Abstract
Nurses may, and often do, experience moral distress in their careers. This is related to the complicated work environment and the complex nature of ethical situations in everyday nursing practice. The outcomes of moral distress may include psychological and physical symptoms, reduced job satisfaction and even inadequate or inappropriate nursing care. Moral distress can also impact retention of nurses. Although research has grown considerably over the past few decades, there is still a great deal about this topic that we do not know including how to deal well with moral distress. A critical key step is to develop a deeper understanding of relational practice as it pertains to moral distress. In this article, exploration of the experience of moral distress among nurses is guided by the key elements of relational ethics. This ethical approach was chosen because it recognizes that ethical practice is situated in relationships and it acknowledges the importance of the broader environment on influencing ethical action. The findings from this theoretical exploration will provide a theoretical foundation upon which to advance our knowledge about moral distress.
Introduction
Nurses are moral agents with the responsibility to conduct themselves ethically and provide ethical care. Codes of ethics for nurses are developed to provide guidance for ethical situations and to inform nurses of the moral responsibilities to which they are bound. 1,2 However, due to the complex work environment and nature of ethical situations in everyday practice, codes of ethics alone cannot ensure ethical practice. 1 Nurses are not always able to provide patients with the care they need due to these complexities, and therefore the professional goals of nurses cannot be achieved. When this occurs, nurses may experience moral distress. 3 This phenomenon can include a wide range of feelings such as anxiety, despair, worthlessness, resentment and anguish. Reports of moral distress are increasing as is our understanding of its numerous effects on nurses, patient care, the healthcare system and the nursing profession. 3,4 Although the research on moral distress has grown considerably over the past few decades, there is still a great deal about this topic that we do not know particularly, effective interventions to address moral distress. A critical key step is to develop a deeper understanding of relational practice as it pertains to moral distress.
A deeper understanding of relational practice, and relational ethics as it pertains to moral distress, may guide our actions. Relational ethics is an action ethic that recognizes the significance of close-up ethical moments and the relationships that exist in those moments. It focuses on each person as a whole in the encounter, the connection between the individuals and the environment that surrounds them. 5 The foundational importance of relationships in nursing and relational ethics, and the lack of specific direction in making ethical decisions from codes of ethics, has guided us to ask, ‘could relational ethics serve as the theoretical lens through which to explore and address moral distress?’
In this article, we will demonstrate how moral distress in nursing can be examined through a relational ethics lens. First, the moral agency of nurses will be discussed to explain how nurses may experience moral distress. Next, a definition of moral distress, its key characteristics, and the rising concerns associated with it, will be presented. Furthermore, we will provide a brief overview of ethics in the nursing context then introduce relational ethics and its key elements. Finally, we will explore the possibility of relational ethics in advancing our knowledge of moral distress.
Nurses as moral agents
Nursing practice is inherently ethical. The foundation of the nursing profession is grounded in disciplinary standards, codes of ethics and values of beneficence, empathy, compassion, conscientiousness and integrity. 1,3,6 An important part of nursing includes ethical dilemmas or difficulties. 7 Nurses work with vulnerable patients and face ethical challenges surrounding patient care situations daily. 3,8 These daily ethical situations become part of nursing work and their significance often goes unrecognized. 9 The Canadian Nurses Association (CNA) 1 explicitly states, ‘nurses need to recognize that they are moral agents in providing care’ (p. 5). When nurses are not able to conduct themselves in an ethical manner due to the realities of the workplace, their identity as a health professional is undermined and nurses can experience moral distress. 3,8,10
Moral distress in nursing
Moral distress originated as a philosophical term described for the first time by Andrew Jameton in 1984. He described moral distress as a situation ‘when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’ (p. 6). 11
Since that time, the literature on moral distress has grown significantly and numerous definitions of moral distress have been generated. More recently, the CNA
1
has defined moral distress as a situation where nurses feel they know the right thing to do, but system structures or personal limitations make it nearly impossible to purse the right course of action. Moral distress can lead to negative consequences such as feelings of anger, frustration and guilt, yet it can also be a catalyst for self-reflection, growth and advocacy. (p. 6)
Included in the moral distress literature is a proposed theory on the phenomenon presented by Corley. 3 This theory was designed to clarify what happens when a nurse is unable to act as a moral agent and therefore experiences moral distress. Internal and external contexts are considered with particular attention paid to the work environment. 3 In this theory, Corley 3 states that medical ethics provides limited direction and acknowledges the importance of relationships in these difficult situations. Although this theory proposes a research agenda, it does not provide guidance for nurses to act upon in their day-to-day practice. One key piece that is lacking in this theory, and in the large body of literature on moral distress, is exploration of moral distress through the key elements of relational ethics. This will be discussed in detail later.
