Moral Distress in Cancer Care

By Elaine S. DeMeyer, RN, MSN, AOCN®, BMTCN® - Last Updated: August 2, 2022


Every day, oncology nurses face ethical challenges and situations that can create moral distress. Moral distress occurs when your ability to provide the desired quality of care and continuity of care is impeded. Both internal and external stressors can cause moral distress. Recognizing, assessing, and addressing moral distress are important to combat those.



What Is Moral Distress?

Moral distress is a complex problem that differs from other forms of distress like burnout and compassion fatigue. There are many different definitions, but a concise one is from the American Association of Critical Care Nurses (AACN):

“Moral distress occurs when you know the ethically correct action to take, but you are constrained from taking it.”

Oncology nurses are at higher risk for moral distress than other nurses because they often form close bonds with patients and their families during a very vulnerable time in their life. The frequent exposure to distress, pain, conflicts about goals of care, and end-of-life decisions increases oncology nurses’ risk of experiencing moral distress. Decisions about care and the kind of care can challenge a nurse’s fundamental values and beliefs. Moral distress sometimes can be so severe that it manifests in physical and psychological symptoms. For example, it can lead to symptoms such as gastrointestinal problems, sleep difficulties, headaches, panic attacks, flashbacks, or nightmares.

What Causes Moral Distress in Cancer Care?

Causes of moral distress are multifactorial, often causing a “ripple effect.” Sources of moral distress can be personal, interpersonal, and/or environmental. For example, lack of workplace support (eg, staff, supplies, or leadership) in combination with inadequate communication, or a patient’s sense of false hope, can contribute to moral distress. Some perceived causes in cancer care include:

• Inadequate pain control

• Inappropriate resources

• Overly aggressive or futile treatment

• Unclear goals

• Disrespecting, disregarding patient/family choices

• Incomplete disclosure or lack of informed consent

• Ineffective communication

• Trivializing or objectifying patients

Often, the challenge of witnessing suffering or frequent loss without adequate time to grieve can predispose nurses to distress. Oncology nurses are particularly susceptible due to the long-lasting relationships we build with patients and the visibility of a slow decline in quality of life.

Another cause leading to moral distress comes with crossing boundaries. Professional boundaries are on a continuum with the “zone of helpfulness” in the middle. At times, oncology nurses can become under-involved or over-involved at either end of the spectrum. Under-involvement is “too little” involvement when you disengage or distance yourself. On the other end of the spectrum, calling in on your day off to check on a patient or buying presents or food for patients are examples of over-involvement. Your intentions may be good, but too much involvement can compromise a therapeutic relationship. Maintaining a therapeutic professional boundary and not stepping over the line can minimize moral distress.

How Can You Recognize Moral Distress in Cancer Care?

Often nurses do not recognize distress until they have symptoms. Symptoms of moral distress can mimic those of PTSD, such as gastrointestinal problems, sleep difficulties, headaches, panic attacks, flashbacks, or nightmares.

Learn to recognize and address moral distress using AACN’s The 4A’s to Rise Above Moral Distress framework.

  1. Ask yourself: “Am I feeling distressed or showing symptoms?”
  2. Affirm it: “Yes, I am suffering, and I plan to share my feelings with a trusted colleague.”
  3. Assess your willingness to change: “What can I do personally? How can I help my team?”
  4. Act: “I plan to make changes to help myself.”

Moral distress can affect all nurses, particularly those working in high-intensity areas like oncology. For a long-term sustainable career in oncology, take steps today to name and recognize moral distress. Be on the lookout for moral distress in yourself and your colleagues.



Moral Distress in Oncology Nurses: A Qualitative Study

Moral Distress in Nursing: What You Need to Know

Moral Distress: What It Is and What to Do About It

The 4A’s to Rise Above Moral Distress

Post Tags:Resilience