This study examined the relationship between moral distress intensity, moral distress frequency and the ethical work environment, and explored the relationship of demographic characteristics to moral distress intensity and frequency. A group of 106 nurses from two large medical centers reported moderate levels of moral distress intensity, low levels of moral distress frequency, and a moderately positive ethical work environment. Moral distress intensity and ethical work environment were correlated with moral distress frequency. Age was negatively correlated with moral distress intensity, (...) whereas being African American was related to higher levels of moral distress intensity. The ethical work environment predicted moral distress intensity. These results reveal a difference between moral distress intensity and frequency and the importance of the environment to moral distress intensity. (shrink)

As professionals, nurses are engaged in a moral endeavour, and thus confront many challenges in making the right decision and taking the right action. When nurses cannot do what they think is right, they experience moral distress that leaves a moral residue. This article proposes a theory of moral distress and a research agenda to develop a better understanding of moral distress, how to prevent it, and, when it cannot be prevented, how to manage it.

Moral distress has been widely reviewed across many care contexts and among a range of disciplines. Interest in this area has produced a plethora of studies, commentary and critique. An overview of the literature around moral distress reveals a commonality about factors contributing to moral distress, the attendant outcomes of this distress and a core set of interventions recommended to address these. Interventions at both personal and organizational levels have been proposed. The relevance of this overview resides in the implications (...) moral distress has on the nurse and the nursing workforce: particularly in regard to quality of care, diminished workplace satisfaction and physical health of staff and increased problems with staff retention. (shrink)

Once a term used primarily by moral philosophers, “moral distress” is increasingly used by health professionals to name experiences of frustration and failure in fulfilling moral obligations inherent to their fiduciary relationship with the public. Although such challenges have always been present, as has discord regarding the right thing to do in particular situations, there is a radical change in the degree and intensity of moral distress being expressed. Has the plight of professionals in healthcare practice changed? “Plight” encompasses not (...) only the act of pledging, but that of predicament and peril. The author claims that health professionals are increasingly put in peril by healthcare reform that undermines their efficacy and jeopardizes ethical engagement with those in their care. The re-engineering of healthcare to give precedence to corporate and commercial values and strategies of commodification, service rationing, streamlining, and measuring of “efficiency,” is literally demoralizing health professionals. Healthcare practice needs to be grounded in a capacity for compassion and empathy, as is evident in standards of practice and codes of ethics, and in the understanding of what it means to be a professional. Such grounding allows for humane response to the availability of unprecedented advances in biotechnological treatments, for genuine dialogue and the raising of difficult, necessary ethical questions, and for the mutual support of health professionals themselves. If healthcare environments are not understood as moral communities but rather as simulated marketplaces, then health professionals’ moral agency is diminished and their vulnerability to moral distress is exacerbated. Research in moral distress and relational ethics is used to support this claim. (shrink)

Suffering repeated experiences of moral distress in intensive care units due to applications of futility reflects on nurses’ patient care negatively, increases their burnout, and reduces their job satisfaction. This study was carried out to investigate the levels of job satisfaction and exhaustion suffered by intensive care nurses and the relationship between them through the futility dimension of the issue. The study included 138 intensive care nurses. The data were obtained with the futility questionnaire developed by the researchers, Maslach Burnout (...) Inventory and Minnesota Satisfaction Questionnaire. It was determined that nurses who agreed to the proposition that the application of futility demoralizes health-care professionals had low levels of job satisfaction but high levels of depersonalization. It was determined that nurses had moderate levels of job satisfaction, emotional exhaustion, and personal achievements but high levels of sensitivity. Nurses’ job satisfaction and sensitivities are positively affected when they consider that futility does not contradict the purposes of medicine. (shrink)

Little is known about the consequences of moral distress. The purpose of this study was to identify clinical situations that caused nurses to experience moral distress, to understand the consequences of those situations, and to determine whether nurses would change their practice based on their experiences. The investigation used a descriptive approach. Open-ended surveys were distributed to a convenience sample of 204 critical care nurses employed at a university medical center. The analysis of participants’ responses used an inductive approach and (...) a thematic analysis. Each line of the data was reviewed and coded, and the codes were collapsed into themes. Methodological rigor was established. Forty-nine nurses responded to the survey. The majority of nurses had experienced moral distress, and the majority of situations that caused nurses to experience moral distress were related to end of life. The nurses described negative consequences for themselves, patients, and families. (shrink)