Attributes of moral distress
Moral distress is not predetermined or inevitable; it occurs due to a specific situation in combination with a nurse’s belief system. 16,18,19 Internal and external factors contribute to moral distress. Internal factors include feelings of powerlessness, inadequacy and fear, as well as feeling conflicted having to choose between the institution and the patient. 6,10,18,20,21 External factors include power dynamics or unequal hierarchies within the institution, lack of resources and support, complex patient/family care, excessive use of technology and conflicts among the team (including lack of support/respect from peers and management). 6,11,20,22 –25 Although morally distressing situations are unpredictable, moral distress is more likely to occur in situations concerned with medically prolonging life, unnecessary pain and suffering of the patient, objectification of patients, constraints in health policy, inadequate staffing, challenging professional and inter-professional relationships and limited resources due to cost constraints. 3,10,19
Consequences of moral distress
Moral distress may significantly affect nurses, both psychologically and physically. Some of the psychological symptoms that nurses could experience include decreased self-esteem, loss of integrity and feelings of anger, fear, sadness, numbness, frustration, depression, misery and guilt. 3,4,8,22,25,26 Physical symptoms include loss of appetite, nausea, diarrhoea, migraines and heart palpitations. 11,22,27
The effects of moral distress, however, reach far beyond the nurse. Moral distress can also affect patient care and the health care system as a whole. If a nurse develops ineffective coping strategies to deal with a morally distressing situation, he or she can lose the ability to provide good patient care, emotionally withdraw from patients and even avoid patients altogether. 18,19,25 This can lead to poor patient care, an increased length of stay for a patient and decreased patient satisfaction. 23,28 Moral distress may also be a contributing factor to the critical nursing shortage. 8,22,29 It has been reported that moral distress has implications for not only job satisfaction, but also recruitment and retention. 30 In an early grounded theory study of 21 registered nurses, Nathaniel 8 found that 43% of nurses have left a position due to morally distressing situations. The nursing shortage can further negatively impact patient care. Due to the fundamental ethical nature of moral distress, it needs to be examined through an ethical lens in hopes to further develop our knowledge of the phenomena.
Ethics and morals in the nursing context
Ethics is ‘the discipline dealing with what is good and bad and with moral duty and obligation’ 31 and it commonly refers to the values and standards which an individual or a profession strives to achieve. 32 Ethics is about understanding how to reach our potential as humans. 33 The tenets of moral philosophy, on the contrary, examine ways an individual may approach decisions about how to act in a given situation. The principles of moral philosophy therefore act as a guide for nurses and provide a foundation for the nurse in making logical and ethical decisions. 33 Signs of a moral situation are often feelings such as guilt, hope or shame or responding to a situation with words such as ought, should, right, wrong, good and bad. 34 The terms morals and ethics are often used interchangeably 33,34 and will be used interchangeably throughout this article.
