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Sources of Moral Distress

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Moral Distress in the Health Professions

Abstract

Since Andrew Jameton defined the concept of moral distress over three decades ago, clinicians and ethicists have sought to define the phenomenon and understand its impact on professionals, patients, and organizations. Moral agency, a hallmark of professional practice, is essential for high-quality, person-centered health care. Identifying the root causes of moral distress, distinguished from other emotional stressors inherent in health care, is necessary to develop and study strategies to mitigate or prevent its negative consequences. First identified as a phenomenon nurses experienced in acute care practice, moral distress is now known to be experienced in a wide variety of clinical settings and by all professional groups. Descriptive studies have revealed root causes of moral distress that extend beyond institutional constraints and power hierarchies. As researchers have studied the phenomenon in other disciplines and practice norms have evolved, additional root causes have been identified through qualitative, quantitative, and mixed method studies. Clinicians and researchers continue to explore the phenomenon, proposing expanded definitions and revealing internal factors, practice patterns, and cultural norms and changing professional roles that contribute to our evolving understanding of this significant phenomenon. There is a relational aspect to moral distress; although experienced by individuals, it is shaped not only by the characteristics of each individual but also by the multiple contexts within which the individual is operating. It is imperative to understand the sources of moral distress to address the negative consequences for the health of professionals, patients, organizations, and communities.

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References

  1. Jameton A. Nursing practice: the ethical issues. Prentice Hall: Englewood Cliffs; 1984.

    Google Scholar 

  2. Moss M, Good VS, Gozal D, Kleinpell R, Sessler CNA. Critical care societies collaborative statement: burnout syndrome in critical care health-care professionals. a call for action. Am J Respir Crit Care Med. 2016;194(1):106–13.

    Article  PubMed  Google Scholar 

  3. Rushton CH. Moral resilience: a capacity for navigating moral distress in critical care. AACN Advanced Critical Care. 2016;27(1):111–9.

    Google Scholar 

  4. Weigand DL, Funk M. Consequences of clinical situations that cause critical care nurses to experience moral distress. Nurs Ethics. 2012;19(4):479–87.

    Article  Google Scholar 

  5. Epstein EG, Hamric AB. Moral distress, moral residue, and the crescendo effect. J Clin Ethics. 2009;20(4):330–42.

    PubMed  PubMed Central  Google Scholar 

  6. Allen R, Judkins-Cohn T, de Velasco R, Forges E, Lee R, Clark L, et al. Moral distress among healthcare professionals at a health system. JONA’s Healthcare Law Ethics Regul. 2013;15(3):111–8. quiz 9–20

    Article  Google Scholar 

  7. Henrich NJ, Dodek PM, Alden L, Keenan SP, Reynolds S, Rodney P. Causes of moral distress in the intensive care unit: a qualitative study. J Crit Care. 2016;35:57–62.

    Article  PubMed  Google Scholar 

  8. Houston S, Casanova MA, Leveille M, Schmidt KL, Barnes SA, Trungale KR, et al. The intensity and frequency of moral distress among different healthcare disciplines. J Clin Ethics. 2013;24(2):98–112.

    PubMed  Google Scholar 

  9. Whitehead PB, Herbertson RK, Hamric AB, Epstein EG, Fisher JM. Moral distress among healthcare professionals: report of an institution-wide survey. J Nurs Scholarsh. 2015;47(2):117–25.

    Article  PubMed  Google Scholar 

  10. Hamric AB. Empirical research on moral distress: issues, challenges, and opportunities. HEC Forum. 2012;24:39–49.

    Google Scholar 

  11. Hanna DR. Moral distress: the state of the science. Res Theory Nurs Pract. 2004;18(1):73–93.

    Article  PubMed  Google Scholar 

  12. Campbell SM, Ulrich CM, Grady C. A broader understanding of moral distress. AJOB. 2016;16(12):2–9.

    PubMed  Google Scholar 

  13. Varcoe C, Pauly B, Webster G, Storch J. Moral distress: tensions as springboards for action. HEC Forum. 2012;24(1):51–62.

    Article  PubMed  Google Scholar 

  14. Cribb A. Integrity at work: managing routine moral stress in professional roles. Nurs Philos. 2011;12(2):119–27.

    Article  PubMed  Google Scholar 

  15. Berlinger N. Are workarounds ethical? Managing moral problems in health care systems. New York: Oxford University Press; 2016.

