Abstract
Background
Over the past few decades, moral distress has been examined in the nursing literature. It is thought to occur when an individual has made a moral decision but is unable to act on it, often attributable to constraints, internal or external. Varying definitions can be found throughout the healthcare literature. This lack of cohesion has led to complications for study of the phenomenon, along with its effects to nursing practice, education and targeted policy development.
Objectives
The aim of this analysis was to uncover unique definitions of moral distress as found in the nursing literature and to examine the relationship between these definitions.
Research Design and Context
Morse’s method of concept clarification was applied given the large body of literature which includes definitions, descriptions and measurements of the concept in research. The steps include (a) conducting a literature review; (b) analysing the literature; and (c) identifying, describing, comparing, and contrasting attributes, antecedents and consequences of each category.
Findings
Each of the 18 included studies described constraints in their definition of moral distress, whether implied or explicitly stated. External constraints are widely described as obstacles outside of the individual, whether institutional, systemic or situational, while internal constraints are located within the individuals themselves and are described as personal limitations, failings or weakness of will.
Conclusion
Upon reviewing these definitions, we determined that the term ‘internal constraints’ is problematic due to the emphasis of responsibility on the individual experiencing moral distress. We propose an alteration to ‘internal characteristics’ that will assume less responsibility of change from the individual to place a heavier onus on systemic and institutional constraints.
Introduction
Over the past few decades, the concept of moral distress has been widely discussed within nursing research as well as other healthcare disciplines. Despite numerous definitions of moral distress presented in the healthcare literature, these are not always clear. 1,2 This lack of clarity effects not only nursing practice and the study of the phenomenon but also education and policy development targeted at moral distress. 2 –4 A number of authors have stated that in order to move forward in our understanding of moral distress, there needs to be more conceptual clarity. 1 –3 Indeed in 2019, Morley et al. 4 argued that the growing body of research surrounding moral distress has paradoxically muddled its conceptual clarity and that without a coherent and reliable conceptual understanding, empirical studies of moral distress, including possible responses, are likely to be confused and contradictory.
Morse 5 argued that the nursing theoretical base is the foundation of nursing research and asserted that the most urgent need is in conceptual inquiry. In this article, we aim to clarify the concept of moral distress as presented in the healthcare literature by applying Morse’s 5 method of concept clarification. First, we compare and analyse the similarities, differences, antecedents, attributes and consequences among existing definitions in the healthcare literature. Second, we discuss the limitations and assumptions among these definitions in terms of constraints. Furthermore, having discussed differences between an individual’s responses to external demands versus the personal ‘failings’ of an individual, we propose alternative language to existing conceptualizations of the term ‘internal constraints’ in an effort to create clarity for this element of moral distress. Through this discussion, we propose consistent and unambiguous language for internal constraints, a quality that is vital for understanding this complex concept and allows for more precision in performing nursing research. 4
Background
The contemporary healthcare work environment is widely acknowledged as being increasingly complex and ever changing. Given the trends towards reductions in staffing, increasing patient acuity, challenging family and patient needs, and the requirement to maintain practice standards in the context of minimizing healthcare costs, it is perhaps not surprising that healthcare providers experience stress associated with the ethical elements of their daily practice. 6 –8 This experience has been characterized as moral distress, a term that is increasingly used by healthcare professionals. 6
The concept of moral distress is relatively new in healthcare; however, the body of literature on moral distress has grown substantially in the healthcare literature since it was first defined by Andrew Jameton in 1984. 2,3,9,10 At that time, Jameton 11 described moral distress as a situation ‘when one nurse knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’ (p. 6). Since his seminal piece on moral distress, the empirical work on this topic has escalated and other definitions have been developed and used in multiple settings (e.g. long-term care facilities, paediatric/neonatal units, acute care units and psychiatry).
Method
In order to determine the appropriate approach for any concept analysis, Morse et al. 12 suggested that the first step is to review the literature. These authors recommend that concept clarification is necessary when the concept appears mature and well described due to the large body of literature including definitions, descriptions and instruments measuring the concept. This is the case even when the concept appears well described with internal and external characteristics delineated, has no competing concepts, has clearly defined parameters and is operationalized, but on closer examination, the concept is murky with competing assumptions. 12 Furthermore, Meleis 13 states that the aim of a concept clarification is to re-examine existing definitions, explore relationships between definitions, develop new relationships and discuss these relationships in a way that resolves any conflicts that currently exist surrounding the concept. For these reasons, we believe that a concept clarification is the most appropriate form of concept analysis for moral distress.