Nurses are often faced with ethical situations in practice. In Canada, the CNA’s 1 Code of Ethics for Registered Nurses set the ethical standards for nursing practice. It identifies the seven foundational nursing values that are required to provide ethical nursing care: providing safe, compassionate, competent and ethical care; promoting health and well-being; promoting and respecting informed decision-making; honouring dignity; maintaining privacy and confidentiality; promoting justice and being accountable (p. 3). 1 These values provide guidance for nurses in all contexts experiencing ethical challenges that arise in practice (either with a patient or a colleague). They form the basis for all professional relationships in nursing. However, due to the complexity of ethical situations in practice, codes of ethics cannot be used alone. 1 According to Risjord, 35 ethical codes demonstrate professional commitment, yet provide little guidance in nursing practice because they are too abstract.
Traditionally, nursing ethics has been greatly influenced by bioethics, a dominant ethic in the medical community. 36 Bioethics was specifically developed to address healthcare-related issues. It follows four guiding principles: autonomy, non-maleficence, beneficence and justice. According to this ethic, health care providers are to prioritize these principles in a given situation and act accordingly. 32,34 Critiques of bioethics argue that it does not reflect everyday ethical situations that nurses often find themselves in or take into account the relational nature of these situations. 9,37 Often, nurses’ difficulty is not in determining what the right course of action is, it lies in determining when the choice is apparent, but nurses are not able to implement the morally acceptable action. 20 Moral distress occurs within the context of the environment and the relationships within that environment matter. We, as nurses, need an ethical approach that is better suited to the complexities that occur in what could be morally distressing situations.
Relational ethics and moral distress
Relational ethics is an action ethic based on the assumption that ethical practice is situated in relationships. These relationships are the inherent foundation of relational ethics. Within this understanding, ethical situations are not viewed as completely objective and, therefore, there is no clear correct outcome in relational ethics. It is viewed as pluralistic and the moral space is created by the relationships involved in each situation. 33,38 Relational ethics does not serve as a guide for dramatic ethical conflicts (e.g. which patient should receive the transplant) or blatantly unethical actions. In these situations, there are checks and measures in place such as regulatory bodies, ethic review boards and the legal system. Relational ethics is most informative in guiding the day-to-day ethical moments that occur between people.
Relational ethics requires a commitment to care about those involved in the situation and to actively engage in the relationship. The individual nurse strives to be responsive in each situation and offers genuine communication that fosters mutual respect among everyone involved. Feelings and emotions are explored because they are seen as part of the process, as opposed to something that gets in the way of one’s thinking. 33 Critics of this ethic may state that it is unstructured and lacks the control that can be found in other ethical approaches, and that anything can be right or wrong depending on the situation.
However, cultivating the moral space may be the only way to ethically approach situations where differences in beliefs, values and cultures occur. 5 Relational space is the location where acting morally occurs and in which ethics needs to be considered in every situation with every patient. When attention is paid to the quality of relationships, one must ‘focus on the kind of relationships that allow for the flourishing of good rather than evil, trust rather than fear, difference rather than sameness, healing rather than surviving and so on’ (p. 487). 39 It is through the core elements of relational ethics that a moral space can be achieved. These core elements are mutual respect, engagement, embodied knowledge and interdependent environment. These elements will be described below.