    Google Scholar 

  16. Epstein EG, Hurst AR. Looking at the positive side of moral distress: why it’s a problem. J Clin Ethics. 2017;28(1):37–41.

    PubMed  Google Scholar 

  17. Carse A, Rushton CH. Harnessing the promise of moral distress: a call for re-orientation. J Clin Ethics. 2017;28(1):15–29.

    PubMed  Google Scholar 

  18. Elpern EH, Covert B, Kleinpell R. Moral distress of staff nurses in a medical intensive care unit. Am J Crit Care. 2005;14(6):523–30.

    PubMed  Google Scholar 

  19. Gutierrez KM. Critical care nurses’ perceptions of and responses to moral distress. Dimens Crit Care Nurs. 2005;24(5):229–41.

    Article  PubMed  Google Scholar 

  20. Hefferman P, Heilig S. Giving “moral distress” a voice: ethical concerns among neonatal intensive care unit personnel. Camb Q Healthc Ethics. 1999;8(2):173–8.

    Article  CAS  PubMed  Google Scholar 

  21. Rushton CH. Moral resilience: a capacity for navigating moral distress in critical care. Adv Crit Care. 2016;27(1):111–9.

    Article  Google Scholar 

  22. Oh Y, Gastmans C. Moral distress experienced by nurses: a quantitative literature review. Nurs Ethics. 2015;22(1):15–31.

    Article  PubMed  Google Scholar 

  23. McAndrew NS, Leske J, Schroeter K. Moral distress in critical care nursing: the state of the science. Nurs Ethics. 2016. https://doi.org/10.1177/0969733016664975.

  24. Rice EM, Rady MY, Hamrick A, Verheijde JL, Pendergast DK. Determinants of moral distress in medical and surgical nurses at an adult acute tertiary care hospital. J Nurs Manag. 2008;16(3):360–73.

    Article  PubMed  Google Scholar 

  25. Powell SB, Engelke MK, Swanson MS. Moral distress among school nurses. J Sch Nurs. 2017;2017:1059840517704965.

    Google Scholar 

  26. Robinson R, Stinson CK. Moral distress: a qualitative study of emergency nurses. Dimens Crit Care Nurs. 2016;35(4):235–40.

    Article  PubMed  Google Scholar 

  27. Wolf L, Perhats C, Delao A, Moon MD, Clark PR. Zavotsky. “It’s a burden you carry”: describing moral distress in emergency nursing. J Emerg Nurs. 2016;42(1):37–46.

    Article  PubMed  Google Scholar 

  28. Hamilton Houghtaling DL. Moral distress: an invisible challenge for trauma nurses. J Trauma Nurs. 2012;19(4):232–7. quiz p 8–9

    Article  PubMed  Google Scholar 

  29. Sasso L, Bagnasco A, Bianchi M, Bressan V, Carnevale F. Moral distress in undergraduate nursing students: a systematic review. Nurs Ethics. 2016;23(5):523–34.

    Article  PubMed  Google Scholar 

  30. Loomis K, Carpenter R, Miller B. Moral distress in the third year of medical school: a descriptive review of student case reflections. Am J Surg. 2009;197:107–12.

    Article  Google Scholar 

  31. Dzeng E, Colaianni A, Roland M, Levine D, Kelly MP, Barclay S, et al. Moral distress amongst american physician trainees regarding futile treatments at the end of life: a qualitative study. J Gen Intern Med. 2016;31(1):93–9.

    Article  PubMed  Google Scholar 

  32. Sajjadi S, Norena M, Wong H, Dodek P. Moral distress and burnout in internal medicine residents. Can Med Educ J. 2017;8(1):e36–43.

    PubMed  PubMed Central  Google Scholar 

  33. McCarthy J, Gastmans C. Moral distress: a review of the argument-based nursing ethics literature. Nurs Ethics. 2015;22(1):131–52.

    Article  PubMed  Google Scholar 

  34. Austin W. The ethics of everyday practice: healthcare environments as moral communities. Adv Nurs Sci. 2007;30(1):81–8.

    Article  Google Scholar 

  35. Hamric AB. Moral distress in everyday ethics. Nurs Outlook. 2000;48(5):199–201.

    Article  CAS  PubMed  Google Scholar 

  36. Komesaroff P. Experiments in love and death – medicine, postmodernism, microethics and the body. Austin: River Grove Books; 1995.

    Google Scholar 

  37. Truog RD, Brown SD, Browning D, Hundert EM, Rider EA, Bell SK, et al. Microethics: the ethics of everyday clinical practice. Hast Cent Rep. 2015;45(1):11–7.

