A Jameton

A Nivens

A Wakefield

EM Rice

I Begat

J Bell

J Schluter

JS Luquette

L Aiken

M Sinnott

M van Soeren

Michael Sinnott

Ramon Shaban

Sarah Winch

Crossref

Journal of Bioethical Inquiry

It Is Not Your Fault: Suggestions for Building Ethical Capacity in Individuals Through Structural Reform to Health Care Organisations

Winch, Sarah

Sinnott, Michael

Shaban, Ramon

University of Queensland eSpace

This is a post-print version of the following article: Winch, Sarah, Sinnott, Michael and Shaban, 
Ramon (2013) It Is Not Your Fault: Suggestions for Building Ethical Capacity in Individuals Through 
Structural Reform to Health Care Organisations: Comment on "Moral Distress in Uninsured Health 
Care" by Anita Nivens and Janet Buelow. Journal of Bioethical Inquiry, 10 3: 423-424.  
 
[issue] 10(3) 
[category] Case Studies 
[title/headline] It Is Not Your Fault: Suggestions for Building Ethical Capacity in 
Individuals Through Structural Reform to Health Care Organisations 
[subtitle/subhead] Comment on “Moral Distress in Uninsured Health Care” by Anita 
Nivens and Janet Buelow 
[byline] Sarah Winch; Michael Sinnott; Ramon Shaban 
 
Received: 13 May 2013 / Accepted: 19 May 2013 
 
[article note] The original article by Anita Nivens and Janet Buelow, published in the Journal 
of Bioethical Inquiry, 10(1): 123–125, can be located at DOI 10.1007/s11673-013-9425-z. 
 
Keywords Moral distress, nursing, staff safety, self-blame. 
 
 [author information] 
S. Winch 
School of Medicine, The University of Queensland. Queensland, Australia 
e-mail: sarah.winch@uq.edu.au 
 
M. Sinnott 
Emergency Medicine, Princess Alexandra Hospital, Queensland, Australia 
 
R. Shaban 
School of Nursing and Midwifery, Griffith University, Queensland, Australia 
 
Moral distress is known to cause skilled nurses to exit the profession (Schluter et al. 2008), 
resulting in less-than-optimal patient outcomes (Aiken et al. 2002). For the case presented by 
Nivens and Buelow (2013), two broad responses are required. First, management should 
recognise this field of nursing may cause moral distress. This has implications both for nurse 
and patient safety. A timely and focussed review or implementation of structures to support 
This is a post-print version of the following article: Winch, Sarah, Sinnott, Michael and Shaban, 
Ramon (2013) It Is Not Your Fault: Suggestions for Building Ethical Capacity in Individuals Through 
Structural Reform to Health Care Organisations: Comment on "Moral Distress in Uninsured Health 
Care" by Anita Nivens and Janet Buelow. Journal of Bioethical Inquiry, 10 3: 423-424.  
 
staff to maintain moral momentum is required. Second, all nurses need to recognise that 
moral distress is an occupational hazard and accept support and training in managing the 
ethical implications of these very difficult cases.  
We will now explore these recommendations in detail. Health care managers have a clear 
responsibility to keep their staff safe. This is both an ethical obligation and in some practice 
environments legally mandated.1 While concern should be for staff members, the logic of 
staff safety as requisite for patient safety has been acknowledged (Sinnott and Shaban 2011). 
Much work has been done to improve staff safety in the physical sense. Yet safeguarding the 
moral health of nurses who are repeatedly exposed to traumatic and difficult cases, where 
their best response will be constrained by circumstances beyond their control, is only recently 
gaining recognition. This is despite a well-established literature on moral distress and the 
related concepts of compassion fatigue in nursing, stretching across several decades (Jameton 
1977).  
Recognition of the moral impact of particular forms of health care work leads to managerial 
responsibility for creating and sustaining ethical work environments that support the ethical 
safety of staff as well as their physical well-being. Structural elements can be introduced into 
the work environment that develop and sustain ethical resilience in staff members. These 
include promoting and scheduling regular case review for debriefing (van Soeren and Miles 
2005), establishing peer supervision (Begat, Ellefsen, and Severinsson 2005), monitoring the 
case-mix for individual clinicians (Rice et al. 2008), and tracking and treating levels of moral 
distress and compassion fatigue amongst staff (Luquette 2005). Hiring a clinical ethicist to 
build ethical capacity within the organisation also has been recommended (Bell and Breslin 
2008). 
These managerial interventions are visible markers of support for clinicians to help navigate 
and manage the moral distress associated with many fields of nursing practice. More nuanced 
and complex is the work required by nurses to actually use the services provided; to 
overcome what has been identified in other domains of the staff safety literature as a “self-
blame culture” amongst health workers (Sinnott and Shaban 2011). This type of behaviour 
                                                             