In our analysis, we follow the concept clarification approach outlined by Morse et al. 5 The steps include (a) conducting a literature review; (b) analysing the literature; and (c) identifying, describing, comparing and contrasting attributes, antecedents and consequences of each category.
Search strategy
Data selection was initiated with a search of the electronic databases MEDLINE, EBSCOhost version (1946–2019) and CINAHL Plus with full text (1937–2019). Search terms included ‘moral distress’, ‘def*’, ‘definition’ and ‘nurs*’. This term strategy was used to narrow the scope of articles to those specifically describing the moral distress definition in a new light where the authors were not simply restating or quoting a previous definition. Furthermore, our aim was to avoid yielding articles where the focus of the text was elsewhere beyond definition development or where the definition had simply been restated in the authors’ own words. Articles were included if the authors presented a unique definition (as described above) of moral distress. These criteria were necessary to identify how the concept of moral distress is conceptualized in the literature, determine overlapping attributes and clarify the concept. Articles were excluded if they did not define moral distress or defined moral distress by referencing another source. Articles were restricted to English only, because this is the only common language among the authors, and those published after 1984, as this is when moral distress was first notably defined. Titles and abstracts of all citations were read by two reviewers independently. All potentially relevant articles were read in full by both reviewers to ensure eligibility criteria, defined a priori, was met.
Search outcome
The total number of articles yielded from the database searches was 19. Of these, 17 articles were removed in total; 13 due to duplication, 1 for being in a language other than English and 3 did not explicitly include an original definition. Therefore, two articles remained that met inclusion criteria. Given these results, articles describing unique definitions were found by a reference-based search strategy, which involved tracing back authors who described original or unique definitions, as cited by authors in recent publications. There were 16 references retrieved from the reference-based search strategies; these comprised of 13 articles, 2 books and 1 report (the Canadian Nurses Association (CNA) Code of Ethics for Registered Nurses). Therefore, a total of 18 references were included and read in their entirety by two reviewers to identify the definition, attributes, antecedents and consequences of moral distress. Essential information on moral distress was extracted.
Results
A total of 15 articles, 1 –3,10,12,14 –23 two books 11,24 and the Code of Ethics for Registered Nurses 25 had unique definitions of moral distress and were included in this concept clarification (Table 1).
Definitions of moral distress.
MD: moral distress.
a Not provided by the author.
Some authors simply defined the concept, while others provided a more robust description with details such as antecedents, attributes and/or consequences of moral distress. The resulting definitions of moral distress have a single commonality; each definition describes constraints (whether implied or explicitly stated). External constraints such as institutional, systemic, situational or circumstantial constraints have been discussed as source of moral distress that makes it difficult for a nurse to follow through with morally acceptable action. 10,11,14,19,20,22,24 Internal constraints were described as a contributing factor of moral distress and have been described in terms such as psychological disequilibrium and painful feelings, 23 personal failings or an error in judgement, 24 interior aversion, 18 personal limitations 25 or simply internal constraints. 10,14 With her definition of moral distress as ‘psychological disequilibrium and negative feelings state experienced when a person makes a moral decision but does not follow through by performing the moral behaviour indicated by that decision’, Wilkinson 23 restricts the concept to internal constraints (p. 16). Interestingly, Crane et al., 15 stated that moral distress can arise from autonomous decision making and hypothesized that limited control over one’s decisions was not necessary for moral distress to arise.