Mutual respect
Mutual respect is the central theme of relational ethics. It arises from the realization that we are all fundamentally connected to each other. Our experiences are shaped by the attitudes and actions of others towards us, in the same way our actions and attitudes shape others. Mutual respect acknowledges differences such as power, knowledge, beliefs, values, experiences and attitudes and looks for ways that people can work together with these differences. It requires us to first respect ourselves so we can interact in a respectful way with others. 39 For mutuality to occur, we need to be present in both the mind and heart. It requires us to be self-interested and at the same time interested in the other. Respecting ourselves requires self-awareness knowing our values, beliefs and knowledge. Knowing ourselves, in turn, allows us to know how we respond in a specific situation and we begin to understand ourselves in relation to others. 5 It is from a place of self-respect that we can learn to respect others. This is not a linear process as both self-respect and respect of others can be learned at the same time. Respecting others does require truly listening, addressing others by name and taking a conscious effort to make a connection. 5 Respect for others does not require agreement; it requires recognition of the others’ humanness and taking any differences seriously. It means having a conversation with someone rather than gathering information. 5
Treating individuals respectfully is foundational in nursing, in every nursing situation and in every encounter with patients and other healthcare professionals. 9,38,39 It is an essential aspect of teamwork and necessary for a team to coexist with differences. 39 Mutual respect is vital in the context of moral distress because it acknowledges differences in power which can greatly affect situations when there are differences in opinions and/or values. This power differential is deep-rooted within the healthcare system and is commonly attributed to moral distress. In the moral distress literature, power differentials are typically labelled as ‘external’ or ‘institutional’ constraints. It limits nurses’ abilities to act according to their personal or professional values and beliefs. This power difference can take many forms in morally distressing situations such as nurses being unable to voice their concerns or advocate for patients, lack of recognition of the nurses’ knowledge and devaluing the perspectives of nurses. 14 For this reason, it is critical to approach moral distress in a way that addresses power differentials. 40
From a relational ethics perspective, mutual respect mitigates power. Power is not seen as power over or empowering (giving power). Instead, mutual respect fosters space to remind us of the power every individual rightfully holds. It requires recognizing that we are dependent on each other and therefore power is shared. 5 Every team member has worth and his or her opinions would have to be valued. There are many activities to keep power in place and foster relationships such as listening, helping, being present, taking time to understand one another, and communicating values and responsibilities. 5,40 This element of relational ethics has the potential to deepen our understanding of moral distress and potentially minimize these situations altogether.
Engagement
Ethical engagement between people in the healthcare environment needs intentional action and is located in moments where people come together. Engagement is not possible without conversations. It requires the nurse to come to the relationship with a commitment to explore what is needed in that specific situation and for the patient to come with a desire to share. 5 Ethical engagement requires a relationship beyond a technical one (where the patient is seen as someone requiring care) and focuses on knowing the person and seeing them for who they are. These conversations are not only through verbal communication but also in touch, movement, silence and written words. It is these conversations that allow trust among strangers within healthcare relationships to develop. It allows strangers to begin to understand others’ opinions, values and situations. 5,39 When there is engagement in a relationship, strangers can come together to make meaning out of tragic situations. Patients are willing to discuss their needs and nurses come with a commitment to explore the needs for that patient. Patients are no longer treated as objects in need of care and nurses are not seen as objects to fulfil patients’ needs. 39 When we approach a patient as a component of the whole, the encounter becomes impersonal. The person is lost in their condition or symptoms. 5 Ethical engagement does not require more time. It requires being present, not thinking about other tasks or patients, but taking the time you are already spending with the patient and having a conversation. Ask them questions, hear what they have to say and listen for questions they are not asking or the fear in their voice.
Ethical engagement, in the context of relational ethics, offers a framework to better understand and possibly minimize some of the known contributors of moral distress. Treatment of patients as objects and poor relationships with patients and healthcare professionals are both documented as factors contributing to moral distress. 3,10,19 Consider a situation where the nurse and a patient disagree on starting a potentially life-saving treatment. Through engagement, there is trust between the participants and open communication is possible. There is a deeper understanding of each individual’s perspectives, values and goals and a mutually satisfactory approach is taken. This does not mean that there is a mutual agreement but rather a deeper understanding of their choice. When true engagement occurs, patients are no longer objects, relationships develop between the nurse and the patient, and nurses feel better equipped to handle tragic situations. Patients’ identities are preserved, the nurse’s identity is also upheld by the patient 41 and nurses will not feel as though they violated their own values. Genuine ethical engagement is not something that comes easily, it requires a great deal of practice, but when achieved it can allow both the nurse and the patient to be seen and therefore change our experiences that may otherwise be morally distressing.
