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What’s the best way to resolve moral distress?Don’t suffer in silence.

By Debra R. Hanna, RN, PhD, and Maria Romana, RN, APRN,BC, MSN

D e b r i e f i n gafter a crisis

oral distress . . . It surfaces, especially inhigh-stakes, high-stress healthcare set-tings. Research shows that nurses whoexperience moral distress in their worksetting without receiving situational

support aren’t able to easily process the experience.1

Nurses who eventually resolve their moral distressalone may take longer than a year to do so.1

Whereas dramatic, “newsworthy” events trigger anoutpouring of support for workgroups, the daily, lessdramatic but morally draining events that nurses faceoften remain unacknowledged. Employees may benefitfrom brief interventions, called debriefing or critical inci-dent stress debriefing (CISD), when exposed to a trau-matic event.2 Leadership initiative is needed to bringtogether staff members to acknowledge shared distress,to accept responses to that distress, to affirm the group’shuman suffering, and to help the group cope.4

The processDebriefing is an information-sharing and event-process-ing session conducted as a conversation between peers.Group members become informants to each other abouta situation or event that occurred to them as a group.The listener can be a therapist, counselor, or profes-sional peer who helps the group process the informa-tion being shared. The person who conducts the sessionshould have the professional skills to guide the estab-lished process that will help staff members recoverfrom their distress. An important aspect of debriefing isthat the leader will assess the need for individuals whomight benefit from further individual counseling andwill make recommendations for individual follow-up.2

How can a manager recognize the need for debriefing?

The staff’s mood can provide a clear indication about thetype and level of distress being experienced. Whether theexperience of distress is moral, emotional, psychological,or spiritual in nature, if it’s occurring within the group asa whole, the whole group needs affirmation and support.

First, there can be a somber mood with signs such asan unusual quietness, less conversation, less responsive-ness to each other and to patients, less expressed interestin each other, and obvious signs of sadness such as fre-quent sighing or easy tearfulness. The event itself canbe obvious, one in which the manager was directly in-volved. Rarely, it’s obscure, such as an external eventabout which the manager has no direct knowledge.

Keeping a finger on the pulse of the staff as a groupis an important managerial responsibility. Whenever acritical incident has occurred, debriefing should followas soon as possible. Yet, debriefing isn’t the answer toevery problem, because not every problem that occursin the workplace is a critical incident.

What’s a critical incident?Events that would garner this kind of attention andintervention include episodes of workplace violence orterrorism, industrial accidents, or other events of a seri-ous nature. Yet, the healthcare environment is repletewith examples of critical incidents that aren’t newswor-thy, as they’re protected from public disclosure bypatient confidentiality. For example, adverse drug reac-tions that have led to the unanticipated death ofpatients must be reported to federal and state agencies.These agencies are responsible to safeguard publicsafety by releasing general information as warnings,but wouldn’t release specific details to the media thatcould compromise a particular patient’s right to confi-M

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dentiality about medical treatment.Yet, a healthcare worker who gavea fatal dose of properly prescribedand administered medication to apatient would be involved in a criti-cal incident of great magnitudegiven the loss of life.

In healthcare, there are additionalexamples of critical incidents thataren’t as serious as the actual lossof a patient’s life, but these areevents that can disturb the sense ofpeace and purpose of healthcareworkers. These lower-level criticalincidents can accumulate and con-tribute to staff burnout, which ulti-mately detracts from care quality.Therefore, a critical incident couldbe an unusual event or unantici-pated loss that negatively affectsthe staff as a group.

How it’s conductedOnce the nurse manager perceivesthe need for debriefing, a reliableprofessional peer skilled in CISDshould be asked to assist with theprocess. Our psychiatric clinicalnurse specialist (CNS) was theexpert advanced practice nursewith the appropriate educationand skill set able to facilitate thisprocess. The nurse managerexplained the crisis situation andher observations about the staff’sresponses to the psychiatric CNS.A time that was convenient fordebriefing was agreed upon by themanager, psychiatric CNS, and theaffected staff.

Ideally, all individuals involvedin the distressing situation shouldbe invited to participate in thedebriefing session. A single groupsession can last between 30 minutesto 3 hours, depending on the natureof the event. An event that resultsin one or more deaths requiresmore time and may warrantnumerous group and one-on-onesessions. Events that are more ordi-nary, such as daily sources of dis-tress, are less likely to receive man-agerial attention, yet they can

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become more permanently dam-aging to the workgroup and topatient care if continuously unac-knowledged.

