Aim: The aim of this review is to examine the ways in which the concept of moral distress has been delineated and deployed in the argument-based nursing ethics literature. It adds to what we already know about moral distress from reviews of the qualitative and quantitative research. Data sources: CINAHL, PubMed, Web of Knowledge, EMBASE, Academic Search Complete, PsycInfo, Philosophers’ Index and Socindex. Review methods: A total of 20 argument-based articles published between January 1984 and December 2013 were analysed. Results: (...) We found that like the empirical literature, most authors in this review draw on Jameton’s original definition and describe moral distress in psychological–emotional–physiological terms. They also agree that moral distress is linked to the presence of some kind of constraint on nurses’ moral agency, and that it is best understood as a two-staged process that can intensify over time. There is also consensus that moral distress has an important normative meaning, although different views concerning the normative meaning of moral distress are expressed. Finally, the authors generally agree that moral distress arises from a number of different sources and that it (mostly) affects negatively on nurses’ personal and professional lives and, ultimately, harms patients. However, despite this consensus, many authors take issue with the way in which moral distress is conceptualized and operationalized. Moreover, while some worry that identifying nurses as a group of health professionals whose voices are ignored or marginalized might disempower nurses and encourage them to avoid their moral responsibilities, others take situations involving moral distress as indicative of more fundamental, structural inequities at the heart of contemporary healthcare provision. Conclusion: We conclude that research on moral distress in nursing is timely and important because it highlights the specifically moral labour of nurses. However, we suggest that significant concerns about the conceptual fuzziness and operationalization of moral distress also flag the need to proceed with caution. (shrink)

On the traditional view, moral distress arises only in cases where an individual believes she knows the morally right thing to do but fails to perform that action due to various constraints. We seek to motivate a broader understanding of moral distress. We begin by presenting six types of distress that fall outside the bounds of the traditional definition and explaining why they should be recognized as forms of moral distress. We then propose and defend a new and more expansive (...) definition of moral distress and examine how it can enable the development of a taxonomy of moral distress. (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)

Background The phenomenon of ‘moral distress’ has continued to be a popular topic for nursing research. However, much of the scholarship has lacked conceptual clarity, and there is debate about what it means to experience moral distress. Moral distress remains an obscure concept to many clinical nurses, especially those outside of North America, and there is a lack of empirical research regarding its impact on nurses in the United Kingdom and its relevance to clinical practice. Research aim To explore the (...) concept of moral distress in nursing both empirically and conceptually. Methodology Feminist interpretive phenomenology was used to explore and analyse the experiences of critical care nurses at two acute care trauma hospitals in the United Kingdom. Empirical data were analysed using Van Manen’s six steps for data analysis. Ethical considerations The study was approved locally by the university ethics review committee and nationally by the Health Research Authority in the United Kingdom. Findings The empirical findings suggest that psychological distress can occur in response to a variety of moral events. The moral events identified as causing psychological distress in the participants’ narratives were moral tension, moral uncertainty, moral constraint, moral conflict and moral dilemmas. Discussion We suggest a new definition of moral distress which captures this broader range of moral events as legitimate causes of distress. We also suggest that moral distress can be sub-categroised according to the source of distress, for example, ‘moral-uncertainty distress’. We argue that this could aid in the development of interventions which attempt to address and mitigate moral distress. Conclusion The empirical findings support the notion that narrow conceptions of moral distress fail to capture the real-life experiences of this group of critical care nurses. If these experiences resonate with other nurses and healthcare professionals, then it is likely that the definition needs to be broadened to recognise these experiences as ‘moral distress’. (shrink)

Moral injury is a term whose popularity has grown in psychology and psychiatry, as well as philosophy, over the last several years. This presents challenges, because these fields use the term in different ways and draw their understanding from different sources, creating the potential for contradiction. This, however, is also an opportunity. Comparison between behavioral sciences and philosophy can help enrich understandings of harms considered not just psychological but moral. To this end, I provide an overview of the more influential (...) writing of moral injury, mapping them into three broad discourses: clinical, juridical-critical, and structural. This overview then leads to a discussion of how comparative engagement among these discourses promises to expand on current theories of moral harm. I argue that such a comparison will demonstrate that more emphasis on structural violence will strengthen current understandings of moral injury, often understood in a more narrow sense to be a result of more direct, physical violence, allowing us to view moral injury as a result of institutional and social violence and injustices. (shrink)

