Abstract
While researchers have examined the types of ethical issues that arise in long-term care, few studies have explored long-term care nurses’ experiences of moral distress and fewer still have examined responses to initial moral distress. Using an interpretive description approach, 15 nurses working in long-term care settings within one city in Canada were interviewed about their responses to experiences of initial moral distress, resources or supports they identified as helpful or potentially helpful in dealing with these situations, and factors that hindered nurses in their responses. Using a thematic analysis process, three major themes were identified from the nurses’ experiences: (i) the context of the situation matters; (ii) the value of coming together as a team; and (iii) looking for outside direction. The work of responding to initial moral distress was more fruitful if opportunities existed to discuss conflicts with other team members and if managers supported nurses in moving their concerns forward through meetings or conversations with the team, physician, or family. Access to objective others and opportunities for education about ethics were also identified as important for dealing with value conflicts.
Similar content being viewed by others
References
Aigner, M.J., S. Drew, and J. Phipps. 2004. A comparative study of nursing home resident outcomes between care provided by nurse practitioners/physicians versus physicians only. Journal of the American Medical Directors Association 5(1): 16–23.
Andrews, G.J., and E. Peter. 2006. Moral geographies of restraint in nursing homes. Worldviews on Evidence-Based Nursing 3(1): 2–7.
Badger, J.M., and B. O’Connor. 2006. Moral discord, cognitive coping strategies, and medical intensive care unit nurses: Insights from a focus group. Critical Care Nursing Quarterly 29(2): 147–151.
Bell, J., and J.M. Breslin. 2008. Healthcare provider moral distress as a leadership challenge. JONA’s Healthcare Law, Ethics, and Regulation 10(4): 94–97.
Benner, P., C. Tanner, and C. Chesla. 1996. Expertise in nursing practice: Caring, clinical judgment, and ethics. New York: Springer Publishing Company.
Beumer, C.M. 2008. Innovative solutions: The effect of a workshop on reducing the experience of moral distress in an intensive care unit. Dimensions of Critical Care Nursing 27(6): 263–267.
Bishop, A.H., and J.R. Scudder Jr. 1990. The practical, moral, and personal sense of nursing: A phenomenological philosophy of practice. Albany: State University of New York Press.
Bolmsjo, I.A., L. Sandman, and E. Andersson. 2006. Everyday ethics in the care of elderly people. Nursing Ethics 13(3): 249–263.
Braun, V., and V. Clarke. 2006. Using thematic analysis in psychology. Qualitative Research in Psychology 3(2): 77–101.
Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, and Social Sciences and Humanities Research Council of Canada. 2010. Tri-council policy statement: Ethical conduct for research involving humans. http://www.pre.ethics.gc.ca/pdf/eng/tcps2/TCPS_2_FINAL_Web.pdf. Accessed October 31, 2012.
Canadian Nurses Association. 2008. Code of ethics for registered nurses. http://www.cna-aiic.ca/en/improve-your-workplace/nursing-ethics/. Accessed October 21, 2012.
Corley, M.C. 2002. Nurse moral distress: A proposed theory and research agenda. Nursing Ethics 9(6): 636–650.
Corley, M.C., R.K. Elswick, M. Gorman, and T. Clor. 2001. Development and evaluation of a moral distress scale. Journal of Advanced Nursing 33(2): 250–256.
Corley, M.C., P. Minick, R.K. Elswick, and M. Jacobs. 2005. Nurse moral distress and ethical work environment. Nursing Ethics 12(4): 381–390.
Deady, R., and J. McCarthy. 2010. A study of the situations, features, and coping mechanisms experienced by Irish psychiatric nurses experiencing moral distress. Perspectives in Psychiatric Care 46(3): 209–220.
DeKeyser Ganz, F., and K. Berkovitz. 2011. Surgical nurses’ perceptions of ethical dilemmas, moral distress and quality of care. Journal of Advanced Nursing 68(7): 1516–1525.
DiCicco-Bloom, B., and B.F. Crabtree. 2006. The qualitative research interview. Medical Education 40(4): 314–321.