Background:Moral distress is one of intensive care unit nurses’ major problems, which may happen due to various reasons, and has several consequences. Due to various moral distress outcomes in intensive care unit nurses, and their impact on nurses’ personal and professional practice, recognizing moral distress is very important.Research objective:The aim of this study was to determine correlation between moral distress with burnout and anticipated turnover in intensive care unit nurses.Research design:This study is a descriptive-correlation research.Participants and research context:A total of (...) 159 intensive care unit nurses were selected from medical sciences universities in Iran. Data collection instruments included “demographic questionnaire,” “ICU Nurses’ Moral Distress Scale,” “Copenhagen Burnout Inventory” and “Hinshaw and Atwood Turnover Scale.” Data analysis was done by using SPSS19.Ethical considerations:Informed consent from samples and research approval was obtained from Shahid Beheshti Medical Sciences University Research Ethics Board in Tehran.Findings:The findings showed intensive care unit nurses’ moral distress and anticipated turnover was high, but burnout was moderate. The results revealed that there was a positive statistical correlation between intensive care unit nurses’ age, their work experience and the fraction of nurses’ number to number of intensive care unit beds with their moral distress and burnout. However, there were no correlation between gender, marriage status, educational degree and work shift and moral distress.Discussion:Some of the findings of this research are consistent with other studies and some of them are inconsistent.Conclusion:Similarly, moral distress with burnout and anticipated turnover did not have statistical correlation. However, a positive correlation was found between burnout and anticipated turnover. The results showed that increase in the recruitment of young nurses, and nursing personnel, and diminishing intensive care unit nurses’ moral distress, burnout and their turnover intention are essential. (shrink)

Researchers have identified the phenomena of moral distress through many studies in Western countries. This research reports the first study of moral distress in Iran. Because of the differences in cultural values and nursing education, nurses working in intensive care units may experience moral distress differently than reported in previous studies. This research used a qualitative method involving semistructured and in-depth interviews of a purposive sample of 31 (28 clinical nurses and 3 nurse educators) individuals to identify the types of (...) moral distress among clinical nurses and nurse educators working in 12 cities in Iran. A content analysis of the data produced four themes to describe the nurses’ moral distress. The four themes were as follows: (a) institutional barriers and constraints; (b) communication problems; (c) futile actions, malpractice, and medical/care errors; (d) inappropriate responsibilities, resources, and competencies. The results demonstrate that moral distress for intensive care unit nurses is different and that the nursing leaders must reduce moral distress among nursing in intensive care. (shrink)

Amidst the wealth of literature on the topic of moral distress in nursing, a single citation is ubiquitous, Andrew Jameton’s 1984 book Nursing practice. The definition Jameton formulated reads ‘... moral distress arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’. Unfortunately, it appears that, despite the frequent use of Jameton’s definition of moral distress, the definition itself remains uncritically examined. It seems as if the context (...) of how moral distress arises (i.e. anger, frustration etc.) has been co-opted as its definition. This current work suggests that the current definition is not moral distress as defined by Jameton, but rather, in large part, nursing’s discomfort with moral subjectivity in end-of-life decision making. A critical examination of how the Catholic tradition’s normative ethical framework accounts for moral subjectivity in end-of-life decision making serves to aid nursing’s discomfort and as a starting point to recontextualize moral distress. (shrink)

The purpose of this article is to report what can be learned about nurses’ ethical conflicts by the systematic analysis of methodologically similar studies. Five studies were identified and analysed for: (1) the character of ethical conflicts experienced; (2) similarities and differences in how the conflicts were experienced and how they were resolved; and (3) ethical conflict themes underlying four specialty areas of nursing practice (diabetes education, paediatric nurse practitioner, rehabilitation and nephrology). The predominant character of the ethical conflicts was (...) disagreement with the quality of medical care given to patients. A significant number of ethical conflicts were experienced as ‘moral distress’, the resolution of which was variable, depending on the specialty area of practice. Ethical conflict themes underlying the specialty areas included: differences in the definition of adequacy of care among professionals, the institution and society; differences in the philosophical orientations of nurses, physicians and other health professionals involved in patient care; a lack of respect for the knowledge and expertise of nurses in specialty practice; and difficulty in carrying out the nurse’s advocacy role for patients. (shrink)

