HEC Forum

, Volume 24, Issue 1, pp 39–49 | Cite as

Empirical Research on Moral Distress: Issues, Challenges, and Opportunities

Article

Abstract

Studying a concept as complex as moral distress is an ongoing challenge for those engaged in empirical ethics research. Qualitative studies of nurses have illuminated the experience of moral distress and widened the contours of the concept, particularly in the area of root causes. This work has led to the current understanding that moral distress can arise from clinical situations, factors internal to the individual professional, and factors present in unit cultures, the institution, and the larger health care environment. Corley et al. (2001) was the first to publish a quantitative measure of moral distress, and her scale has been adapted for use by others, including studies of other disciplines (Hamric and Blackhall 2007; Schwenzer and Wang 2006). Other scholars have proposed variations on Jameton’s core definition (Sporrong et al. 2006, 2007), developing measures for related concepts such as moral sensitivity (Lutzen et al. 2006), ethics stress (Raines 2000), and stress of conscience (Glasberg et al. 2006). The lack of consistency and consensus on the definition of moral distress considerably complicates efforts to study it. Increased attention by researchers in disciplines other than nursing has taken different forms, some problematic. Cultural differences in the role of the nurse and understanding of actions that represent threats to moral integrity also challenge efforts to build a cohesive research-based understanding of the concept. In this paper, research efforts to date are reviewed. The importance of capturing root causes of moral distress in instruments, particularly those at unit and system levels, to allow for interventions to be appropriately targeted is highlighted. In addition, the issue of studying moral distress and interaction over time with moral residue is discussed. Promising recent work is described along with the potential these approaches open for research that can lead to interventions to decrease moral distress. Finally, opportunities for future research and study are identified, and recommendations for moving the research agenda forward are offered.

Keywords

Moral distress Empirical research Moral residue Moral distress scale Moral distress thermometer 