1 For comprehensive legislative requirements in Australia see “Safe Work Australia” 
(www.safeworkaustralia.gov.au).  
This is a post-print version of the following article: Winch, Sarah, Sinnott, Michael and Shaban, 
Ramon (2013) It Is Not Your Fault: Suggestions for Building Ethical Capacity in Individuals Through 
Structural Reform to Health Care Organisations: Comment on "Moral Distress in Uninsured Health 
Care" by Anita Nivens and Janet Buelow. Journal of Bioethical Inquiry, 10 3: 423-424.  
 
occurs where clinicians “self-blame” based on the cultural perception of risk. That is, they 
know these situations are difficult, but they feel they should be able to cope. When they fail 
to do so, they attribute the fault to themselves. This requires, as Wakefield (2000) argues, a 
“relentless approach to self-care” to enable nurses to reconcile their limitations and 
obligations. Heroic measures are frequently demanded from all clinicians, including nurses, 
who willingly oblige by negotiating a plethora of emotional and physical barriers to provide 
excellent care. Ultimately, however, unless systematic structures are not only established but 
also accessed by nurses exposed to these morally challenging environments, the wellspring of 
compassion runs dry—causing poor outcomes for staff and ultimately patients.  
 
References 
Aiken, L., S.P. Clarke, D.M. Sloane, J. Sochalski, and J.H. Silber. 2002. Hospital nurse 
staffing and patient mortality, nurse burnout, and job dissatisfaction. The Journal of 
the American Medical Association 288(16): 1987–1993.  
Begat, I., B. Ellefsen, and E. Severinsson. 2005. Nurses’ satisfaction with their work 
environment and the outcomes of clinical nursing supervision on nurses’ experiences 
of well-being: A Norwegian study. Journal of Nursing Management 13(3): 221–230.  
Bell, J. and J.M. Breslin, (2008). Healthcare provider moral distress as a leadership challenge. 
JONA’s Healthcare Law, Ethics, and Regulation 10(4): 94–99. 
Jameton, A. 1977. The nurse: When roles and rules conflict. The Hastings Center Report 
7(4): 22–23. 
Luquette, J.S. 2005. The role of on-site counselling in nurse retention. Oncology Nursing 
Forum 32(2): 234–236. 
Nivens, A., and J. Buelow. 2013. Moral distress in uninsured health care. Journal of 
Bioethical Inquiry 10(1): 123–125. 
Rice, E.M., M.Y. Rady, A. Hamrick, J.L. Verheijde, and D.K. Pendergast. 2008. 
Determinants of moral distress in medical and surgical nurses at an adult acute tertiary 
care hospital. Journal of Nursing Management 16(3): 360–373. 
Schluter, J., S. Winch, K. Holzhauser, and A. Henderson. 2008. Nurses’ moral sensitivity and 
hospital ethical climate: A literature review. Nursing Ethics 15(4): 304–321.  
This is a post-print version of the following article: Winch, Sarah, Sinnott, Michael and Shaban, 
Ramon (2013) It Is Not Your Fault: Suggestions for Building Ethical Capacity in Individuals Through 
Structural Reform to Health Care Organisations: Comment on "Moral Distress in Uninsured Health 
Care" by Anita Nivens and Janet Buelow. Journal of Bioethical Inquiry, 10 3: 423-424.  
 
Sinnott, M., and R.Z. Shaban. 2011.  Can we have a culture of patient safety without one of 
staff safety? British Medical Journal 342(March 4): c6171. 
doi:http://dx.doi.org/10.1136/bmj.c6171.  
van Soeren, M., and A. Miles. 2003. The role of teams in resolving moral distress in intensive 
care unit decision making. Critical Care 7(3): 217–218. 
Wakefield, A. 2000. Nurses’ responses to death and dying: A need for relentless self-care. 
International Journal of Palliative Nursing 6(5): 245–251. 
 


It Is Not Your Fault: Suggestions for Building Ethical Capacity in Individuals Through Structural Reform to Health Care Organisations: Comment on "Moral Distress in Uninsured Health Care" by Anita Nivens and Janet Buelow

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It Is Not Your Fault: Suggestions for Building Ethical Capacity in Individuals Through Structural Reform to Health Care Organisations: Comment on "Moral Distress in Uninsured Health Care" by Anita Nivens and Janet Buelow

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