This article reports the findings of a qualitative study that explored the organizational influences on moral distress for health professionals working in pediatric intensive care units across Canada. Participants were recruited to the study from PICUs across Canada. The PICU is a high-tech, fast-paced, high-pressure environment where caregivers frequently face conflict and ethical tension in the care of critically ill children. A number of themes including relationships with management, organizational structure and processes, workload and resources, and team dynamics were identified. (...) This study provides a rare and important multi-disciplinary perspective on this topic and the findings have implications for administrators and leaders who seek to improve the moral climate of healthcare delivery. (shrink)

Public, private, non-profit and for-profit nursing education enterprises in the U.S. are competing with one another in a newly complex and volatile educational landscape, placing academic leaders into situations fraught with moral, ethical and legal compromise with few precedents for guidance. This case study provides a richly contextualized narrative exploration of ethical and legal challenges to one leader’s moral courage, a fictionalized exploration drawn from multiple sources over time, to form a composite that is nonetheless firmly rooted in the complexity (...) and competitiveness characteristic of nursing education today. Our purpose is three-fold: 1) to direct the reader to moral and ethical questions that require thoughtful discourse and analysis among current and future academic nursing leaders; 2) to raise the issue of the need for regulations and oversight that reflect the changing realities of today’s increasingly complex and competitive educational arena; and 3) to encourage nursing education leaders to share additional cases that resonate for them, and in so doing, to expand the wellspring of ideas from which we can all draw in becoming more effective and morally courageous leaders. (shrink)

Moral distress is a complex phenomenon experienced by individuals across multiple healthcare professions, teams, organizations, and educational settings. It arises when any healthcare professional...

Moral distress is one of the core topics of clinical ethics. Although there is a large and growing empirical literature on the psychological aspects of moral distress, scholars, and empirical investigators of moral distress have recently called for greater conceptual clarity. To meet this recognized need, we provide a philosophical taxonomy of the categories of what we call ethically significant moral distress: the judgment that one is not able, to differing degrees, to act on one’s moral knowledge about what one (...) ought to do. We begin by unpacking the philosophical components of Andrew Jameton’s original formulation from his landmark 1984 work and identify two key respects in which that formulation remains unclear: the origins of moral knowledge and impediments to acting on that moral knowledge. We then selectively review subsequent literature that shows that there is more than one concept of moral distress and that explores the origin of the values implicated in moral distress and impediments to acting on those values. This review sets the stage for identifying the elements of a philosophical taxonomy of ethically significant moral distress. The taxonomy uses these elements to create six categories of ethically significant moral distress: challenges to, threats to, and violations of professional integrity; and challenges to, threats to, and violations of individual integrity. We close with suggestions about how the proposed philosophical taxonomy of ethically significant moral distress sheds light on the concepts of moral residue and crescendo effect of moral distress and how the proposed taxonomy might usefully guide prevention of and future qualitative and quantitative empirical research on ethically significant moral distress. (shrink)

Background:Moral distress occurs when constraints prevent healthcare providers from acting in accordance with their core moral values to provide good patient care. The experience of moral distress in nurses might be magnified during the current Covid-19 pandemic.Objective:To explore causes of moral distress in nurses caring for Covid-19 patients and identify strategies to enhance their moral resiliency.Research design:A qualitative study using a qualitative content analysis of focus group discussions and in-depth interviews. We purposively sampled 31 nurses caring for Covid-19 patients in (...) the acute care units within large academic medical systems in Maryland and New York City during April to June 2020.Ethical considerations:We obtained approval from the Institutional Review Board at the University of Maryland, Baltimore.Results:We identified themes and sub-themes representative of major causes of moral distress in nurses caring Covid-19 patients. These included (a) lack of knowledge and uncertainty regarding how to treat a new illness; (b) being overwhelmed by the depth and breadth of the Covid-19 illness; (c) fear of exposure to the virus leading to suboptimal care; (d) adopting a team model of nursing care that caused intra-professional tensions and miscommunications; (e) policies to reduce viral transmission (visitation policy and PPE policy) that prevented nurses to assume their caring role; (f) practicing within crisis standards of care; and (g) dealing with medical resource scarcity. Participants discussed their coping mechanisms and suggested future strategies.Discussion/Conclusion:Our study affirms new causes of moral distress related to the Covid-19 pandemic. Institutions need to develop a supportive ethical climate that can restore nurses’ moral resiliency. Such a climate should include non-hierarchical interdisciplinary spaces where all providers can meet together as moral peers to discuss their experiences. (shrink)

