Moral distress in emergency and critical care nurses: A metaethnography

Abstract

Background:

Moral distress has detrimental effects on nurses which impacts the entire healthcare cycle. Described as a crescendo effect, resolved situations of moral distress leave residue on the nurse with three potential outcomes: moral numbing, conscious objection to the situation, and burnout.

Objective:

This metaethnography strives to achieve a fuller understanding of moral distress by interpreting the body of qualitative work of moral distress in emergency and critical care nurses.

Method:

This study used the Noblit and Hare’s approach of interpretative synthesis. Ten studies met the criteria and were used in this synthesis.

Ethical considerations:

Ethical issues were minimal since no human subjects were involved. Ethical requirements were respected in all study phases.

Results:

The synthesis of qualitative research on moral distress resulted in one central theme, “the battle within,” and five subthemes.

Conclusions:

The unique nature of this nursing specialty resulted in a lasting inner conflict for nurses that is consistent with the previously described crescendo effect. The effects are complex and long lasting and may potentially affect the nurses’ future patient care.

Keywords

Metaethnography metasynthesis critical care moral distress literature review qualitative synthesis

Introduction

The concept of moral distress in nursing has been studied since first being defined by Andrew Jameton¹ as “occurring when one believes one knows an ethical dilemma is at stake and also the morally right thing to do, but institutional constraints make it impossible to pursue the desired course of action” (p. 6). Highlighting the detrimental effects of moral distress, researchers have conducted both quantitative and qualitative studies on moral distress to evaluate its prevalence, essence, and consequences, giving evidence to the significant problem of moral distress within the nursing profession. According to Lamiani et al.,² moral distress has been found to have a “negative impact on healthcare professionals’ professional attitudes” (p. 63). In addition, moral distress has been associated with burnout and intention to leave.³

The purpose of this research is to extract the common, central, and core metaphors and/or concepts of moral distress in emergency and critical care nurses following an extensive review of published qualitative studies. These can then be used to develop an interpretative synthesis⁴ of moral distress that can be applied to nursing care in the emergency and critical care specialties. The use of interpretative synthesis in qualitative research promotes the building of a cumulative body of knowledge in a fundamental area as advocated by Glaser and Strauss⁵ when they warned that qualitative research had the potential to remain as “little islands of knowledge” (p. 181). As moral distress has been associated with severe burnout⁶ and negative consequences for nurses and patients,^2,7 a common and fuller understanding of moral distress is necessary to develop prevention and mitigation strategies. In addition, this understanding has the potential to give nursing leadership a better foundation for supporting their nursing staff during morally distressing situations.

Review of literature

Building upon Jameton’s 1984 definition, Wilkinson⁸ defined moral distress as “the psychological disequilibrium and negative feeling states experienced when a person makes a moral decision but does not follow through by performing the moral behavior indicated by that decision” (p. 16). Further building upon the aforementioned definitions, Kälvemark et al.⁹ developed the following definition of moral distress:

Traditional negative stress symptoms, such as feelings of frustration, anger and anxiety, which might lead to depressions, nightmares, headaches and feelings of worthlessness, that occur due to a conviction of what is ethically correct but institutional and structural constraints prevent the desired course of action. (p. 1077)

In her work to propose a theory of moral distress in nurses, Corley¹⁰ identified the sources of moral distress as pain and suffering inflicted on patients, institutional dehumanizing of patients, constraints from health policies, costs related to treatment, staffing concerns, continued life support to prevent death without informing family of choices, and brain death criteria. Corley¹⁰ stated that moral distress impacts the entire healthcare cycle including patient care, nurse satisfaction, and organizational culture.

Recognizing the impact of moral distress on nurses and healthcare organizations, both the American Nurses Association (ANA) and the American Association of Critical Care Nurses (AACN) developed professional stances on moral distress. The 4 As to Rise Above Moral Distress was developed by ACCN’s Ethics Workgroup.¹¹ Devised initially to help create a healthy critical care unit work environment, this framework can be used for both administrative and non-critical care clinical situations. The 4 As of ask, affirm, assess, and act are used to guide staff and leaders in decreasing and diffusing moral distress situations. An additional guide to address moral distress and its consequences was developed in 2017 by the ANA’s¹² Center for Ethics and Human Rights entitled A Call to Action: Moral Resilience as a Potential Direction for Addressing Ethical Challenges. This guide addresses moral resilience as a defense against moral distress on both the individual and organizational levels with definitions, explanations, and further recommendations.

In summary, moral distress is seen as a crescendo effect¹³ that occurs as the morally distressing situation progresses. While individual moral distress situations are resolved, each situation leaves an amount of residue for the nurse. Over time, this residue crescendos with each similar and each new morally distressing situation resulting in three potential outcomes: moral numbing, conscious objection to the situation, and burnout.¹³ The aim of this research is to focus on an interpretation of the body of qualitative work of moral distress in critical care and emergency nurses who care for critically ill patients across the life span, allowing for a common understanding applicable to nursing care in the emergency and critical care specialties. Using a metaethnographic approach in this interpretation achieves a fuller understanding of moral distress.¹⁴

Methodology

Research design

This metaethnography uses Noblit and Hare’s⁴ approach of interpretative synthesis. This approach allows for a new interpretation to emerge after published qualitative studies are translated into each other uncovering the analogies between them.⁴ This allows the reader to understand how the studies relate to each other.