The CNA 25 not only asserted that moral distress can lead to feelings of anger, frustration and guilt but also discussed how it can be beneficial leading to self-reflection, growth and advocacy. Nathaniel 21 broadened the definition of moral distress by describing an individual who makes a moral judgement about the corrective action to take yet, as a result of real or perceived constraints, participates, either by act or omission, in a manner he or she perceives to be morally wrong. In 2017, Fourie 17 further broadened the definition to recognize that constraint is not a necessary condition, rather moral distress can arise from ‘morally troubling situations’, including moral conflict, dilemma and uncertainty. Fourie 17 further argued for distinctive categorization of these different kinds of moral distress (constraint-distress, uncertainty-distress). Interestingly, Crane et al. 15 described a post-facto emergence of moral distress (a lack of moral conflict identification prior to an action to a subsequent action to cause moral distress) as well as retroactive moral distress (recalling an emergence of moral distress years after the event). Uniquely, McCarthy and Deady 3 contended that moral distress is best understood as an umbrella concept that includes a range of experiences of those who are morally constrained.
Antecedents of moral distress
Antecedents are events that exist before or logically precede an event; therefore, for the purpose of our analysis, we define antecedents of moral distress as an event or factor that occurred prior to the morally distressing situation. Based on this definition, a few notable antecedents of moral distress were found in the included articles. Some authors proposed that antecedents of moral distress include the belief framework of the individual nurse, the compatibility of that framework with one’s colleagues and the institution, the type of unit, lack of resources and inadequate staffing. 14,16,20 While antecedents are limited to the precursor factors or situations that can influence the occurrence of moral distress, there is a great deal of overlap with what is described as attributes of moral distress.
Attributes of moral distress
Morse describes attributes as being components or characteristics of the concept. 5 For our analysis, we define attributes as components or characteristics that contributed to the morally distressing situation at the time of the event. Therefore, we conceptualize that the true attribute of moral distress may be a combination of the antecedents described in conjunction with a situation that violates a nurse’s own moral values. Pauly et al. 2 stated that the specific situations that cause moral distress vary based on position and profession, and the extent of the experience can vary across disciplines. Fourie 17 further described varying types of situations that could result in moral distress to also include cases of moral uncertainty which has been noted by Kälvemark et al. 20 and Austin et al. 10 Nathaniel 21 noted that previous studies state the nurse must actually participate in the act of moral wrongdoing, violating his or her own moral values to experience moral distress. She further explained, it is the dynamic interplay of nurses’ moral outlook, relationships with patients, role identification and commitment to moral principles that may be intrinsically incompatible with certain situations, therefore causing moral distress. Webster and Baylis 24 stated, it is the incoherence between one’s beliefs and one’s action as well as compromised integrity that lead to moral distress. Crane et al. 15 echoed this account, noting moral distress can arise from a failure to have power or resources to act according to one’s beliefs of what ‘ought to be done’ (p. 5). From this analysis, we identified two themes within attributes: external factors and internal factors.
External
Elements outside of the individual such as actual or perceived imbalances of power as well as constraints (situational, legal, nursing/hospital administration or policies) were described as limiting one’s ability to act in a specific situation leading to moral distress. 14,19,21 –23 Powerlessness has also been described as a lack of voice in decision making, personal moral conflicts within workplace realities, and complex issues of power and authority, and this can be the cause of moral distress in some situations. 10 This powerlessness may also include a ‘my way or the highway’ attitude or a ‘policies over people’ attitude that those in power feel nurses should be adopting. This attitude is intended to shift the primary commitment of the nurse to their employer, rather than patients. 6 Incompatibility of values between the nurse and the unit, such as conflict between policy and practice, particularly related to unsafe practices and poor care, can also be seen as antecedents of moral distress. 6 In contrast, Kälvemark et al. 20 stated that moral distress ‘is not dependent on the position held in the workplace hierarchy’ (p. 1083) but could be related to a difference in morals, knowledge and access to different facts about the specific situation.
Another external attribute of moral distress includes a lack of structure and resources. 6,20 According to Austin, 6 not providing time or places for debriefing, problem solving or relationship building, as well as short staffing and a lack of resources for training are precursory situations that can lead to moral distress. Finally, Hanna 18 emphasized five properties of moral distress including perception, pain, valuing, altered participation and perspective that allowed moral distress to be categorized into shocked, muted and suppressed. This author further supposes that situational conditions may be shaped by, yet do not equate to, moral distress.
