Moral distress: A theorized model of influences to facilitate mitigation and resilience

Abstract

Moral distress results from the threat to professional moral integrity and identity. This phenomenon is well documented in nursing literature. Persistent and unresolved moral distress is frequently linked to high nursing staff turnover and shortages. Engagement in a structured hermeneutic critical reflective process facilitated identification of micro, meso, and macro factors influencing the experience of moral distress. Following this process, a theorized model was developed to illustrate interactions between influences contributing to the experience of moral distress in nurses. The model highlights where opportunities lay to take action to avoid or minimize the negative consequences of this phenomenon. Professional resilience is achieved via the conscientious development of professional identity and practice of critical reflection, as components of enculturation of nurses into the profession. Undergraduate and further nurse education activities must focus on developing the necessary attitude, confidence, and skills to address issues in practice which contribute to the experience moral distress to build resilience.

Moral distress and spiritual/religious orientation: Moral agency, norms and resilience

“…37 Nurses in this study noted a lack of voice against certain institutional practices, yet they also spoke of acting to encourage goals of care conversations and ensure what they saw as a good death, even when it meant going outside conventional scope of practice. Similar to earlier studies, 17,18 our findings suggest that remaining morally resilient involves, where necessary, challenging an institutional system whose decisions and policies do not align with nurses' personal or professional ethical values.…”

“…14,15 The positive impact of cognitive coping strategies which involve reflection on and meaning making of moral distress has been described as well. 13,14,16,17 The most recent focus of interest has been the cultivation of moral resilience to sustain and restore moral integrity. 16,18 Moral resilience refers to “the capacity of an individual to sustain or restore their integrity in response to moral confusion, complexity, distress or setbacks.” (p. 581) 19 Going beyond an individualistic conception of moral resilience, Sala Defilippis et al have proposed that moral resilience is a virtuous character trait, which allows nurses to “remain open for compromises with themselves and with the given situation without compromising their own moral integrity.” (p.8) 20 This broadened perspective acknowledges moral uncertainty and ambiguity.…”

“…14,15 The positive impact of cognitive coping strategies which involve reflection on and meaning making of moral distress has been described as well. 13,14,16,17 The most recent focus of interest has been the cultivation of moral resilience to sustain and restore moral integrity. 16,18 Moral resilience refers to "the capacity of an individual to sustain or restore their integrity in response to moral confusion, complexity, distress or setbacks."…”

The paradox of the impact of the COVID-19 pandemic on massage therapists in Australia and Canada: The reporting of a qualitative strand of a mixed methods study

“…With much of massage therapists' professional identity being linked to patient relationships (communication, individual care, patient empowerment), it was not surprising that when this was disrupted, via the desire to both keep patients safe and continue to provide care, that disaccord occurred. This ‘disorientation of professional identity resulting from conflict between a therapist's professional values and constraints imposed on professional practice’ is the fundamental causative factor of moral distress ( Guzys, 2021 ). Early in the pandemic an experienced massage researcher identified the potential for moral distress amongst massage therapists given the inability for massage therapists to provide care to patients during lockdowns ( Munk, 2020 ).…”

“…No difference in moral distress was found in therapists who were seeing patients compared to those who were not seeking patients ( Wilson et al, 2022 ). While moral distress is not new for other professions ( Guzys, 2021 ), this is not something common to massage therapists' experience of practice, except in specialized areas of care, such as oncology massage. Thus, many massage therapists have not been educated about moral distress, how to recognise it or how to manage it when it occurs, nor had the opportunity to build moral resilience, which is ‘the capacity to sustain or restore moral integrity in response to moral complexity, confusion, distress, or setbacks’ ( Wald and Ruddy, 2021 , p. 59).…”