Background: Nurse managers are responsible for solving work-related ethical problems to promote a positive ethical culture in healthcare organizations. Objectives: The aim of this study was to describe the activities that nurse managers use to solve work-related ethical problems. The ultimate aim was to enhance the ethical awareness of all nurse managers. Research Design: The data for this descriptive cross-sectional survey were analyzed through inductive content analysis and quantification. Participants and research context: The data were collected in 2011 using a (...) questionnaire that included an open-ended question and background factors. Participants were nurse managers working in Finnish healthcare organizations (n = 122). Ethical considerations: Permission for the study was given by the Finnish Association of Academic Managers and Experts of Health Sciences. Findings: Nurse managers identified a variety of activities they use to solve work-related ethical problems: discussion (30%), cooperation (25%), work organization (17%), intervention (10%), personal values (9%), operational models (4%), statistics and feedback (4%), and personal examples (1%). However, these activities did not follow any common or systematic model. Discussion and conclusion: In the future, nurse managers need a more systematic approach to solve ethical problems. It is important to establish new kinds of ethics structures in organizations, such as a common, systematic ethical decision-making model and an ethics club for nurse manager problems, to support nurse managers in solving work-related ethical problems. (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.

Background Over the past few decades, moral distress has been examined in the nursing literature. It is thought to occur when an individual has made a moral decision but is unable to act on it, often attributable to constraints, internal or external. Varying definitions can be found throughout the healthcare literature. This lack of cohesion has led to complications for study of the phenomenon, along with its effects to nursing practice, education and targeted policy development. Objectives The aim of this (...) analysis was to uncover unique definitions of moral distress as found in the nursing literature and to examine the relationship between these definitions. Research Design and Context Morse’s method of concept clarification was applied given the large body of literature which includes definitions, descriptions and measurements of the concept in research. The steps include (a) conducting a literature review; (b) analysing the literature; and (c) identifying, describing, comparing, and contrasting attributes, antecedents and consequences of each category. Findings Each of the 18 included studies described constraints in their definition of moral distress, whether implied or explicitly stated. External constraints are widely described as obstacles outside of the individual, whether institutional, systemic or situational, while internal constraints are located within the individuals themselves and are described as personal limitations, failings or weakness of will. Conclusion Upon reviewing these definitions, we determined that the term ‘internal constraints’ is problematic due to the emphasis of responsibility on the individual experiencing moral distress. We propose an alteration to ‘internal characteristics’ that will assume less responsibility of change from the individual to place a heavier onus on systemic and institutional constraints. (shrink)

Recent medical and bioethics literature shows a growing concern for practitioners’ emotional experience and the ethical environment in the workplace. Moral distress, in particular, is often said to result from the difficult decisions made and the troubling situations regularly encountered in health care contexts. It has been identified as a leading cause of professional dissatisfaction and burnout, which, in turn, contribute to inadequate attention and increased pain for patients. Given the natural desire to avoid these negative effects, it seems to (...) most authors that systematic efforts should be made to drastically reduce moral distress, if not altogether eliminate it from the lives of vulnerable practitioners. Such efforts, however, may be problematic, as moral distress is not adequately understood, nor is there agreement among the leading accounts regarding how to conceptualize the experience. With this article I make clear what a robust account of moral distress should be able to explain and how the most common notions in the existing literature leave significant explanatory gaps. I present several cases of interest and, with careful reflection upon their distinguishing features, I establish important desiderata for an explanatorily satisfying account. With these fundamental demands left unsatisfied by the leading accounts, we see the persisting need for a conception of moral distress that can capture and delimit the range of cases of interest. (shrink)

Problematic substance use (PSU) among nurses has wide‐ranging adverse implications. A critical integrative literature review was conducted with an emphasis on building knowledge regarding the influence of structural factors within nurses' professional environments on nurses with PSU. Five thematic categories emerged: (i) access, (ii) stress, and (iii) attitudes as contributory factors, (iv) treatment policies for nurses with PSU, and (v) the culture of the nursing profession. Conclusions were that an overemphasis on individual culpability and failing predominates in the literature and (...) that crucial knowledge gaps exist regarding the influence of structural factors on driving and shaping nurses' substance use. (shrink)

Nurses are frequently confronted with ethical dilemmas in their nursing practice. As a consequence, nurses report experiencing moral distress. The aim of this review was to synthesize the available quantitative evidence in the literature on moral distress experienced by nurses. We appraised 19 articles published between January 1984 and December 2011. This review revealed that many nurses experience moral distress associated with difficult care situations and feel burnout, which can have an impact on their professional position. Further research is required (...) to examine worksite strategies to support nurses in these situations and to develop coping strategies for dealing with moral distress. (shrink)

