Moral distress: A concept clarification

Abstract

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.

Moral injury in healthcare professionals: A scoping review and discussion

“…On the contrary, moral distress emerges from moral conflict in morally distressing situations caused by external constraints (situational, legal, nursing/hospital administration or policies) or internal characteristics (moral sensitivity, threatened moral values, thwarted moral actions, feeling powerlessness). 59 They also differ in severity of the resulting consequences for the individual. Moral injury creates a deep emotional wound unique to those who bear witness to human suffering and cruelty.…”

“…Moral distress results in psychological disequilibrium and negative feeling states (blaming others, self-blaming, self-criticising, depression, anxiety, embarrassment, anguish, sarcasm manifesting in psychological distress) and can also have a negative impact on patient care (loss of ability to provide care, loss of integrity betrayal of values and overall impediment of ethical practice), leading to reduced job satisfaction and burnout, and ultimately to leaving the profession. 59 Some of the consequences of moral distress may also be found among the consequences of moral injury (guilt, blaming others, self-blaming, anguish and powerlessness) leading to functional impairment. 24 The main difference between moral distress and moral injury is that moral distress represents a form of situational problem (due to the external or internal constraints), while moral injury represents an experience of the problem that results in a long-lasting change to an individual’s sense of losing hope, trust, integrity and so on.…”

Practical ethical challenges and moral distress among staff in a hospital COVID‐19 screening service

“…This has disrupted many of the key tenets and practices of traditional nursing and medical care, 2 in particular patient‐ and family‐centred care. Repeated exposure to ethically challenging situations can lead to moral distress, which may be experienced when individuals are faced with external circumstances or situations that conflict with their internal beliefs and values 3 …”

Nurses Who Assume the Role of Advocate for Older Hospitalized Patients: A Qualitative Study

“…Nurses have reported this distress often, which suggests that they suffer when coping with ethical dilemmas related to older patients’ end-of-life care. This discomfort is known as “moral distress”, to describe the psychological, emotional and physiological suffering that nurses and other health professionals experience when they act in ways that are inconsistent with deeply held ethical values, principles or commitments ( Corley, 2002 ; Deschenes et al., 2020 ; McCarthy & Gastmans, 2015 ; Woods, 2014 ). The result of such repeated diversity of views about what is appropriate for patients’ care can lead to psychological disequilibrium and emotional exhaustion ( Corley, 2002 ; Malloy et al., 2009 ; Oh & Gastmans, 2015 ).…”

“…This can cause moral dilemmas in care practice, when, for example, aggressive, futile treatments are adopted that prolong suffering without a clear clinical rationale ( Eriksson et al., 2014 ; Haahr et al., 2020 ; Perin et al., 2018 ). Therefore, in the care nurses provide at the end of an older persons’ life, they are likely to encounter situations that cause them moral distress, with all of the consequences that entails, physically, psychologically, and professionally ( Deschenes et al., 2020 ; Perin et al., 2018 ). Nurses are confronted increasingly in clinical practice with vulnerable patients who struggle to express their autonomy, which draws attention to the potential need to advocate for their expressed or unexpressed wishes.…”