Moral distress has been something that every healthcare professional has encountered in their career. “Researchers have shown that moral distress is a wide spread problem for health care providers including nurses, pharmacists, social workers, physicians, and health care managers in a wide range of acute and community health care settings” (Pauly et al., 2012). A clinical situation that a nurse may encounter that may cause moral distress is when a patient in critical care unit has a poor prognosis and on the ventilator. Family would still want to have everything done on the patient and keep the patient on the ventilator even if the physicians state that the patient might not be able to be weaned off the ventilator. The Four A’s is used as a guide to identify and analyze moral distress. The four A’s are: ask, affirm, assess, and act. The first A is ask. Ask the appropriate question to be aware that moral distress is present. The questions that should be asked in this situation are: “what would the patient want,” “what are the reasons for the family to have the patient kept on life support,” “what is the prognosis of the patient.” The next A is affirming the distress. Affirming the distress is letting your fellow colleagues know and aware why you feel that way. Next A is to assess sources of moral distress to prepare for an action plan. The sources would be the patient’s prognosis and the family’s decision about the patient. Last part of the Four A’s is to act to implement strategies to preserve integrity and authenticity (Butts, 2016). By talking to family and the healthcare team, that would be acting to preserve integrity and authenticity to have the moral distress addressed.   
  Moral Distress is caused by nurses’ work that involves hard moral choices that result in an emotional or physical suffering, painful ambiguity, contradiction, frustration, anger, guilt and an avoidance of patients (Butts, 2015). Furthermore, it is a situation when a nurse feels that task differs from what he/she thinks it is ethically the correct thing to do. According to American Association of Critical-care Nurses (2004), nurses use the Four A’s plan as a guide to identify and analyze moral distress:

Ask appropriate questions to become aware that moral distress is present. For example, a nurse is faced with a situation when family members decide to remove do not resuscitate (DNR) orders for a 90 year old terminally ill patient because the family states “We are not yet ready to let go, we need to give our dad a fighting chance”. They still decided this even though they were given all the information they needed to make a decision. The nurse follows the wishes of the family to get the order done, even though the nurse feels like it is the wrong decision to do. The nurse feels angered and frustrated with this decision. The nurse then asks herself “Am I feeling this way because of this decision by my patient’s family?”
Affirm your distress and commitment to take care of yourself and address moral distress. The nurse in this situation acknowledges the feeling of distress and decides to make a commitment to address the moral distress.
Assess sources of your moral distress to prepare for an action plan. In this situation the nurse recognizes that the source is the decision of family members to remove DNR orders for the patient who is elderly and terminally ill. She feels it’s futile. She feels like the patient would suffer unnecessarily when the patient arrests.
Act to implement strategies for changes to preserve your integrity and authenticity. In this situation, she may decide to seek support from her charge nurse or other senior nurses on how they dealt with this type of situation. 

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