Internal
Internal attributes refer to one’s values, beliefs and characteristics in relation to moral judgement. These are unique to each individual; therefore, when nurses are faced with similar situations of moral conflict each nurse may have varying degrees of distress, if occurring at all. Other important internal antecedents to moral distress are the nurses’ moral sensitivity, threatened moral values and thwarted moral actions, for example, feelings of powerlessness that may occur in response to external factors. 3,14 As individuals, nurses hold moral values, this may lead them to experience moral distress when these are threatened. 3 Wilkinson 23 described additional internal factors of moral distress as being socialized to follow orders, the futility of past actions, fear of losing one’s job, self-doubt and lack of courage.
Consequences
A number of authors have concluded that moral distress causes consequences at multiple levels of the healthcare system. Micro-level players include individual nurses or other healthcare providers and patients, in addition to the macro-level environment and context of the healthcare system. 2,10,14,16,18,19,21 Individual nurses can be affected by the consequences of moral distress in multiple ways including emotionally, psychologically and physically. Consequences to patient care have been found along with consequences for the healthcare system as a larger organism.
In the literature, there is significant agreement on the emotional and psychological consequences of moral distress as noted by their abundance and specificity. Corley 16 and Nathaniel 21 described the evolution of emotions and actions, including blaming others, self-criticizing, self-blaming, depression, anxiety, embarrassment, anguish and sarcasm. These consequences can then lead to the development of burnout, betrayal of values, internalizing anguish, poor coping strategies, dissociating from feelings, psychological distress and aggressive behaviour patterns. 15,21 Further themes of powerlessness, fear, anger and guilt were also described as a personal consequence of moral distress. 2,10,14,16,19,21 –23
Specific physical consequences are noted less frequently yet among those mentioned, similar themes include heart palpitations, diarrhoea, headaches or migraines, and disturbed sleeping patterns. 14,18,19,21,23 Many authors noted that unresolved personal consequences not only affect the individual experiencing symptoms but also have a negative effect on patient care. Austin et al. 14 and Corley 16 described the effects of personal consequences on patient care resulting in the loss of ability to provide care or to be involved with patients and families, loss of nurse integrity and overall impediment of ethical practice. The delivery of safe and competent quality patient care was also affected and resulted in increased pain, longer hospital stays, and inadequate and inappropriate care of patients. 2,16,21,23 Nathaniel 21 further described patient consequences of moral distress stating that nurses distanced themselves from patients, becoming emotionally unavailable, and avoided patient’s rooms altogether. Fourie 17 described instances of consequences for the well-being of the patient and the well-being of health professionals from a broader perspective.
Systemic consequences were also brought to light in the majority of the articles noted in this concept clarification. Moral distress has been shown to cause nurse frustration, reduced job satisfaction and burnout, which can lead to nurses leaving their position or the profession entirely. 2,10,16,19,21 –23 Therefore, moral distress can be considered a contributing factor in the present nursing shortage and has been described by Nathaniel, 21 as ‘a self-perpetuating downward spiral’ (p. 421).
Although fewer, three articles in this concept clarification discussed positive outcomes of moral distress and these are important to recognize. Resolution of moral distress can create greater clarity and insight that strengthens one’s resolve, and learning from failure can lead to personal and professional growth, and increased skill in compassionate care. 16 –24 McCarthy and Deady 3 further stated that moral distress can also make an individual more reflective about his or her own moral, spiritual and philosophical beliefs. Despite its overwhelmingly negative consequences, moral distress, when resolved, can increase one’s moral sensitivity allowing nurses to enhance their quality of care.
Discussion
Peter and Liaschenko 26 asserted that moral distress is truly a reaction to constraints of the moral identity, relationships and responsibilities of a nurse that underlie a morally uninhabitable workplace, in which incoherent understandings and unstainable practices are present. For Peter and colleagues, 27,28 moral identity is fundamental to moral agency, a moral life and is, at its core, relational. Interactions occur between the individual and others; one’s identity may flourish or be injured depending on the wellness of connections and influences. Damaged identities can result in moral distress. 28 Within our cited articles, constraints are found throughout many of the definitions, an occurrence that has also been noted by Morley et al. 4 in a 2019 systematic literature review and narrative synthesis of moral distress. We found constraints to be explicitly stated or implied, yet largely lacking clarity. However, it is important to note that Fourie 17 explicitly stated constraint is not a necessary condition for moral distress to occur and proposes new definitions of moral distress that delineates when constraints occur versus moral distress due to uncertainty. This led us to question what constraint is and how is it understood from an ‘internal’ standpoint relationally.