    Article  Google Scholar 

  38. Zizzo N, Bell E, Racine E. What is everyday ethics? A review and a proposal for an integrative concept. J Clin Ethics. 2016;27(2):117–28.

    PubMed  Google Scholar 

  39. Benner P, Tanner C, Chesla C. Expertise in nursing practice – caring, clinical judgment, and ethics. 2nd ed. New York: Springer Publishing Company; 2009. p. 58–9.

    Google Scholar 

  40. Tulsky JA, Beach MC, Butow PN, Hickman SE, Mack JW, Morrison RS, et al. A research agenda for communication between health care professionals and patients living with serious illness. JAMA Intern Med. 2017;177(9):1361–6.

    Article  PubMed  Google Scholar 

  41. Schulz R. In: Schulz R, Eden J, editors. Families caring for an aging America. Washington DC: National Academies Press; 2016.

    Chapter  Google Scholar 

  42. Gillick MR. The critical role of caregivers in achieving patient-centered care. JAMA. 2013;310(6):575–6.

    Article  CAS  PubMed  Google Scholar 

  43. Browning AM. CNE article: moral distress and psychological empowerment in critical care nurses caring for adults at end of life. Am J Crit Care. 2013;22(2):143–51.

    Article  PubMed  Google Scholar 

  44. Ferrell BR. Understanding the moral distress of nurses witnessing medically futile care. Oncol Nurs Forum. 2006;33(5):922–30.

    Article  PubMed  Google Scholar 

  45. Hamric AB, Blackhall LJ. Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. Crit Care Med. 2007;35(2):422–9.

    Article  PubMed  Google Scholar 

  46. IOM. Dying in America: Improving quality and honoring individual prefererences near end of life. Washington, DC: National Academies Press; 2015.

    Google Scholar 

  47. Fairman J, Lynaugh JE. Critical care nursing a history. Philadelphia: University of Pennsylvania Press; 1998. p. 6.

    Google Scholar 

  48. Bosslet GT, Pope TM, Rubenfeld GD, Lo B, Truog RD, Rushton CH, et al. An official ATS/AACN/ACCP/ESICM/SCCM policy statement: responding to requests for potentially inappropriate treatments in intensive care units. Am J Respir Crit Care Med. 2015;191(11):1318–30.

    Article  PubMed  Google Scholar 

  49. Bruce CR, Miller SM, Zimmerman JL. A qualitative study exploring moral distress in the ICU team: the importance of unit functionality and intrateam dynamics. Crit Care Med. 2015;43(4):823–31.

    Article  PubMed  Google Scholar 

  50. Traudt T, Liaschenko J, Peden-McAlpine C. Moral agency, moral imagination, and moral community: antidotes to moral distress. J Clin Ethics. 2016;27(3):201–13.

    PubMed  Google Scholar 

  51. Olsen DP, Chan R, Lehto R. Ethical nursing care when the terminally ill patient seeks death. Am J Nurs. 2017;117(7):50–5.

    Article  Google Scholar 

  52. Fiester A. Teaching nonauthoritarian clinical ethics: using an inventory of bioethical positions. Hast Cent Rep. 2015;45(2):20–6.

    Article  Google Scholar 

  53. Stein LI. The doctor-nurse game. Arch Gen Psychiatry. 1967;16(6):699–703.

    Article  CAS  PubMed  Google Scholar 

  54. Interprofessional Education Collaborative. Core competencies for interprofessional collaborative practice: 2016 update. Washington, DC: Interprofessional Education Collaborative; 2016.

    Google Scholar 

  55. Hamric AB. Reflections on being in the middle. Nurs Outlook. 2001;49(6):254–7.

    Article  CAS  PubMed  Google Scholar 

  56. Murphy P. Clinical ethics: must nurses be forever in the middle? Bioethics Forum. 1993;9(4):3–4.

    PubMed  Google Scholar 

  57. Varcoe C, Doane G, Pauly B, Rodney P, Storch JL, Mahoney K, et al. Ethical practice in nursing: working the in-betweens. J Adv Nurs. 2004;45(3):316–25.

    Article  PubMed  Google Scholar 

  58. Berkowitz KA, Katz AL, Powderly KE, Spike JP. Quality assessment of the ethics consultation service at the organizational level: accrediting ethics consultation services. Am J Bioeth. 2016;16(3):42–4.