Embodied knowledge
Embodiment focuses on knowledge generated from the mind, body and spirit. It gives equal weight to feelings and emotions as it does to physical signs and symptoms. Emotions are given value and embodied knowledge provides space for these to be meaningfully examined. Emotions provide a foundation for our mental and social lives and are part of embodied knowledge. 38 This type of knowledge involves being present in our bodies, in relationships and in the environment. 5 Embodied knowledge acknowledges that people are passionate by nature and bodies hold experiences in their flesh and bones. It recognized that there is more to knowing than factual knowledge. This form of knowledge is lived in real time, is subjective and includes things that cannot be easily known. 5,39 It includes the feeling of someone’s flesh beneath your hand and becoming aware that it is not an object that is there but a person, one who you are sharing space and an experience with. Bergum and Dossetor 5 state that if we treat a person as an object, there is a danger that all people become objects, and we will lose our capacity to be affected by and affect others.
Moral distress is dependent not only on the situation, but also on those involved in the situation. Each physical body that is present in a situation holds past experiences that are tied to feelings and emotions. Moral distress is a result of the dynamic interplay between this embodied knowledge, nurses’ beliefs and the situation at hand. Factors contributing to moral distress, encompassed in internal constraints, include a lack of courage and insecurity, 18 and these may be recognized and mitigated if embodied knowledge is valued. Applying the concept of embodied knowledge to potentially morally distressing situations could decrease the possibility of a nurse experiencing moral distress. This aspect of relational ethics looks at objectivity and subjectivity, thinking and feeling, as well as the self and others. This approach allows everyone involved in the situation to come together in spite of differences, describe how they are feeling and understand that this is a vital part of the lived experience. 5
Increased sensitivity to morally distressing situations is one suggestion for dealing with moral distress. Austin et al. 18 posit that if providers are better able to recognize his or her distress and reflect upon situations that give rise to the distress, then this may increase one’s moral sensitivity and a ‘moral awakening’ may occur (p. 39). Through this awakening, nurses are better able to identify morally distressing situations, and this can be seen as a desired asset to increase one’s moral sensitivity and therefore better prepare them for the situation at hand. 18 Valuing embodied knowledge can provide a foundation for understanding and increasing one’s moral sensitivity. It requires nurses to be present in a given situation and acknowledge and learn from what she or he is feeling. Nurses need to think about not only what they are doing, but also how they are feeling or what they are thinking. This type of knowledge looks at the self, others and the context. It requires valuing the lived experience that is necessary in this element of relational ethics.
Interdependent environment
The interdependent environment, within the relational ethics context, includes the physical environment in which healthcare occurs, as well as the environment of each situation within it. It is not seen as something beyond nurses or patients that can be manipulated, rather the environment needs to be understood relationally – where actions occur that affect and are affected by the whole system. The interdependent environment considers the environment as a living system enacted through each individual’s connection to one another. Through this lens, each individual act is important and therefore ethics is seen not only as social, political or personal, but also as part of a community of individuals working alongside one another. 39 Choices that are made in the practice environment, in moments between patients and nurses or other healthcare professionals, are impacted by the larger society. Societal views or values (e.g. the death of a child) will impact a single decision within the smaller environment of a particular situation. In just the same way, that situation and the decisions that come out of it will cause a ripple effect and impact those around them near and far.
Moral distress occurs within the healthcare environment and has been described as a nurse’s response to constraints within the environment in which they work. This environment is under strain and has been labelled as a morally inhabitable place, making it challenging for nurses to enact moral care. 9 There are many environmental constraints described in the moral distress literature; they are categorized as external constraints. Examples of these include structural inequities, difficult working conditions, limited resources, inadequate staffing, lack of support and working in isolation. 3,14,21,23,25,42 These constraints limit nurses’ abilities to act according to their morals, values and beliefs, thus contributing to potential morally distressing situations. The environment, large or small, impacts nurses’ work. An example of how the larger environment impacts a single nurse was eloquently demonstrated in a study by Wall and colleagues 43 conducted in the paediatric intensive care unit. In the study, a nurse expressed anguish stating, ‘we’re supposed to save them, but we can’t save them all and saving has definitely different meanings to different people’.