Each session uses a clearlydefined set of counseling proce-dures, developed in 2000 byexperts Lim, Childs, and Gon-salves, that unfold in eight phases:

1. Introduction: The facilitatorestablishes the group goals andrules and reinforces the need forconfidentiality about anything thattranspires within the group.

2. Fact gathering: Each staff per-son describes what happened andfacts are gathered.

3. Reaction phase: Led by thefacilitator, the group examines itsfeelings, thoughts, and responses to the event experienced. If thedebriefing session happens soonafter the event occurred, theremight not be any symptoms.

4. Symptom phase: If some timehas elapsed since the event, groupmembers may be experiencing symp-toms. The facilitator helps the groupexamine how these reactions haveaffected personal and work lives.

5. Stress response: The facilitatorteaches group members about theirstress response.

6. Suggestions: The facilitatoroffers guidance on how to copewith stress related to the incident.

7. Incident phase: Group membersidentify positive aspects of the event.

8. Referral phase: The facilitatorconcludes with this phase, wherebyspecific individuals who requireadditional support are referred forindividual follow-up.

The following vignettes showtwo types of events that led to staffdistress, and how each issue washandled during debriefing sessions.

Vignette 1: Conflicted family deci-sion coupled with an unexpectedpatient outcome

A ventilator-dependent, terminallyill patient from the intensive care

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unit (ICU) arrived to a floor-careunit with an endotracheal tube inplace. Due to the patient’s condi-tion, physicians believed that thepatient’s death was imminent. Thepatient’s healthcare proxy hadsigned a do-not-resuscitate (DNR)order, and comfort care was initi-ated prior to transfer out of theICU. About a day after transfer tothe floor-care unit, the patient’s con-dition changed suddenly and visi-bly, heralding the patient’s death.The patient’s healthcare proxybegged the staff to “Do something!Do something!” Recognizing theright of the healthcare proxy toreverse the DNR status at any time,staff members came to the immedi-ate assistance of the patient. Aftertheir resuscitative efforts, thepatient’s appearance was marred.The healthcare proxy began toaccuse the staff of having harmedthe patient. Within minutes, thebehavior of the healthcare proxy

escalated out of control. Together,the nurse manager, nursing super-visor, and the patient’s attendingphysician tried to intervene to calmthe healthcare proxy. The unit felt“under siege” for approximately 2to 3 hours afterward.

The staff present at the time ofthe event felt traumatized by thepatient’s appearance and by theaccusations of the healthcare proxy.The nurse manager was aware thatthe group was experiencing moraldistress related to the attempt tointervene that had produced a dra-matic change in the patient’s appear-ance in the final hours of life—disfig-urement that wouldn’t have time toheal before the patient died.

Due to the social silence andaltered sociability that can occurwithin a group experiencing moral

distress, workgroups need leaderswho will recognize their distressand initiate an acceptant groupintervention.4 The reason that thistype of distress is called moral dis-tress and not psychological, emo-tional, or spiritual distress is thatthe harm to an objective good isperceived in the context of the val-ues held by the person who experi-ences moral distress. In this case,the staff valued providing comfortcare in the last hours of thispatient’s life. Such care wouldn’tinclude the unexpected outcome ofa disfigured appearance. Neitherwould it include ignoring thechanging condition if the healthcareproxy wasn’t able to accept themoment of death. The “do some-thing” command of the healthcareproxy in the context of a signedDNR order demonstrated theproxy’s ambivalence about theDNR decision and concurrentlyrevoked the decision. The action

taken by the staff was a good actionthat respected the proxy’s deci-sional conflict and right to revokethe DNR order, and yet, it produceda harm that no one expected tooccur. The entire team, includingstaff nurses, other healthcare profes-sionals, and the nurse managerneeded to process this event inorder to continue to provide care.