This article proposes to identify risk factors for moral distress from the literature, validate them through expert analysis and provide the basis for a new tool to assess the risk of moral distress among nurses. Moral distress is related to the psychological, emotional and physiological aspects of nursing. It arises from constraints caused by various circumstances and can lead to significant negative consequences. A scoping review and validation through expert analysis were used. The research question guiding this study was as (...) follows: What is known about risk factors for moral distress in nursing? The research was conducted using multiple sources including electronic databases and lists of references from relevant literature. The final sample consisted of 38 studies. A validation analysis was conducted by experts during December 2014 and June 2015. To exclude a risk factor item, at least 80% of the experts had to agree with the exclusion. In total, 53 risk factors for moral distress were identified, reviewed by the experts and grouped to form a new instrument that may help to identify risk for moral distress and to address its consequences. (shrink)

Background:Nurses and nursing students appear vulnerable to moral distress when faced with ethical dilemmas or decision-making in clinical practice. As a result, they may experience professional dissatisfaction and their relationships with patients, families, and colleagues may be compromised. The impact of moral distress may manifest as anger, feelings of guilt and frustration, a desire to give up the profession, loss of self-esteem, depression, and anxiety.Objectives:The purpose of this review was to describe how dilemmas and environmental, relational, and organizational factors contribute (...) to moral distress in undergraduate student nurses during their clinical experience and professional education.Research design:The research design was a systematic literature review.Method:The search produced a total of 157 articles published between 2004 and 2014. These were screened with the assessment sheet designed by Hawker and colleagues. Four articles matched the search criteria (one quantitative study and three qualitative), and these were separately read and analyzed by the researchers. The process of review and analysis of the data was supervised by a colleague experienced in moral distress who provided an independent quality check.Ethical consideration:Since this was a systematic review, no ethical approval was required.Findings:From the analysis, it emerged that inequalities and healthcare disparities, the relationship with the mentor, and students’ individual characteristics can all impact negatively on the decisions taken and the nursing care provided, generating moral distress. All these factors condition both the clinical experience and learning process, in addition to the professional development and the possible care choices of future nurses.Conclusion:Few studies dealt with moral distress in the setting of nurse education, and there is a knowledge gap related to this phenomenon. The results of this review underline the need for further research regarding interventions that can minimize moral distress in undergraduate nursing students. (shrink)

The concept of moral distress comes from nursing ethics, and was initially defined as ‘…when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’. There is a large body of literature associated with moral distress, yet multiple definitions now exist, significantly limiting its usefulness. We undertook a systematic review of the argument-based bioethics literature on this topic as the basis for a critical appraisal, identifying 55 papers for analysis. (...) We found that moral distress is most frequently framed around individual experiences of distress in relation to local practices and constraints, and understood in terms of power relations and workplace hierarchies. This understanding is directly derived from, and often still seen as specific to, nursing. Frequently the perspective of the morally distressed individual is privileged. Understandings of moral distress have evolved towards an ‘occupational health approach’, with the assumption that moral distress should be measured and prevented. Counter-perspectives were identified, highlighting conceptual problems. Based on our review, we propose a redefinition of moral distress: ‘Ethical unease or disquiet resulting from a situation where a clinician believes they have contributed to avoidable patient or community harm through their involvement in an action, inaction or decision that conflicts with their own values’. This definition is specific enough for research use, anchored in clinicians’ professional responsibilities and concerns about harms to patients, framed relationally rather than hierarchically, and amenable to multiple perspectives on any given morally distressing situation. (shrink)

