Moral distress was originally defined as occurring "when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action."1 Most nurses can give examples of personal moral distress because several issues in healthcare increase the risk of it. First, there's the disconnect between nursing education (where students are taught the ideal) and the real world of nursing (where compromises about what should be done and what can be done occur daily). By the time nursing students graduate, the current educational system has primed them to experience moral distress.

Then there are the real-world work environment issues. Nurses have always had two bosses-the patient's physician and the employing organization. Because most physicians aren't employed by the hospitals where they admit patients, conflicting expectations can occur between what the physician wants and what the hospital allows. Nurses are often caught in the middle, resulting in moral distress. Dysfunctional communication between physicians and nurses continues. A movement is under way to improve communication between all healthcare workers, but historical communication patterns are difficult to change. Transdisciplinary care is needed in today's complex healthcare system, but there are barriers to providing it.

Research shows that the leading cause of moral distress for nurses involves end-of-life care. We still aggressively treat too many terminally ill patients when a referral to hospice for comfort care is needed. Hospice is underutilized and often only called in when death is imminent. Caring for terminally ill patients, who are suffering both physical and emotional pain at end of life, increases moral distress. Research shows that the longer nurses care for terminally ill patients, the greater they experience moral distress.

Managed care has increased moral distress in all healthcare providers, not just nurses. Providing the best, evidence-based care to patients within a managed-care system is often problematic. Many of the patient-care decisions once made by those caring for patients are now dictated by managed-care corporations, which tend to be more focused on the financial impact of care than on patients' needs. Healthcare workers often feel powerless to overcome managed-care directives. The result is doing what's allowed instead of what's best, increasing moral distress.

Needlessly on the rise, moral distress causes burnout and decreased nurse retention. The time to act is now. Nurses should insist their organizations develop strategies to decrease situations of moral distress. Strategies include:

* Create healthy work environments. Both the American Nurses Association and the American Association of Critical-Care Nurses have readily available resources to do this.

Figure. Do you ever feel stuck between what's right and what's possible?

* Ask your organization to provide a self-care intervention program for nurses to reduce moral distress.

* Recognize signs of moral distress in others and intervene.

* Have the courage to change, not your core ethical structure but your job, if your organization refuses to address the issue of moral distress.

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