The term constraint is generally understood to be ‘a barrier to acting as one would want’ (p. 655). 4 In this context, it relates to the inability or perceived inability for one to carry out the right course of action in a situation based on their moral judgements. This restrictive description associates the term ‘constraint’ negatively, in which it acts as a barrier to a desired moral response. 14 McCarthy and Deady 3 cited that, in general, internal constraints are often related to a personal failing, such as fear or lack of resolve, and our analysis found internal constraints to be described in terms of psychological disequilibrium, 23 interior aversion 18 or personal limitations. 25 In our understanding, these descriptors (e.g. being afraid or an interior aversion) are expressive of one’s personal or individual characteristics of personhood or personal identity. To understand identities, Peter et al. 26,28 described them to have complex features that are multiple, relational and often unchosen; they are socially created by practices and sociopolitical contexts, and reflect the moral histories of what one is concerned for, responds to, cares for and values. When examining moral practices, the authors stated that identities are important to consider. 26 Philosopher Bernard Williams 29 discussed the Greek notion of anangkē ‘constraint exercised by the power of others’ (p. 152), wherein choices by an agent are designedly limited either by context or others to create a situation of ‘imposed choice’ for the agent. Williams 29 additionally noted that an individual can be constrained when there is an imposed choice between two undesirable options which he described as ‘being given no alternative’ (p. 113). Indeed, our analysis found descriptions of responses and reactions to power in terms of being socialized to follow orders, futility of past actions, fear of losing one’s job and difficulties navigating rules versus praxis. 20,23 These restrictions of exercised power of others and ‘imposed choice’ signify the relationship and social network that is created between the institution and the individual, one that restricts acting autonomously as a moral agent, does not account for core values and professional responsibilities, and thereby creates constraints on and potentially damages nurses’ moral identities, as described by Peter and Liaschenko. 26 Furthermore, we question whether these internal constraints, such as fear, 3 a personal failing 3 or ‘a crimp in one’s character’ (p. 218), 24 may more so indicate a lack of cohesion between the individual’s identity (e.g. nursing or moral) and that of the institution. Peter et al. 28 noted that identity maintenance is socially mediated and, therefore, requires reciprocity to flourish. The authors found that, oftentimes, the recipients of care were necessary actors in maintaining nurses’ identities, for example, as people who ‘make a difference’, yet in navigating the everyday realities of healthcare work and constraining forces, nurses are compelled to perform an identity that lacks authenticity and is emotionally laborious and fatiguing. In a traditional understanding of internal constraints, personal characteristics act as one’s own barrier for the individual to act based on their moral judgements. However, examining the relational elements of institutions and identities, we suggest that what is described as internal constraints may be more indicative of an individual’s prior or current responses or perceptions to imposed power or resulting from a lack of reciprocity in the healthcare environment rather than certain inherent failings of the individual, emotional or otherwise.