    Article  PubMed  Google Scholar 

  59. Hamric AB, Wocial LD. Institutional ethics resources: creating moral spaces. Hast Cent Rep. 2016;46(Suppl 1):S22–7.

    Article  Google Scholar 

  60. Grady C, Danis M, Soeken KL, O”Donnell P, Taylor C, Farrar A, et al. Does ethics education influence the moral action of practicing nurses and social workers. Am J Bioeth. 2008;8(4):4–11.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Robinson EM, Lee SM, Zollfrank A, Jurchak M, Frost D, Grace P. Enhancing moral agency: clinical ethics residency for nurses. Hast Cent Rep. 2014;44(5):12–20.

    Article  Google Scholar 

  62. Verkerk M, Lindemann H, Maeckelberghe E, Feenstra E, Hartoungh R, De Bree M. Enhancing reflection: an interpersonal exercise in ethics education. Hast Cent Rep. 2004;34(6):31–8.

    Article  Google Scholar 

  63. Fowler MMDM. Guide to the Code of Ethics for Nurses with Interpretative Statements, 2nd Ed. Silver Spring, MD: American Nurses Association. 2015.

    Google Scholar 

  64. Institute of Medicine (IOM). Crossing the quality chasm: A new health system for the 21st century. Washington DC: National Academies Press; 2001.

    Google Scholar 

  65. Cronenwett L, Sherwood G, Barnsteiner J, Disch J, Johnson J, Mitchell P, et al. Quality and safety education for nurses. Nurs Outlook. 2007;55(3):122–31.

    Article  PubMed  Google Scholar 

  66. Lines LM, Lepore M, Wiener JM. Patient-centered, person-centered, and person-directed care: they are not the same. Med Care. 2015;53(7):561–3.

    Article  PubMed  Google Scholar 

  67. Scheunemann LP, Arnold RM, White DB. The facilitated values history: helping surrogates make authentic decisions for incapacitated patients with advanced illness. Am J Respir Crit Care Med. 2012;186(6):480–6.

    Article  PubMed  PubMed Central  Google Scholar 

  68. American Nurses Association. Position Statement: Incivility, Bullying and Workplace Violence. 2015.

    Google Scholar 

  69. Leape LL, Shore MF, Dienstag JL, Mayer RJ, Edgman-Levitan S, Meyer GS, et al. Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med. 2012;87(7):845–52.

    Article  PubMed  Google Scholar 

  70. The Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert; 2008.

    Google Scholar 

  71. Berlinger N. When policy produces moral distress: reclaiming conscience. Hast Cent Rep. 2016;46(2):32–4.

    Article  Google Scholar 

  72. Corley MC, Minick P, Elswick RK, Jacobs M. Nurse moral distress and ethical work environment. Nurs Ethics. 2005;12(4):381–90.

    Article  PubMed  Google Scholar 

  73. Rushton CH, Caldwell M, Kurtz MCE. Moral distress: a catalyst in building moral resilience. Am J Nurs. 2016;116(7):40–9.

    Article  PubMed  Google Scholar 

  74. Hamric AB, Epstein EGA. Health system-wide moral distress consultation service: development and evaluation. HEC Forum. 2017;29(2):127–43.

    Article  PubMed  Google Scholar 

  75. Sabin JE. Using moral distress for organizational improvement. J Clin Ethics. 2017;28(1):33–6.

    PubMed  Google Scholar 

  76. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129–46.

    Article  PubMed  Google Scholar 

  77. Mason DJ. Promoting the health of families and communities: a moral imperative. Hast Cent Rep. 2016;46(Suppl 1):S48–51.

    Article  Google Scholar 

  78. Berlinger N. Workarounds are routinely used by nurses-but are they ethical? Am J Nurs. 2017;117(10):53–5.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Nursing, Hospital of the University of Pennsylvania, Philadelphia, PA, USA

    Mary K. Walton

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  1. Mary K. Walton
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Correspondence to Mary K. Walton .

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Editors and Affiliations

  1. Lillian S. Brunner Endowed Chair, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA

    Connie M. Ulrich

  2. Department of Bioethics, National Institute of Health Clinical Center, Bethesda, Maryland, USA

    Christine Grady

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Walton, M.K. (2018). Sources of Moral Distress. In: Ulrich, C., Grady, C. (eds) Moral Distress in the Health Professions . Springer, Cham. https://doi.org/10.1007/978-3-319-64626-8_5

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  • DOI: https://doi.org/10.1007/978-3-319-64626-8_5

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