Moral distress has been written about extensively in nursing and other fields. Often, however, it has not been used with much theoretical depth. This paper focuses on theorizing moral distress using feminist ethics, particularly the work of Margaret Urban Walker and Hilde Lindemann. Incorporating empirical findings, we argue that moral distress is the response to constraints experienced by nurses to their moral identities, responsibilities, and relationships. We recommend that health professionals get assistance in accounting for and communicating their values and (...) responsibilities in situations of moral distress. We also discuss the importance of nurses creating “counterstories” of their work as knowledgeable and trustworthy professionals to repair their damaged moral identities, and, finally, we recommend that efforts toward shifting the goal of health care away from the prolongation of life at all costs to the relief of suffering to diminish the moral distress that is a common response to aggressive care at end-of-life. (shrink)

Moral distress is a phenomenon of increasing concern in nursing practice, education and research. Previous research has suggested that moral distress is associated with perceptions of ethical climate, which has implications for nursing practice and patient outcomes. In this study, a randomly selected sample of registered nurses was surveyed using Corley’s Moral Distress Scale and Olson’s Hospital Ethical Climate Survey (HECS). The registered nurses reported moderate levels of moral distress intensity. Moral distress intensity and frequency were found to be inversely (...) correlated with perceptions of ethical climate. Each of the HECS factors (peers, patients, managers, hospitals and physicians) was found to be significantly correlated with moral distress. Based on these findings, we highlight insights for practice and future research that are needed to enhance the development of strategies aimed at improving the ethical climate of nurses’ workplaces for the benefit of both nurses and patients. (shrink)

Moral distress in health care has been identified as a growing concern and a focus of research in nursing and health care for almost three decades. Researchers and theorists have argued that moral distress has both short and long-term consequences. Moral distress has implications for satisfaction, recruitment and retention of health care providers and implications for the delivery of safe and competent quality patient care. In over a decade of research on ethical practice, registered nurses and other health care practitioners (...) have repeatedly identified moral distress as a concern and called for action. However, research and action on moral distress has been constrained by lack of conceptual clarity and theoretical confusion as to the meaning and underpinnings of moral distress. To further examine these issues and foster action on moral distress, three members of the University of Victoria/University of British Columbia (UVIC/UVIC) nursing ethics research team initiated the development and delivery of a multi-faceted and interdisciplinary symposium on Moral Distress with international experts, researchers, and practitioners. The goal of the symposium was to develop an agenda for action on moral distress in health care. We sought to develop a plan of action that would encompass recommendations for education, practice, research and policy. The papers in this special issue of HEC Forum arose from that symposium. In this first paper, we provide an introduction to moral distress; make explicit some of the challenges associated with theoretical and conceptual constructions of moral distress; and discuss the barriers to the development of research, education, and policy that could, if addressed, foster action on moral distress in health care practice. The following three papers were written by key international experts on moral distress, who explore in-depth the issues in three arenas: education, practice, research. In the fifth and last paper in the series, we highlight key insights from the symposium and the papers in the series, propose to redefine moral distress, and outline directions for an agenda for action on moral distress in health care. (shrink)

This study aimed to: (1) develop and evaluate the Moral Distress Scale for Psychiatric nurses (MDS-P); (2) use the MDS-P to examine the moral distress experienced by Japanese psychiatric nurses; and (3) explore the correlation between moral distress and burnout. A questionnaire on the intensity and frequency of moral distress items (the MDS-P: 15 items grouped into three factors), a burnout scale (Maslach Burnout Inventory — General Survey) and demographic questions were administered to 391 Japanese psychiatric nurses in 2007—2008. These (...) nurses experienced relatively low levels of moral distress despite the fact that they were commonly confronted by morally distressing situations. All the circumstances in which the participants experienced moral distress were included in the ‘low staffing’ factor, which reflects the characteristics of Japanese psychiatric care. The frequency score of the low staffing factor was a significant predictor of burnout. (shrink)