Undoubtedly, as identities are multiple and socially formed, 26 individuals hold unique characteristics, values and beliefs; for example, an individual’s awareness of roles 26 and knowledge base 23 may aid or hinder one’s abilities to cope with distressing situations. Indeed, our analysis further reveals that nurses hold moral values; that these values, beliefs and characteristics are unique to each individual; and that even simply having these values may place nurses at risk of moral distress. While we have previously noted, internal constraints in the moral distress literature have been labelled as personal limitations, 25 weakness of will or a personal failing, 3 or ‘…a weakness or crimp in one’s character’ (p. 218), 24 we now observe the vagueness to what precisely these interior aversions or personal limitations are in reference to. Does a personal failing occur in weakness to an individual’s own value or belief system such as religion, or is it a perceived failing of one’s nursing identity? The vagueness of internal constraints allows for interpretations of all internal characteristics to be a constraint, ranging from traits or mannerisms to belief systems that individuals hold. For example, what it means to have a personal limitation 25 ; does this indicate an individual who is shy, who lacks self-confidence, who follows their values convictions that may misalign with a healthcare ethos? This ambiguity assumes that an individual’s own characteristics, values or beliefs can, in and of themselves, be constraints. While characteristic traits that make up one’s identity, moral or otherwise, may influence how individuals fare in the face of morally distressing situations, labelling one’s values and beliefs as constraints assumes these characteristics hold a negative connotation. In discussing virtue ethics framework, Tessman 30 described examples of moral damage as a disposition to feel persistent hopelessness or a lack of self-confidence, traits and wording that closely resemble internal constraints within moral distress literature. Tessman 30 stated that in labelling ‘damage’, as we argue ‘constraints’, one is making a normative judgement, in this case, a negative judgement, based on the trait’s tendency to impede flourishing. We therefore propose that foundational elements such as values and beliefs that make up one’s identity should not inherently be termed as a constraint as it implies these may inherently negatively impact the individual while negating the flourishing and fulfilment that can occur from these elements. As an interesting aside, authors Crane et al. 15 hypothesized that moral distress can arise from autonomous decision making and that limited control over one’s decisions was not necessary for the occurrence of moral distress. This was an outlier remark in our search; however, it raises an important point to reinforce that internal characteristics of the individual may predispose or contribute to occurrence of moral distress, such as a nurse with lesser knowledge or experience in facing certain scenarios in order to implement a moral decision. 23 We are in no way stating this to be untrue, we simply assert that the term ‘constraint’ inappropriately ties negative connotation to foundational characteristics of one’s identity.
An additional concern with the wording ‘internal constraint’ involves how an individual, nurses as a profession or researchers aim to address it and mitigate the consequences of moral distress. Returning back to its definition, constraint is understood to be ‘a barrier to acting as one would want’ (p. 655). 4 Wilkinson 23 stated that the amount of experience and knowledge of available options affect the degree to which a nurse can circumvent constraints. If we apply this understanding that constraints can be circumvented, this implies that ‘internal constraints’, or the values and characteristics that make up one’s identity, may be circumvented or evaded in some way. We question whether the elements of an individuals’ identity should be circumvented. Williams 29 stated beliefs are properties of an agent. Peter and Liaschenko 26 further described this saying moral agents are embodied beings whose identities are moulded by historical circumstances that shape what one is concerned about, cares for and values. In our analysis, we found that acting as a moral agent is restricted through institutional constraints, which manifest as what is classically described as internal constraints of fear, doubt and the feeling of powerlessness. As Richardson 31 noted, it is conceivable that our capacity for outrage is a relatively reliable detector of wrong actions, even novel ones. We purport that the experience of an emotion (negative or otherwise) is not inherently a constraint, rather is a guide for agents to reach certain conclusions. It is our conviction that the properties (beliefs, emotions and reasonings) and elements of a moral agent should not be circumvented or resolved, but rather the institutional or environmental obstacles imposed on the agent should be what is labelled ‘constraint’ and what should be most targeted. Austin 6 stated that without morally sensitive nurses, we will no longer have the ability to recognize early warning signs of a toxic healthcare environment. We feel that internal constraint, therefore, is not appropriate language to be applied in this context.
We propose a clarification of the current understanding of ‘internal constraints’ to separate influences and responses to organizational or institutional constraints from the influences of an individual’s inherent values, belief systems and identity. Therefore, going forward, we propose that the term ‘internal characteristics’ be used in place of internal constraints: moral distress occurs when nurses are unable to act according to their own professional judgement and/or personal values due to external constraints or internal characteristics. While understanding that personal advancement in areas, for example, of coping are important, the new term assumes that the responsibility of change lies more so within the relationship between individual and institution, rather than solely from the individual themselves. It places a heavier onus on systemic factors, such as the moral environment, barriers to ethical practice, and support for moral learning and value sharing, which may help identify targeted strategies in future research. Strategies that focus on creating a moral and ethical climate facilitate flourishing influences for its agents.
Conclusion
This concept clarification was conducted to better understand the varying definitions of moral distress that exist in the literature. Upon reviewing the current definitions, we conclude that the term ‘internal constraints’ is problematic within this context and proposes a change to ‘internal characteristics’. This change would rightfully shift the responsibility from the individual to the institution or organization. Therefore, we propose that the responsibility of change be placed on systemic and institutional constraints more so than on the individual’s perspective.