Dreyer, A., R. Førde, and P. Nortvedt. 2009. Autonomy at the end of life: Life-prolonging treatment in nursing homes—relatives’ role in the decision-making process. Journal of Medical Ethics 35(11): 672–677.
Dreyer, A., R. Førde, and P. Nortvedt. 2010. Life-prolonging treatment in nursing homes: How do physicians and nurses describe and justify their own practice? Journal of Medical Ethics 36(7): 396–400.
Enes, S.P., and K. de Vries. 2004. A survey of ethical issues experienced by nurses caring for terminally ill elderly people. Nursing Ethics 11(2): 150–164.
Engelhardt, T. 1985. Physicians, patients, health care institutions—and the people in between: Nurses. In Caring, curing, coping, ed. A.H. Bishop and J.R. Scudder Jr., 62–79. Birmingham: University of Alabama Press.
Ferrell, B.R. 2006. Understanding the moral distress of nurses witnessing medically futile care. Oncology Nursing Forum 33(5): 922–930.
Gaudine, A.P., and M.R. Beaton. 2002. Employed to go against one’s values: Nurse managers’ accounts of ethical conflict with their organizations. Canadian Journal of Nursing Research 34(2): 17–34.
Gaudine, A., L. Thorne, S.M. LeFort, and M. Lamb. 2010. Evolution of hospital clinical ethics committees in Canada. Journal of Medical Ethics 36(3): 132–137.
Gjerberg, E., R. Førde, R. Pedersen, and G. Bollig. 2010. Ethical challenges in the provision of end-of-life care in Norwegian nursing homes. Social Science and Medicine 71(4): 677–684.
Green, A.E., and B.R. Jeffers. 2006. Exploring moral distress in the long-term care setting. Perspectives 30(4): 5–9.
Gutierrez, K.M. 2005. Critical care nurses’ perceptions of and responses to moral distress. Dimensions of Critical Care Nursing 24(5): 229–241.
Hamric, A.B. 2012. Empirical research on moral distress: Issues, challenges, and opportunities. HEC Forum 24(1): 39–49.
Jakobsen, R., and V. Sørlie. 2010. Dignity of older people in a nursing home: Narratives of care providers. Nursing Ethics 17(3): 289–300.
Jameton, A. 1984. Nursing practice: The ethical issues. Upper Saddle River: Prentice-Hall.
Jameton, A. 1993. Dilemmas of moral distress: Moral responsibility and nursing practice. AWHONN's Clinical Issues in Perinatal and Women's Health Nursing 4(4): 542–551.
Manning, M. 2010. Moral distress among regulated and unregulated care providers employed in long term care settings. Master’s thesis, Queen’s University.
Mauthner, N.S., and A. Doucet. 2003. Reflexive accounts and accounts of reflexivity in qualitative data analysis. Sociology 37(3): 413–431.
Maxwell, J.A. 1992. Understanding and validity in qualitative research. Harvard Educational Review 62(3): 279–300.
McNeill, P.M. 2001. A critical analysis of Australian clinical ethics committees and the functions they serve. Bioethics 15(5–6): 443–460.
Meltzer, L.S., and L.M. Huckabay. 2004. Critical care nurses’ perceptions of futile care and its effect on burnout. American Journal of Critical Care 13(3): 202–208.
Mitton, C., S. Peacock, J. Storch, N. Smith, and E. Cornelissen. 2011. Moral distress among health system managers: Exploratory research in two British Columbia health authorities. Health Care Analysis 19(2): 107–121.
Murphy, K. 2007. A qualitative study explaining nurses’ perceptions of quality care for older people in long-term care settings in Ireland. Journal of Clinical Nursing 16(3): 477–485.
Nathaniel, A.K. 2006. Moral reckoning in nursing. Western Journal of Nursing Research 28(4): 419–438.
Newton, L., J.L. Storch, K.S. Makaroff, and B. Pauly. 2012. “Stop the noise!” from voice to silence. Nursing Leadership 25(1): 90–104.
Piers, R.D., M. Van den Eynde, E. Steeman, P. Vlerick, D.D. Benoit, and N.J. Van Den Noortgate. 2012. End-of-life care of the geriatric patient and nurses’ moral distress. Journal of the American Medical Directors Association 13(1): 80.e7–80.e13. doi:10.1016/j.jamda.2010.12.014.