Background:Nursing practice is complex, as nurses are challenged by increasingly intricate moral and ethical judgments. Inadequately studied in underrepresented groups in nursing, moral distress is a serious problem internationally for healthcare professionals with deleterious effects to patients, nurses, and organizations. Moral distress among nurses has been shown to contribute to decreased job satisfaction and increased turnover, withdrawal from patients, physical and psychological symptoms, and intent to leave current position or to leave the profession altogether.Research question:Do significant gender differences exist in (...) the moral distress scores of critical care nurses?Research design:This study utilized a quantitative, descriptive methodology to explore moral distress levels in a sample of critical care nurses to determine whether gender differences exist in their mean moral distress scores.Participants and research context:Participants ( n = 31) were critical care nurses from an American Internet nursing community who completed the Moral Distress Scale–Revised online over a 5-day period in July 2013.Ethical considerations:Institutional review board review approved the study, and accessing and completing the survey implied informed consent.Findings:The results revealed a statistically significant gender difference in the mean moral distress scores of participants. Females reported statistically significantly higher moral distress scores than did males. Overall, the moral distress scores for both groups were relatively low.Discussion:The findings of a gender difference have not previously been reported in the literature. However, other findings are consistent with previous studies on moral distress.Conclusion:Although the results of this study are not generalizable, they do suggest the need for continuing research on moral distress in underrepresented groups in nursing, including cultural and ethnic groups. (shrink)

The aim of this study was to explore the existence of moral distress among nurses in Lilongwe District of Malawi. Qualitative research was conducted in selected health institutions of Lilongwe District in Malawi to assess knowledge and causes of moral distress among nurses and coping mechanisms and sources of support that are used by morally distressed nurses. Data were collected from a purposive sample of 20 nurses through in-depth interviews using a semi-structured interview guide. Thematic analysis of qualitative data was (...) used. The results show that nurses, irrespective of age, work experience and tribe, experienced moral distress related to patient/nursing care. The major distressing factors were inadequate resources and lack of respect from patients, guardians, peers and bosses. Nurses desire teamwork and ethics committees in their health institutions as a means of controlling and preventing moral distress. There is a need for creation of awareness for nurses to recognize and manage moral distress, thus optimizing their ability to provide quality and uncompromised nursing care. (shrink)

There have been recurrent reports of fragilities in the Brazilian health system, especially in public institutions. In this commentary, I argue that moral distress in nursing in Brazil can still be considered an innovative and important subject of study. I also highlight the relevance of engaging educational institutions in the development of policies about environmental sustainability. It is relevant to continue studying moral distress in nursing and in health care generally in order to contribute to the transformation of reality by (...) confronting the multiple common situations in the work environment that are recognized by many as morally problematic because they infringe upon the rights of people, patients, and health care professionals and are an affront to environmental health. (shrink)

One of the difficulties nurses experience in clinical practice in relation to ethical issues in connection with young oncology patients is moral distress. In this descriptive correlational study, the Moral Distress Scale-Paediatric Version (MDS-PV) was translated from the original language and tested on a conventional sample of nurses working in paediatric oncology and haematology wards, in six north paediatric hospitals of Italy. 13.7% of the total respondents claimed that they had changed unit or hospital due to moral distress. The items (...) with the highest mean intensity in the sample were almost all connected with medical and nursing competence and have considerably higher values than frequency. The instrument was found to be reliable. The results confirmed the validity of the MDS-PV (Cronbach’s alpha = 0.959). This study represents the first small-scale attempt to validate MDS-PV for use in paediatric oncology-ematology nurses in Italy. (shrink)

Moral distress has been characterised in the nursing literature as a major problem affecting nurses in all healthcare systems. It has been portrayed as threatening the integrity of nurses and ultimately the quality of patient care. However, nursing discourse on moral distress is not without controversy. The notion itself is conceptually flawed and suffers from both theoretical and practical difficulties. Nursing research investigating moral distress is also problematic on account of being methodologically weak and disparate. Moreover, the ultimate purpose and (...) significance of the research is unclear. In light of these considerations, it is contended that the notion of moral distress ought to be abandoned and that concerted attention be given to advancing inquiries that are more conducive to improving the quality and safety of moral decision-making, moral conduct and moral outcomes in nursing and healthcare domains. (shrink)

