Do you remember that moment when you recited the Nightingale Pledge?  Although antiquated in language, the modified Hippocratic Oath, written in 1893, still rings true in many ways today. I recall the weightiness of those words. As reiterated in the ANA Code of Ethics for Nurses (2015), nurses are expected to hold those values and ethical principles in the highest regard and should afford them to all people. This is quite a responsibility for even the most seasoned nurse. Moreover, oncology nurses are often faced with issues that test ethical and moral principles. 

Principles of bioethics include non-maleficence (not doing harm), beneficence (doing “good”), justice (doing “right”), fidelity (being faithful), truth-telling, and respect for autonomy.  Ostensibly it’s just the right thing to do, but these principles can come into direct conflict with the realities of oncology nursing practice. Conflict regarding what choices to make in a difficult situation, where seemingly no good choices exist, are the crux of ethical dilemmas. Being caught in such decision-making (or decision-not-making) can cause moral distress in nurses.

Consider a situation that many of us may have encountered: the distraught daughter of a dying mother pleads you not to discuss her mother’s true condition in front of her elderly father, allowing her father to believe that the mother is going to rally and stabilize.  You are personally struck by the daughter’s plea, as your own mother died in similar circumstances. Yet, you have an ethical duty to this patient.  Situations like this, even if the actions you should make are clear, can result in moral distress. 

Moral distress is the term used to describe our responses to such dilemmas. Oncology nurses report higher levels of moral distress than nurses in other acute care settings. Moral distress can illicit anguish in mind, body, and spirit, whether the response to a moral responsibility is clear or unclear. Moral distress is different from other types of distress, because, although taking the ethically appropriate action, the nurse experiencing moral distress feels as though their moral values have been compromised.

Nurses respond to moral distress in many ways. Withdrawal, self-doubt, and even outrage are common responses. Unattended moral distress can lead to longer hospital stays and increased pain for patients. It causes erosion of communication and effective teamwork for healthcare teams, distrust, frustration, and mental exhaustion for individual healthcare providers.

Nurses do have avenues to combat these concerns. Professional standards like the ANA Code of Ethics, your state Board of Nursing’s standards, and specialty organizations’ position statements and guidelines of practice support clear recommendations. Strong organizational policies should define frameworks for steps to take when ethical considerations arise. If your organization doesn’t have these policies, ask to be part of defining them! Reach out to the chaplain or social work services to request facilitated debriefings following difficult discussions or ethically distressing events. 

Finally, take care of your “house,” so to speak. Ongoing team communication and ethical decision-making education builds collegial support and early recognition of potentially distressing events. Knowing that as colleagues you are looking out for each other ethically strengthens moral confidence and may lessen distress. Practice how to handle situations like the one described, and how to recognize your feelings about it.

Oncology nurses live in a world of gray areas, where the population we serve will encounter moral decision-making events more often than most. Our commitment to moral and ethical care, underscored in our early Nightingale Pledge, need not be at the expense of our own moral compass.

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