References

  1. Austin, W., Bergum, V., & Goldberg, L. (2003). Unable to answer the call of our patients: Mental health nurses’ experience of moral distress. Nursing Inquiry, 10(3), 177–183.CrossRefGoogle Scholar
  2. Austin, W., Lemermeyer, G., Goldberg, L., Bergum, V., & Johnson, M. S. (2005). Moral distress in healthcare practice: The situation of nurses. HEC Forum, 17(1), 33–48.CrossRefGoogle Scholar
  3. Beumer, C. M. (2008). Innovative solutions: The effect of a workshop on reducing the experience of moral distress in an intensive care unit setting. Dimensions of Critical Care Nursing, 27(6), 263–267.CrossRefGoogle Scholar
  4. Brazil, K., Kassalainen, S., Ploeg, J., & Marshall, D. (2010). Moral distress experienced by health care professionals who provide home-based palliative care. Social Science and Medicine, 71(9), 1687–1691.CrossRefGoogle Scholar
  5. Cavaliere, T. A., Daly, B., Dowling, D., & Montgomery, K. (2010). Moral distress in neonatal intensive care unit RNs. Advances in Neonatal Care, 10(3), 145–156.Google Scholar
  6. Chen, P. (2009). When nurses and doctors can’t do the right thing, New York Times. http://www.nytimes.com/2009/02/06/health/05chen.html. Accessed 5 Feb 2009.
  7. Corley, M. C. (1995). Moral distress of critical care nurses. American Journal of Critical Care, 4(4), 280–285.Google Scholar
  8. Corley, M. C., Elswick, R. K., Gorman, M., & Clor, T. (2001). Development and evaluation of a moral distress scale. Journal of Advanced Nursing, 33(2), 250–256.CrossRefGoogle Scholar
  9. Corley, M. C., Minick, P., Elswick, R. K., & Jacobs, M. (2005). Nurse moral distress and ethical work environment. Nursing Ethics, 12(4), 381–390.CrossRefGoogle Scholar
  10. Creswell, J. (2009). Research design: Qualitative, quantitative and mixed methods approaches (3rd ed.). Thousand Oaks: Sage Publications.Google Scholar
  11. Eizenberg, M. M., Desivilya, H. S., & Hirschfeld, M. J. (2009). Moral distress questionnaire for clinical nurses: Instrument development. Journal of Advanced Nursing, 65(4), 885–892.CrossRefGoogle Scholar
  12. Elpern, E. H., Covert, B., & Kleinpell, R. (2005). Moral distress of staff nurses in a medical intensive care unit. American Journal of Critical Care, 14(6), 523–530.Google Scholar
  13. Epstein, E. G. (2008). End-of-life experiences of nurses and physicians in the newborn intensive care unit. Journal of Perinatology, 28, 771–778.CrossRefGoogle Scholar
  14. Epstein, E. G., & Hamric, A. B. (2009). Moral distress, moral residue, and the crescendo effect. Journal of Clinical Ethics, 20(4), 330–342.Google Scholar
  15. Erlen, J. A., & Frost, B. (1991). Nurses’ perceptions of powerlessness in influencing ethical decisions. Western Journal of Nursing Research, 13, 397–407.CrossRefGoogle Scholar
  16. Ferrell, B. R. (2006). Understanding the moral distress of nurses witnessing medically futile care. Oncology Nursing Forum, 33(5), 922–930.CrossRefGoogle Scholar
  17. Fry, S. T., Harvey, R. M., Hurley, A. C., & Foley, B. J. (2002). Development of a model of moral distress in military nursing. Nursing Ethics, 9(4), 373–387.CrossRefGoogle Scholar
  18. Glasberg, A. L., Eriksson, S., Dahlqvist, V., Lindahl, E., Strandberg, G., Soderberg, A., et al. (2006). Development and initial validation of the stress of conscience questionnaire. Nursing Ethics, 13(6), 633–648.CrossRefGoogle Scholar
  19. Gordon, E. J., & Hamric, A. B. (2006). The courage to stand up: The cultural politics of nurses’ access to ethics consultation. Journal of Clinical Ethics, 17, 231–254.Google Scholar
  20. Gutierrez, K. M. (2005). Critical care nurses’ perceptions of and responses to moral distress. Dimensions of Critical Care Nursing, 24(5), 229–241.CrossRefGoogle Scholar
  21. Hamric, A. B., & Blackhall, L. J. (2007). Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate. Critical Care Medicine, 35(2), 422–429.CrossRefGoogle Scholar
  22. Hamric, A.B., Borchers, C.T., & Epstein, E.G. (2012). Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Research, 3(2), 1–9.Google Scholar
  23. Harrowing, J. N., & Mill, J. (2010). Moral distress among Ugandan nurses providing HIV care: A critical ethnography. International Journal of Nursing Studies, 47, 723–731.CrossRefGoogle Scholar
  24. Hefferman, P., & Heilig, S. (1999). Giving “moral distress” a voice: Ethical concerns among neonatal intensive care unit personnel. Cambridge Quarterly of Healthcare Ethics, 8(2), 173–178.CrossRefGoogle Scholar
  25. Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs: Prentice-Hall.Google Scholar
  26. Jameton, A. (1993). Dilemmas of moral distress: moral responsibility and nursing practice. AWHONN’s Clinical Issues in Perinatal Women’s Health Nursing, 4, 542–551.Google Scholar
  27. Kalvemark, S., Hoglund, A. T., Hansson, M. G., Westerholm, P., & Arnetz, B. (2004). Living with conflicts-ethical dilemmas and moral distress in the health care system. Social Science and Medicine, 58(6), 1075–1084.CrossRefGoogle Scholar
  28. Lutzen, K., Dahlqvist, V., Eriksson, S., & Norberg, A. (2006). Developing the concept of moral sensitivity in health care practice. Nursing Ethics, 13, 187–196.CrossRefGoogle Scholar
  29. Parker-Hope, T. (2009). Medicine and moral distress, New York Times. Anonymous quote posted February 5, 2009. http://well.blogs.nytimes.com/2009/02/05/medicine-and-moral-distress/. Accessed 10 Feb 2009.
  30. Pauly, B., Varcoe, C., Storch, J., & Newton, L. (2009). Registered nurses’ perceptions of moral distress and ethical climate. Nursing Ethics, 16(5), 561–573.CrossRefGoogle Scholar
  31. Pike, A. W. (1991). Moral outrage and moral discourse in nurse-physician collaboration. Journal of Professional Nursing, 7(6), 351–362.CrossRefGoogle Scholar
  32. Raines, M. L. (2000). Ethical decision making in nurses. Relationships among moral reasoning, coping style, and ethics stress. JONA’s Healthcare Law Ethics Regulation, 2, 29–41.CrossRefGoogle Scholar
  33. Rodney, P., Varcoe, C., Storch, J. L., McPherson, G., Mahoney, K., Brown, H., et al. (2002). Navigating towards a moral horizon: A multisite qualitative study of ethical practice in nursing. Canadian Journal of Nursing Research, 34(3), 75–102.Google Scholar
  34. Rogers, S., Babgi, A., & Gomez, C. (2008). Educational interventions in end-of-life care: Part I: An educational intervention responding to the moral distress of NICU nurses provided by an ethics consultation team. Advances in Neonatal Care, 8(1), 56–65.Google Scholar
  35. Schwenzer, K. J., & Wang, L. (2006). Assessing moral distress in respiratory care practitioners. Critical Care Medicine, 34(12), 2967–2973.Google Scholar
  36. Sporrong, S. K., Arnetz, B., Hansson, M. G., Westerholm, P., & Hoglund, A. T. (2007). Developing ethical competence in health care organizations. Nursing Ethics, 14(6), 825–837.CrossRefGoogle Scholar
  37. Sporrong, S. K., Hoglund, A. T., & Arnetz, B. (2006). Measuring moral distress in pharmacy and clinical practice. Nursing Ethics, 13(4), 416–427.CrossRefGoogle Scholar
  38. Ulrich, C., O’Donnell, P., Taylor, C., Farrar, A., Danis, M., & Grady, C. (2007). Ethical climate, ethics stress, and the job satisfaction of nurses and social workers in the United States. Social Science and Medicine, 65, 1708–1719.CrossRefGoogle Scholar
  39. Varcoe, C., Hartrick, G., et al. (2004). Ethical practice in nursing: Working the in-betweens. Journal of Advanced Nursing, 45(3), 316–325.CrossRefGoogle Scholar
  40. Webster, G., & Bayliss, F. (2000). Moral residue. In S. Rubin & L. Zoloth (Eds.), Margin of error: The ethics of mistakes in the practice of medicine. Hagerstown: University Publishing Group, Inc.Google Scholar
  41. Wiggleton, C., Petrusa, E., Loomis, K., Tarpley, J., Tarpley, M., O’Gorman, M. L., et al. (2010). Medical students’ experiences of moral distress: Development of a web-based survey. Academic Medicine, 85(1), 111–117.CrossRefGoogle Scholar
  42. Wilkinson, J. M. (1987/1988). Moral distress in nursing practice: Experience and effect. Nursing Forum, 23(1), 16–29.CrossRefGoogle Scholar
  43. Wocial, L. D., & Weaver, M. T. (in press). Development and psychometric testing of a new tool for detecting moral distress: The moral distress thermometer. Journal of Advanced Nursing, 53. Google Scholar

Copyright information

© Springer Science+Business Media B.V. 2012

Authors and Affiliations

  1. 1.School of NursingVirginia Commonwealth UniversityRichmondUSA

Personalised recommendations