The concept of moral distress can be extended from clinical settings to larger environmental concerns affecting health care. Moral distress—a common experience in complex societies—arises when individuals have clear moral judgments about societal practices, but have difficulty in finding a venue in which to express concerns. Since health care is large in scale and climate change is proving to be a major environmental problem, scaling down health care is inevitably a necessary element for mitigating climate change. Because it is extremely (...) challenging to discuss these concerns in health care settings, those concerned about climate change and health care experience distress. This article outlines some philosophical concepts and perspectives that may be useful in mitigating this distress. (shrink)

Abstract Studying a concept as complex as moral distress is an ongoing challenge for those engaged in empirical ethics research. Qualitative studies of nurses have illuminated the experience of moral distress and widened the contours of the concept, particularly in the area of root causes. This work has led to the current understanding that moral distress can arise from clinical situations, factors internal to the individual professional, and factors present in unit cultures, the institution, and the larger health care environment. (...) Corley et al. ( 2001 ) was the first to publish a quantitative measure of moral distress, and her scale has been adapted for use by others, including studies of other disciplines (Hamric and Blackhall 2007 ; Schwenzer and Wang 2006 ). Other scholars have proposed variations on Jameton’s core definition (Sporrong et al. 2006 , 2007 ), developing measures for related concepts such as moral sensitivity (Lutzen et al. 2006 ), ethics stress (Raines 2000 ), and stress of conscience (Glasberg et al. 2006 ). The lack of consistency and consensus on the definition of moral distress considerably complicates efforts to study it. Increased attention by researchers in disciplines other than nursing has taken different forms, some problematic. Cultural differences in the role of the nurse and understanding of actions that represent threats to moral integrity also challenge efforts to build a cohesive research-based understanding of the concept. In this paper, research efforts to date are reviewed. The importance of capturing root causes of moral distress in instruments, particularly those at unit and system levels, to allow for interventions to be appropriately targeted is highlighted. In addition, the issue of studying moral distress and interaction over time with moral residue is discussed. Promising recent work is described along with the potential these approaches open for research that can lead to interventions to decrease moral distress. Finally, opportunities for future research and study are identified, and recommendations for moving the research agenda forward are offered. Content Type Journal Article Pages 1-11 DOI 10.1007/s10730-012-9177-x Authors Ann B. Hamric, School of Nursing, Virginia Commonwealth University, P.O. Box 980567, Richmond, VA 23298-0567, USA Journal HEC Forum Online ISSN 1572-8498 Print ISSN 0956-2737. (shrink)

The purpose of this article is to describe the development of a model of moral distress in military nursing. The model evolved through an analysis of the moral distress and military nursing literature, and the analysis of interview data obtained from US Army Nurse Corps officers (n = 13). Stories of moral distress (n = 10) given by the interview participants identified the process of the moral distress experience among military nurses and the dimensions of the military nursing moral distress (...) phenomenon. Models of both the process of military nursing moral distress and the phenomenon itself are proposed. Recommendations are made for the use of the military nursing moral distress models in future research studies and in interventions to ameliorate the experience of moral distress in crisis military deployments. (shrink)

While researchers have examined the types of ethical issues that arise in long-term care, few studies have explored long-term care nurses’ experiences of moral distress and fewer still have examined responses to initial moral distress. Using an interpretive description approach, 15 nurses working in long-term care settings within one city in Canada were interviewed about their responses to experiences of initial moral distress, resources or supports they identified as helpful or potentially helpful in dealing with these situations, and factors that (...) hindered nurses in their responses. Using a thematic analysis process, three major themes were identified from the nurses’ experiences: (i) the context of the situation matters; (ii) the value of coming together as a team; and (iii) looking for outside direction. The work of responding to initial moral distress was more fruitful if opportunities existed to discuss conflicts with other team members and if managers supported nurses in moving their concerns forward through meetings or conversations with the team, physician, or family. Access to objective others and opportunities for education about ethics were also identified as important for dealing with value conflicts. (shrink)