When healthcare professionals feel constrained from acting in a patient’s best interests, moral distress ensues. The resulting negative sequelae of burnout, poor retention rates, and ultimately poor patient care are well recognized across healthcare providers. Yet an appreciation of how particular disciplines, including physicians, come to be “constrained” in their actions is still lacking. This paper will examine how the application of shared decision-making may contribute to the experience of moral distress for physicians and why such distress may go under-recognized. (...) Appreciation of these dynamics may assist in cross-discipline sensitivity, enabling more constructive dialogue and collaboration. (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)

This manuscript proposes a proactive framework for preventing or mitigating disruptive ethical conflicts that often result from delayed or avoided conversations about the ethics of care. Four components of the framework are explained and illustrated with evidenced-based actions. Clinical implications of adopting a prevention-based, system-wide ethics framework are discussed. While some aspects of ethically-difficult situations are unique, system patterns allow some issues to occur repeatedly—often with lingering effects such as healthcare providers’ disengagement and moral distress (McAndrew et al. Journal of (...) Trauma Nursing 18(4):221–230, 2011), compromised inter-professional relationships (Rosenstein and O’Daniel American Journal of Nursing, 105(1):54–64, 2005), weakened ethical climates (Pauly et al. HEC Forum 24:1–11, 2012), and patient safety concerns (Cimiotti et al. American Journal of Infection Control 40:486–490, 2012). This work offers healthcare providers and clinical ethicists a framework for developing a comprehensive set of proactive, ethics-specific, and evidence-based strategies for mitigating ethical conflicts. Furthermore, the framework aims to encourage innovative research and novel ways of collaborating to reduce such conflicts and the moral distress that often results. (shrink)

Stephen Campbell, Connie Ulrich, and Christine Grady argue that we need to a broader understanding of moral distress – broader, that is, than the one commonly used within nursing-ethics and, more recently, healthcare ethics in general. On their proposed definition, moral distress is any self-directed negative attitude we might have in response to viewing ourselves as participating in a morally undesirable situation. While being in general agreement with much of what Campbell et al. say, I make two suggestions. First, in (...) order to distinguish moral distress that is specifically related to the roles and responsibilities of healthcare-workers from other kinds of moral distress, it would be useful for the broadened definition to contain an explicit reference to the distinctive situation and challenges faced by healthcare-workers. Second, whereas Campbell et al. write in a manner that suggests that there is very little that is positive or redeeming about moral distress, we should also ask if there is anything morally good about such distress. I suggest that the disposition to respond with moral distress to situations that call for it can plausibly be seen as a virtue on the part of healthcare-workers. The moral value of responses of appropriate moral distress is positive (because it is a display of virtue on the part of the healthcare-worker), whereas the state of affairs that moral distress is called for is bad and regrettable. (shrink)

Moral distress is a phenomenon that has been receiving increasing attention in nursing and other health care disciplines. Moral distress is a concept that entered the nursing literature – and subsequently the health care ethics lexicon – in 1984 as a result of the work done by American philosopher and bioethicist Andrew Jameton. Over the past decade, research into moral distress has extended beyond the profession of nursing as other health care disciplines have come to question the impact of moral (...) constraint on individual practitioners, professional practice, and patient outcomes. Along with increased interest in the phenomenon of moral distress have come increasing critiques – critiques that in their essence point to a serious lack of conceptual clarity in the definition, study, and application of the concept. Foundational to gaining conceptual clarity in moral distress in order to develop strategies to prevent and ameliorate the experience is a careful revisiting of the epistemological assumptions underpinning our knowledge and use of the concept of moral distress. It is our contention that the conceptual challenges reveal flaws in the original understanding of moral distress that are based on an epistemological stance that holds a linear conception of cause and effect coupled with a simplistic perspective of ‘constraint’ and ‘agency’. We need a more nuanced approach to our study of moral distress such that our ontological and epistemological stances help us to better appreciate the complexity of moral agents acting in organizational contexts. We believe that critical realism offers such a nuanced approach. (shrink)