If we look at the environment in a broader context, then we recognize that it also includes our connections to one another, with patients and within our healthcare teams. We may start to recognize the impact that our actions and those of others around us have on the environment and understand that we are all connected. With this recognition, we may realize that we need to come together to support each other and make our environment a more habitable place. It is through collaboration and support that moral distress can be minimized. 24
The possibilities of exploring moral distress within a relational ethics lens
Relational ethics provides nurses with an action ethic that can be used in daily ethical interactions. It allows nurses to do the right thing for themselves as well as for others. 5,39 The core elements of relational ethics have the potential to greatly impact the lives of nurses by increasing our understanding of moral distress and potentially reducing the occurrence of this phenomenon. By examining moral distress through a relational ethics lens, individuals recognize that when they come together in an ethically habitable environment, they are all connected. These individuals understand that they are creating an environment together, in real time, through interactions with one another. Trust is developed allowing those involved in the situation to speak more freely. Knowledge in the form of feelings and emotions that are held within one’s body is valued. Mutual respect is present, and values, feelings and beliefs of others are truly heard. Individuals are intentionally engaged in the moments where people come together.
It is important to note that exploring moral distress using the key elements of relational ethics will also help further nursing science. One way to accomplish this is through education. Education is needed on relational ethics as well as moral distress. This education should extend beyond nurses because relational ethics and moral distress occur within the larger context of the health care environment (not just between one nurse and one patient). Education may also include the roles of other disciplines to enhance collaborative practice. 44 This education may be included within the formal undergraduate education or in the educational programme offered in the orientation to a specific unit.
Educational interventions within the research on moral distress are limited and the application of relational ethics to moral distress is even more sparse. There has been limited empirical work that explicitly approaches moral distress using relational ethics. It would be beneficial to develop educational interventions and test them within a particular context to see how (if at all) it affects moral distress within that environment. From there, this educational intervention can be adapted and utilized in other units or other populations.
Relational ethics is not something that should only be discussed. It has to be brought to life in practice. In practice, it is important for the institution to be thought of as a moral community so space for ethical conversations is easier to create. 45 Policies need to be changed to ensure that there is adequate space for all parties involved to state their views, have opinions and be respected: 45 for the individual nurse (or other healthcare professional) to treat others with respect, ask deeper questions, truly listen to others and model the behaviour wanted in others. One small action will build into many small actions and these will turn into movements that will affect change.
Described above is a way to use relational ethics as a theoretical framework for asking innovative questions about moral distress and nursing practice. According to Risjord, 35 new nursing knowledge is obtained through the commitment nurses have to the advancement of nursing. New knowledge can thus be developed from real situations and real problems that nurses face in practice. 35 This approach allows for the development of new nursing theories to describe and explain phenomenon, which according to Meleis 46 is the aim of nursing science.
Conclusion
Nurses need an ethic that better reflects their values as well as the complexities in day-to-day ethical situations. Relational ethics recognizes relational space as the location for moral encounters and considers ethics in every situation. 39 This ethic has the potential to serve as the theoretical lens to advance our knowledge of moral distress. This is possible by examining these situations through the core elements of relational ethics: mutual respect, engagement, embodied knowledge and interdependent environment. Relational ethics may be the answer needed to support nurses to act ethically in such a way that nurses’ values are not violated. Relational ethics will not eliminate moral distress. There will be situations where agreement will not occur, but this approach offers a step towards minimizing the devastating effects of moral distress.
Our next step to support ethical practice is to continue to further develop our knowledge of moral distress through this lens. No matter how we choose to advance nursing knowledge on this topic, new opportunities will be offered that will get us closer to better preparing nurses for complex ethical situations in their everyday practice. New questions will be asked, and new nursing knowledge will inevitably be developed that will better support nurses and advance nursing practice.