A single debriefing sessionoccurred the next day. At the startof the session, the patient was stillalive, and the proxy was still pres-ent in the patient’s room from theearlier evening. The staff worriedabout what would happen whenthe moment of death arrived. Thegroup was led through the debrief-ing process in a stepwise manner(as previously explained) and as itpertained to the tenuous status of

the clinical situation. At first, thestaff identified the events of the crit-ical incident, including the health-care proxy’s request to “do some-thing,” their response, the patient’scondition, and the proxy’s reaction.Teaching about this aspect of thecritical incident was provided bythe psychiatric CNS to enhance thestaff’s understanding of the proxy’sreaction as part of the grievingprocess. The proxy’s reaction wasidentified as the shock or denialresponse. Salient features of thatresponse included: loud protest anddisbelief, followed by acute anguishand expressions of anger, blame,and agitation.5

The staff then engaged in furtherdiscussion, which revealed that theproxy had been personally respon-sible for the patient’s care for thepast 20 years, lived with the patient,and would have no other supportor friends once the patient passedaway. Not all of the staff members

knew these details at the time of theproxy’s reaction. Given their sharedunderstanding of the daunting lossthat the proxy was experiencing,the staff members were able toresume working together as a teamin a therapeutic manner, overcometheir sense of having been trauma-tized, and develop a greater senseof compassion and sensitivity forthe proxy. When the patient died,staff expressed their condolences ina sensitive manner and turned theirattention to comforting the proxy atthe moment of loss. The singledebriefing session lasted approxi-mately 30 minutes and benefitedmore than a dozen employees whohad been exposed to the event.

Vignette 2: Multiple losses by deathand accident among the staff

The staff’s mood can provide a clear indication about the type and level of

distress being experienced.

The staff experienced the suddenloss of a coworker to a serious butnonfatal accident. As the extent ofthe nurse’s injuries became knownamong the staff, it became clear thatthe coworker wouldn’t return towork immediately. Staff scheduleswere rearranged to cover thatnurse’s absence during the height ofvacation season. Soon after, the staffreceived more bad news: anotheraccident left a coworker’s familymember permanently disabled. Afew days later, the staff receivednews of the untimely death of a for-mer coworker. The staff knew thatshe was leaving three young chil-dren behind.

The staff nurses were visibly upsetby these serious, sudden losses in theshort time span of a few weeks. Staffnurses tried to do their work, butbecame tearful at change-of-shift asthey shared the bad news. The staff’smood was generally somber, sub-dued, and sad.

Multiple supportive debriefing ses-sions were held to provide an oppor-tunity for day and night staffs to par-ticipate. When staff nurses wereunable to attend prescheduleddebriefing sessions, the psychiatricCNS returned at a mutually agreeabletime to work with those staff nurses.

The sessions allowed staff mem-bers an opportunity to grieve theirlosses and to identify the personalimpact of these losses on their ownlives. Staff identified sadness, fear,survivor guilt, and deep compas-sion for their coworkers during thesessions. The acknowledgement oftheir losses and grief validated theiremotions and other responses. Asthey shared the personal impactthat these losses represented in theirown lives, they also shared theirpoints of view about how theywould want to help their coworkersand their families. The debriefingprocess gave them an open forumto discuss their thoughts, and thegroup devised a plan to support the needs of each other and their

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injured peers. They communicated the plan to any oth-ers who hadn’t been able to attend the sessions.

Speaking upLack of experience, limited assessment skills, and poortiming can undermine the effectiveness of debriefing.Enlisting the help of a properly credentialed professionalcan reduce potential harm. Yet, what if no one debriefsafter a distressing situation occurs? Staff members couldprocess their responses individually in silence, which isdepersonalizing, fail to acknowledge their dignity asworkers who are suffering, and ultimately alienate them-selves from each other. The resulting fragmentation ofthe workgroup reduces morale and makes it more diffi-cult for workers to work with each other. Some staffmembers can experience a complicated response or aprolonged grief reaction, resulting in distance from theirworkgroup. Because the experience of moral distressinvolves the perception of harm to an objective good, theinterior anguish can lead to a grieving process for theindividual or the group that might not be acknowledgedor addressed if debriefing isn’t initiated. With moral dis-tress, the likelihood that the person who experiences itwill initiate discussion is very low. Debriefing provides asafe forum for the group to discuss and process that typeof experience.

A benefit of debriefing is that the healthy copingskills of some members of the group can be sharedwith other members, giving an example of healthyways of coping for those who might cope in less effec-tive ways. Debriefing was not mandatory. All staffnurses and others involved in the crises were invited toengage in the process, which was directed at supportand affirmation of the staff. The debriefing sessionsprovided opportunities for acceptance of normalresponses to a distressing situation and increasedmutual understanding and empathy among membersof the workgroup.