IntroductionWhen professional nurses face an obstacle in their perfect purposes, they would experience moral distress which is a suffering situation. This study aims at exploring conditions which lead to high levels of moral distress for nursing personnel within a teaching hospital in Iran.MethodsAll nursing staffs worked in ICU, CCU, open heart surgery and emergency ward of a teaching hospital in Mashhad, Iran, were evaluated in a descriptive study by translated and modified moral distress questionnaire of Corley.ResultsAccording to the participants, the (...) mean age and work experience were 34.15 ± 4.17 and 10.77 ± 4.06, respectively. Almost 91.5% of nurses had a bachelor degree, and 51.1% of them were female. The most amount of moral distress was identified in contribution to physicians who have not enough skills, disregarding patients' right, and the inability for providing drugs.DiscussionPost-CCU and assistant nurses, especially female individuals had higher scores of moral distress compare with others... (shrink)

In the last three decades, considerable theoretical and empirical research has been undertaken on the topic of moral distress among health professionals. Understood as a psychological and emotional response to the experience of moral wrongdoing, there is evidence to suggest that—if unaddressed—it contributes to staff demoralization, desensitization and burnout and, ultimately, to lower standards of patient safety and quality of care. However, more recently, the concept of moral distress has been subjected to important criticisms. Specifically, some authors argue that the (...) standard account of moral distress elucidated by Jameton :542–551, 1984) does not refer to a discrete phenomenon and/or that it is not sufficiently broad and that this makes measuring its prevalence among health professionals, and other groups of workers, difficult if not impossible. In this paper, we defend the standard account of moral distress. We understand it as a concept that draws attention to the social, political and contextual determinants of moral agency and brings the emotional landscape of the moral realm to the fore. Given the increasing pressure on health professionals worldwide to meet efficiency, financial and corporate targets and reported adverse effects of these for the quality and safety of patient care, we believe that further empirical research that deploys the standard account moral distress is timely and important. (shrink)

While various definitions of moral distress have been proposed, some agreement exists that it results from illegitimate constraints in clinical practice affecting healthcare professionals’ moral agency. If we are to reduce moral distress, instruments measuring it should provide relevant information about such illegitimate constraints. Unfortunately, existing instruments fail to do so. We discuss here several shortcomings of major instruments in use: their inability to determine whether reports of moral distress involve an accurate assessment of the requisite clinical and logistical facts (...) in play, whether the distress in question is aptly characterized as moral, and whether the moral distress reported is an appropriate target of elimination. Such failures seriously limit the ability of empirical work on moral distress to foster appropriate change. (shrink)

We examined nurses’ perceptions of the ethical climate of their workplace and the relationships among the perceptions, medical error experience and intent to leave through a cross-sectional survey of 1826 nurses in 33 Korean public hospitals. Ethical climate was measured using the Hospital Ethical Climate Survey. Although the sampled nurses perceived their workplace ethical climate positively, 19% reported making at least one medical error during the previous year, and 25% intended to leave their jobs in the near future. Controlling for (...) individual and organizational characteristics, we found that nurses with a more positive perception of the ‘patient’ dimension of ethical climate were less likely to have made medical errors. Nurses with a more positive perception of the ‘patient’, ‘manager’, ‘hospital’ and ‘physician’ dimensions of ethical climate were less likely to leave their current job. Enhancing workplace ethical climate could reduce medical errors and improve nurses’ retention in public hospitals. (shrink)

