagmire of ethical concerns. Many correctional nurses work in solo practices in small facilities without benefit of a healthcare management structure that supports standard healthcare practices. Even in larger systems, ethical practices may be overruled by a security structure that is not attuned to the patient care implications of custody practices.

Moral courage is the courage to take action on a moral issue by overcoming fear of the consequences. The potential for reprisal, social isolation, and termination can lead to fear in responding to a moral issue such as patient coercion. Self-doubt can also cloud the issue. If no one else in the organization is addressing or responding to unethical or immoral practice, a nurse can question her interpretation of the situation.

Do you have what it takes to respond with courage when confronted with a similar ethical or moral issue? How can correctional nurses strengthen their moral courage?

Back to Your Roots

One way to gain moral courage is through reflection on the defining elements of our professional practice. In addressing concerns nurses can have as whistleblowers, Lachman suggests a need to return to our professional roots. As professionals we must be loyal to the definition of nurses as those who alleviate suffering and advocate on behalf of a patient’s well-being. Therefore, as nurses, we can garner the moral courage to act in the face of unethical colleagues, patient safety violation, or fraud by reflecting on the need to report these behaviors as part of who we are as professionals.

Tempered with Wisdom

Moral courage in nursing practice also requires wisdom. The courageous among us can be rash in responding to what, on first review, is an unethical practice. Yet, a wise nurse considers all the facts and perspectives before sounding the alarm. A wise response is determined based on full information; while misdirected courage can lead to foolhardy actions. Wisdom tempers courage to, instead, seek the right response in any situation.

Practice Makes Perfect

Intentionally practicing moral courage can develop the skill and habit of responding even in the face of fear. Some consider courage to be equivalent to fearlessness; but that is a distortion of the concept. Courage means overcoming fear by acting in the face of adversity. By practicing the skill of overcoming small fears, a nurse can develop moral courage by progression. For example, courageously overcoming fear to respond to rude behavior from a colleague develops the moral courage muscle. Like strength training for our physical muscles, our moral courage muscle must be stressed with ever increasing weight.

What would you do if you saw that providers in your setting were performing elective procedures without appropriate administrative clearance as noted in the opening story? How would you seek out enough information to take the right action? Would you know the mechanism to use to report the situation? Would you have the moral courage to take action? Share your thoughts in the comments section of this post.

Read more about ethical practice in corrections in Chapter 2: Ethical Principles of Correctional Nursing from Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Photo Credit: © freshidea –