Rice, E.M., M.Y. Rady, A. Hamrick, J.L. Verheijde, and D.K. Pendergast. 2008. Determinants of moral distress in medical and surgical nurses at an adult acute tertiary care hospital. Journal of Nursing Management 16(3): 360–373.
Robichaux, C.M., and A.P. Clark. 2006. Practice of expert critical care nurses in situations of prognostic conflict at the end of life. American Journal of Critical Care 15(5): 480–491.
Rodney, P., C. Varcoe, J.L. Storch, et al. 2009. Navigating towards a moral horizon: A multisite qualitative study of ethical practice in nursing. Canadian Journal of Nursing Research 41(1): 292–319.
Shield, R.R., T. Wetle, J. Teno, S.C. Miller, and L. Welch. 2005. Physicians “missing in action”: Family perspectives on physician and staffing problems in end-of-life care in the nursing home. Journal of the American Geriatric Society 53(10): 1651–1657.
Slettebø, A., and E.H. Bunch. 2004. Solving ethically difficult care situations in nursing homes. Nursing Ethics 11(6): 543–552.
Solum, E., A. Slettebø, and S. Hauge. 2008. Prevention of unethical actions in nursing homes. Nursing Ethics 15(4): 536–548.
Stolee, P., L.M. Hillier, J. Esbaugh, N. Griffiths, and M.J. Borrie. 2006. Examining the nurse practitioner role in long-term care. Journal of Gerontological Nursing 32(10): 28–36.
Storch, J., P. Rodney, B. Pauly, et al. 2009. Enhancing ethical climates in nursing work environments. The Canadian Nurse 105(3): 20–25.
Thorne, S. 2008. Interpretive description. Walnut Creek: Left Coast Press.
Thorne, S., S.R. Kirkham, and J. MacDonald-Emes. 1997. Interpretive description: A noncategorical qualitative alternative for developing nursing knowledge. Research in Nursing and Health 20(2): 169–177.
Tuckett, A.G. 2005. Residents’ rights and nurses’ ethics in the Australian nursing home. International Nursing Review 52(3): 219–224.
Varcoe, C., G. Doane, B. Pauly, et al. 2004. Ethical practice in nursing: Working the in-between. Journal of Advanced Nursing 45(3): 316–325.
Varcoe, C., B. Pauly, J. Storch, L. Newton, and K. Makaroff. 2012. Nurses’ perceptions of and responses to morally distressing situations. Nursing Ethics 19(4): 488–500.
Wall, S., and W. Austin. 2008. The influence of teams, supervisors and organizations on healthcare practitioners’ abilities to practice ethically. Nursing Leadership 21(4): 85–99.
Weston, C.M., L.A. O’Brien, N.I. Goldfarb, A.R. Roumm, W.P. Isele, and K. Hirschfeld. 2005. The NJ SEED project: Evaluation of an innovative initiative for ethics training in nursing homes. Journal of the American Medical Directors Association 6(1): 68–75.
Wiegand, D.L., and M. Funk. 2012. Consequences of clinical situations that cause critical care nurses to experience moral distress. Nursing Ethics 19(4): 479–487.
Wocial, L.D., M. Hancock, P.D. Bledsoe, A.R. Chamness, and P.R. Helft. 2010. An evaluation of unit-based ethics conversations. JONA’s Healthcare Law, Ethics, and Regulation 12(2): 48–54.
Zuzelo, P.R. 2007. Exploring the moral distress of registered nurses. Nursing Ethics 14(3): 344–359.
Acknowledgments
The authors would like to thank the nurses who volunteered to take part in this study, the long-term care facility that granted us access, and research staff members who worked on the study. Funding for this research was obtained from the Canadian Institutes of Health Research through an Ethics Seed Grant.
Statement of Competing Interests
No conflicts of interest are present.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Edwards, M.P., McClement, S.E. & Read, L.R. Nurses’ Responses to Initial Moral Distress in Long-Term Care. Bioethical Inquiry 10, 325–336 (2013). https://doi.org/10.1007/s11673-013-9463-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11673-013-9463-6