Conscientious objection has become a divisive topic in recent bioethics publications. Discussion has tended to frame the issue in terms of the rights of the healthcare professional versus the rights of the patient. However, a rights-based approach neglects the relational nature of conscience, and the impact that violating one’s conscience has on the care one provides. Using medical assistance in dying as a case study, we suggest that what has been lacking in the discussion of conscientious objection thus far is (...) a recognition and prioritising of the relational nature of ethical decision-making in healthcare and the negative consequences of moral distress that occur when healthcare professionals find themselves in situations in which they feel they cannot provide what they consider to be excellent care. We propose that policies that respect the relational conscience could benefit our healthcare institutions by minimising the negative impact of moral distress, improving communication among team members and fostering a culture of ethical awareness. Constructive responses to moral distress including relational cultivation of moral resilience are urged. (shrink)

Conscientious objection has become a divisive topic in recent bioethics publications. Discussion has tended to frame the issue in terms of the rights of the healthcare professional versus the rights of the patient. However, a rights-based approach neglects the relational nature of conscience, and the impact that violating one’s conscience has on the care one provides. Using medical assistance in dying as a case study, we suggest that what has been lacking in the discussion of conscientious objection thus far is (...) a recognition and prioritising of the relational nature of ethical decision-making in healthcare and the negative consequences of moral distress that occur when healthcare professionals find themselves in situations in which they feel they cannot provide what they consider to be excellent care. We propose that policies that respect the relational conscience could benefit our healthcare institutions by minimising the negative impact of moral distress, improving communication among team members and fostering a culture of ethical awareness. Constructive responses to moral distress including relational cultivation of moral resilience are urged. (shrink)

In rehabilitation, there is a growing interest in ethics. That said, few meta-ethical reflections have been conducted to date. Therefore, a review and critical analysis of the use of the concept of “ethical issue” is warranted. To this end, a systematic and critical review of the literature discussing ethical issues in rehabilitation was conducted. This review, based on the method developed by McCullough and colleagues, identified and analyzed 80 articles. Several characteristics and gaps in the conceptualization of the ethical issue (...) concept were noted. Three main findings emerge from the study: 1) the corpus of texts studied is dominated by descriptive ethics; 2) ethical conceptualisation is marginal, in that ethical concepts are generally stated without being defined; and 3) the corpus is characterized by the use of amalgams and by the multiplication of imprecise ethical concepts that are often used as synonyms while referring to distinct phenomena. These conceptual gaps create conceptual confusion and imprecision that can undermine ethics research, teaching and clinical ethics, and discredit the discipline of ethics. (shrink)

Moral distress is an experience of profound moral compromise with deeply impactful and potentially long‐term consequences to the individual. Critical care areas are fraught with ethical issues, and end‐of‐life care has been associated with numerous incidences of moral distress among nurses. One such area where the dichotomy of life and death seems to be at its sharpest is in the pediatric intensive care unit. The purpose of this study was to understand the moral distress experiences of pediatric intensive care nurses (...) when caring for pediatric patients at the end of life. A secondary analysis was undertaken of seven transcripts from registered nurses across six Canadian pediatric intensive care units and produced three themes: under prioritization of child patient dignity, burden of insider knowledge, and environmental constraints on nursing roles and responsibilities. When caring for patients at the end of life, nurses experienced moral distress when a dignified death was not realized. Furthermore, despite interprofessional collaboration efforts in Canada, the concept of silo mentality persists and contributes to moral distress. Organizational involvement is needed to address moral distress in pediatric intensive care nurses both to achieve a dignified death for child patients and in addressing silo mentality. (shrink)