Much research is currently being conducted on health care practitioners' experiences of moral distress, especially the experience of nurses. What moral distress is, however, is not always clearly delineated and there is some debate as to how it should be defined. This article aims to help to clarify moral distress. My methodology consists primarily of a conceptual analysis, with especial focus on Andrew Jameton's influential description of moral distress. I will identify and aim to resolve two sources of confusion about (...) moral distress: the compound nature of a narrow definition of distress which stipulates a particular cause, i.e. moral constraint, and the distinction drawn between moral dilemma and moral distress, which implies that the two are mutually exclusive. In light of these concerns, I argue that the definition of moral distress should be revised so that moral constraint should not be a necessary condition of moral distress, and that moral conflict should be included as a potential cause of distress. Ultimately, I claim that moral distress should be understood as a specific psychological response to morally challenging situations such as those of moral constraint or moral conflict, or both. (shrink)

Moral distress has received much attention in the international nursing literature in recent years. In this article, we describe the evolution of the concept of moral distress among nursing theorists from its initial delineation by the philosopher Jameton to its subsequent deployment as an umbrella concept describing the impact of moral constraints on health professionals and the patients for whom they care. The article raises worries about the way in which the concept of moral distress has been portrayed in some (...) nursing research and expresses concern about the fact that research, so far, has been largely confined to determining the prevalence of experiences of moral distress among nurses. We conclude by proposing a reconsideration, possible reconstruction and multidisciplinary approach to understanding the experiences of all health professionals who have to make difficult moral judgements and decisions in complex situations. (shrink)

Combat deployments put health care providers in ethically compromising and morally challenging situations. A sample of recently deployed nurses and physicians provided narratives that were analyzed to better appreciate individual perceptions of moral dilemmas that arise in combat. Specific questions to be answered by this inquiry are: 1) How do combat deployed nurses and physicians make sense of morally injurious traumatic exposures? and 2) What are the possible psychosocial consequences of these and other deployment stressors? This narrative inquiry involves analysis (...) of ten deployed military nurses’ and physicians’ aversive or traumatic experiences. Burke’s dramatist pentad is used for structural narrative analysis of stories that confirm and illuminate the impact of war zone events such as betrayal, disproportionate violence, incidents involving civilians, and within-rank violence on military health care provider narrators. Results indicate cognitive dissonance and psychosocial sequelae related to moral and psychological stressors faced by military medical personnel. Discussion addresses where healing efforts should be focused. (shrink)

Amidst the return of military personnel from post-9/11 conflicts, a construct describing the readjustment challenges of some has received increasing attention: moral injury. This term has been variably defined with mental health professionals more recently conceiving of it as a transgression of moral beliefs and expectations that are witnessed, perpetrated, or allowed by the individual. To the extent that morality is a system of conceptualizing right and wrong, individuals’ moral systems are in large measure developmentally and socially derived and interpreted. (...) Thus, in seeking to provide care and aid in reintegration for combat veterans, it is necessary to consider communities that have contributed to an individual’s formation and that might have participated in the interpretation of his/her suffering. This can take many forms, but given that morality is often complexly intertwined with issues of religion, faith, and spirituality for many individuals, and recognizing that much of the current focus on moral injury is emanating out of healthcare contexts, we devote particular attention to how chaplains might be more intentionally engaged in healthcare systems such as the Veterans Health Administration to provide non-judgmental, person-centered, culturally-relevant care rooted in communities of practice to veterans with moral injury. (shrink)

Background: Improved techniques and life sustaining technology in the neonatal intensive care unit have resulted in an increased probability of survival for extremely premature babies. The by-product of the aggressive treatment is iatrogenic pain, and this infliction of pain can be a cause of suffering and distress for both baby and nurse. Research question: The research sought to explore the caregiving dilemmas of neonatal nurses when caring for extremely premature babies. This article aims to explore the issues arising for neonatal (...) nurses when they inflict iatrogenic pain on the most vulnerable of human beings – babies ≤24 weeks gestation. Participants: Data were collected via a questionnaire to Australian neonatal nurses and semi-structured interviews with 24 neonatal nurses in New South Wales, Australia. Ethical consideration: Ethical processes and procedures set out by the ethics committee have been adhered to by the researchers. Findings: A qualitative approach was used to analyse the data. The theme ‘inflicting pain’ comprised three sub-themes: ‘when caring and torture are the same thing’, ‘why are we doing this!’ and ‘comfort for baby and nurse’. The results show that the neonatal nurses were passionate about the need for appropriate pain relief for extremely premature babies. Conclusion: The neonatal nurses experienced a profound sense of distress manifested as existential suffering when they inflicted pain on extremely premature babies. Inflicting pain rather than relieving it can leave the nurses questioning their role as compassionate healthcare professionals. (shrink)