Debriefing has helped our units function in a moretherapeutic manner overall. It has fostered the staff’sability to work together by putting crisis situations,even mild ones, into proper perspective. The group’swork within this guided process supported staff cohe-sion, which is essential to healthy morale. The absenceof this kind of acceptant and affirming managerial sup-port could lead to staff burnout and increased turn-over, which is more likely to occur in junior, inexperi-enced members of the team.7

Relating to forces of Magnetism An interesting point about the process of debriefing ishow it relates to six “forces of Magnetism.”8 First, the“quality of nursing leadership” at the executive levelmust demonstrate compassion for its staff and patients

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by fostering a spirit of supportive collaboration. Second,managers who use the debriefing process appropriatelywill nurture their staff members with this acceptant inter-vention. This practice is evidence of a “managerial style”that’s open, malleable, collaborative, and responsive.Third, the internal consultation provided by the psychi-atric CNS to the staff provides evidence for the force ofMagnetism called “consultation and resources.”

Fourth, since all members of the interdisciplinary teamwere involved in the critical incident, all members wereinvited to participate in the debriefing sessions. This col-laboration supports the “interdisciplinary relationship”element of the force of Magnetism. Fifth, the psychiatricCNS became a teacher to her peers and others during thedebriefing sessions about the proxy’s psychologicalresponses, as well as about their own normal reactions.This perspective is evidence for the force of Magnetism,“nurses as teachers.” Finally, the force of Magnetism called“quality of care” depends on the success of the debriefingprocess because staff members can’t continue to providehigh-quality care if they’re in a state of distress, especiallya state of moral distress.

Freedom to copeThe process of debriefing helped staff members taketime together to identify the personal impact of thetraumas and losses they had experienced as a work-group. By validating their experiences and responses,debriefing freed staff to return to their own work onbehalf of others.

Debriefing isn’t meant to take the place of individualcounseling where needed; it helps identify individualswho might need further assistance to cope. From thenurse manager’s view, this brief group intervention pro-vided tangible support in an acceptant manner for staffmembers when they experienced a difficult time in theirwork environment. Such managerial support fosteredgroup cohesion, which is the foundation of healthymorale and high-quality patient care. It can nurture theprofessional development and personal well-being ofinexperienced staff members who are at higher risk forburnout if distressing events remain unacknowledged.7

In our current healthcare climate, the expectations forexcellent customer service and high productivity requiremanagerial sensitivity to staff when work-related crisesoccur. Debriefing is one way that managers can help theirstaff rebalance after a clinical crisis. NM

REFERENCES1. Hanna DR. Moral Distress Redefined: The Lived Experience of Moral

Distress of Nurses Who Participated in Legal, Elective, SurgicallyInduced Abortions [doctoral dissertation]. Chestnut Hill, Mass:Boston College; Dissertation Abstracts International (Accession No.AAT305365A); 2002.

2. Lim JJ, Childs J, Gonsalves K. Critical incident stress management.AAOHN. 2000;48(10):487-497.

3. Hanna DR. The lived experience of moral distress: nurses whoassisted with elective abortions. Res Theory Nurs Pract. 2005;19(1):95-124.

4. Blake RR, Mouton JS. Consultation: A Handbook for Individual andOrganizational Development. 2nd ed. Reading, Mass: Addison-WesleyPublishing Company; 1983.

5. Kaplan HI, Sadock BJ. Kaplan & Sadock’s Synopsis of Psychiatry:Behavioral Sciences and Clinical Psychiatry. 9th ed. Philadelphia,Pa: Lippincott Williams & Wilkins; 2003.

6. Redinbaugh EM, Sullivan AM, Block SD, et al. Doctors’ emotionalreactions to recent death of a patient: cross sectional study of hos-pital doctors. BMJ. 2003;327(7408):185-189.

7. Shanafelt TD, Sloan JA, Habermann TM. The well-being of physi-cians. Am J Med. 2003;114(6):513-519.

8. McClure ML, Hinshaw AS. Magnet Hospitals Revisited: Attractionand Retention of Professional Nurses. Washington, DC: AmericanNurses Association; 2002.

ABOUT THE AUTHORS Debra R. Hanna is an assistant professor of nursing at Molloy Col-lege, Rockville Centre, N.Y., and Maria Romana is a psychiatric nursepractitioner at New York–Presbyterian Hospital, New York, N.Y.