The main question examined is: How do nurses and other healthcare professionals ensure ethical interprofessional collaboration-in-practice as an everyday practice actuality? Ethical interprofessional collaboration becomes especially relevant and necessary when interprofessional practice decisions are contested. To illustrate, two healthcare scenarios are analyzed through three ethics lenses. Biomedical ethics, relational ethics, and virtue ethics provide different ways of knowing how to be ethical and to act ethically as healthcare professionals. Biomedical ethics focuses on situated, reflective, and nonabsolute principled justification, all things (...) considered; relational ethics on intersubjective, professional, and institutional relations; and virtue ethics on prephilosophical tradition and what it means to be good and to be human embedded in social and political community. Analysis suggests that interprofessional collaboration-in-practice may be more rhetoric than actuality. Key challenges of interprofessional collaboration-in-practice and specific conditions perpetuating dissension and conflict are outlined with specific education and policy recommendations included. (shrink)

In their article “A Broader Understanding of Moral Distress,” Campbell, Ulrich, and Grady (2016) correctly assert that moral distress is well established in the nursing literature and is gaining at...

Secular bioethicists do not speak from a place of distinction, but from within particular culturally, socially, and historically conditioned standpoints. As partisans of moral and ideological agendas, they bring their own biases, prejudices, and worldviews to their roles as ethical consultants, social advocates, and academics, attempting rhetorically to sway others and shift policy to a preferred point of view. Their pronouncements represent just one voice among others, even when delivered with strident rhetoric, in an educated and knowing tone, from within (...) institutional positions of power. This essay argues that, given the hegemony of progressive secular bioethics, traditional Christians routinely face epistemic injustice within medicine. That is, Christian knowledge regarding moral reality is all too often demeaned or dismissed, unless such norms can be translated into and defended within a secular ethos. Given such systemic bias, I argue, Christians also experience significant moral distress: they are fully aware of their moral obligations and what they ought to do, but institutionalized power structures make it nearly impossible to so act. But, Christian physicians are not mere technicians, obliged to provide whatever patients request from the list of legally available treatments. That antireligious critics seek to remove the rights of Christian physicians to limit how they practice medicine, where they do not offer or refer for abortion, euthanasia, physician-assisted suicide, and other inappropriate forms of care, is unjustified and prejudicial, singling out Christians, and other religious groups, for singular treatment. Regardless of what the law requires or institutional policy demands, however, Christians are obliged to submit to God in all things. As a result, they may at times find themselves required to engage in acts of civil disobedience. (shrink)

“Moral hazard” is a term familiar in economics and business ethics that illuminates why rational parties sometimes choose decisions with bad moral outcomes without necessarily intending to behave selfishly or immorally. The term is not generally used in medical ethics. Decision makers such as parents and physicians generally do not use the concept or the word in evaluating ethical dilemmas. They may not even be aware of the precise nature of the moral hazard problem they are experiencing, beyond a general (...) concern for the patient's seemingly excessive burden. This article brings the language and logic of moral hazard to pediatrics. The concept reminds us that decision makers in this context are often not the primary party affected by their decisions. It appraises the full scope of risk at issue when decision makers decide on behalf of others and leads us to separate, respect, and prioritize the interests of affected parties. (shrink)

Moral distress has been well reviewed in the literature with established deleterious side effects for all healthcare professionals, including nurses, physicians, and others. Yet, little is known about the quality and effectiveness of interventions directed to address moral distress. The aim of this integrative review is to analyze published intervention studies to determine their efficacy and applicability across hospital settings. Of the initial 1373 articles discovered in October 2020, 18 were appraised as relevant, with 1 study added by hand search (...) and 2 after a repeated search was completed in January and then in May of 2021, for a total of 22 reviewed articles. This review revealed data mostly from nurses, with some studies making efforts to include other healthcare professions who have experienced moral distress. Education-based interventions showed the most success, though many reported limited power and few revealed statistically lowered moral distress post intervention. This may point to the difficulty in adequately addressing moral distress in real time without adequate support systems. Ultimately, these studies suggest potential frameworks which, when bolstered by organization-wide support, may aid in moral distress interventions making a measurable impact. (shrink)