Procedure

A database search of MEDLINE, PsycINFO, CINAHL, Psychology and Behavioral Sciences Collection, and SocINDEX for the years 2014–2019 initially yielded 102 studies using moral distress AND qualitative research AND nurs* as search terms. This was reduced to 75 studies once duplicates were removed. Inclusion and exclusion criteria were then applied to a title and abstract screening, reducing the number of studies to 61. Inclusion criteria, as determined by this author, consisted of studies involving emergency department registered nurses, critical care registered nurses across the life span, and written in English. The inclusion criteria were limited to emergency and critical care nursing due to the types of care given in these areas that lead to higher rates of moral distress. While prevalence studies support a mixed overall mean of moral distress among emergency nurses^12,15 and a high overall mean of moral distress among critical care nurses,^3,15 the complex care required along with frequent deaths, end-of-life situations, and witnessing of patient suffering is present in both environments. These situations place emergency nurses at a higher potential risk of developing moral distress, hence their inclusion in this metaethnography. Criteria for excluding studies were studies with nonregistered nurse healthcare providers, student nurses, or advanced placement nurses no longer practicing at the bedside; mixed-method studies; and literature reviews. At this point, 14 studies remained and were retrieved and further assessed for eligibility. The same inclusion and exclusion criteria were then applied to a full-text screening resulting in a reduction of four studies for a final count of 10 that were included in the analysis. See Figure 1 for a diagram of this procedure.

Figure 1.

Search strategy.

Sample

A total of 10 qualitative studies are included in this metaethnography. They are profiled in Tables 1 and 2. The total number of participants across the 10 studies was 150 nurses. The majority of participants in the studies were female, and while age was not mentioned in all studies, those that did had ages ranging from 24 to 53 years. Only four of the 10 mentioned educational status ranged from diploma nurses to PhD nurses. Years of experience across the studies ranged from 1 to 37 years. The 10 studies were undertaken in the United States (n = 3), Brazil (n = 1), Korea (n = 1), Canada (n = 2), the Netherlands (n = 1), Australia (n = 1), and the United Kingdom (n = 1) representing the global impact of moral distress in nurses.

Table 1.

Description of study demographics.

Author	Sample size	Nursing specialty	Years of experience	Sex	Age range	Education level
Caram et al.¹⁶	n = 13	Intensive care/surgical	1–10	11 Females, 2 males	26–42	6 undergraduate degrees, 7 specialty certifications
Choe et al.¹⁷	n = 14	Critical care	1.1–16 Average = 6.3	14 Females	24–42	—
Ford and Austin¹⁸	n = 5	Neonatal intensive care	2.5–32	5 Females	27–53 years old	—
Forozeiya et al.¹⁹	n = 7	Intensive care unit	0.66–27 Median = 2	7 Females	—	—
Green et al.²⁰	n = 24	Neonatal intensive care	5+	—	—	—
Lewis²¹	n = 36	Neonatal intensive care	— Median = 23	36 Females	Median 49.7	1 Diploma, 1 associate degree, 11 bachelor’s degree, 15 master’s degree, 5 master’s/nurse practitioner, 1 PhD nurse practitioner
Molloy et al.²²	n = 15	Neonatal intensive care	20–30 Average = 24.8	15 Females	—	—
Page et al.²³	n = 11	Critical care	1.5–27 Average = 12.5	9 Females, 2 males	—	—
Robinson and Stinson²⁴	n = 8	Emergency department	—	6 Females, 3 males	—	5 Associate degree, 3 bachelor’s degree
Wolf et al.²⁵	n = 17	Emergency department	11–37	16 Females, 1 male	>18	89.2% Bachelor’s or master’s degrees

Table 2.

Description of included articles (n = 10).

Author	Country	Year	Sampling method	Qualitative research design	Data analysis
Caram et al.¹⁶	Brazil	2019	—	Case study	Thematic analysis of content (Bardin, 2011)²⁹
Choe et al.¹⁷	Korea	2015	Purposive	Phenomenology	Giorgi’s (2009)³⁰
Ford and Austin¹⁸	Canada	2018	—	Interpretative inquiry	—
Forozeiya et al.¹⁹	The Netherlands	2019	Purposive	Interpretative description (Thorne, 2016)²⁶	Thematic analysis (Aronson, 1995)³¹
Green et al.²⁰	Australia	2016	Purposive	Phenomenology	Van Manen (1990)³²
Lewis²¹	USA	2017	—	Descriptive	Riessman’s (2008)³³ thematic narrative
Molloy et al.²²	Canada	2015	Purposive	Secondary qualitative analysis (Heaton, 2008)²⁷	Inductive content analysis
Page et al.²³	UK	2019	—	Charmaz’s (2006)²⁸ Constructivist Grounded Theory	Constant comparative analysis (Glaser & Strauss, 1967)³⁴
Robinson and Stinson²⁴	USA	2016	Convenience	Phenomenology	Colaizzi (1978)³⁵
Wolf et al.²⁵	USA	2016	Convenience	Exploratory	Iterative analysis

Data analysis

This metaethnography uses the seven-step process proposed by Noblit and Hare.⁴ These steps often overlap and include the following:

Identifying the phenomena of interest.

Exhaustive search to decide which qualitative studies are relevant to the analysis.

Repeated reading of the studies while noting the metaphors.

Determination of relationships between the studies. This is accomplished by making a list of the key metaphors and detailing how they are related to each other. The assumptions that can be made regarding how studies are related are: “(a) the accounts are directly comparable as ‘reciprocal’ translations; (b) the accounts stand in relative opposition to each other and are essentially ‘refutational’; and (c) the studies taken together present a ‘line of argument’ rather than a reciprocal or refutational translation” (p. 36).

Each study is translated into the rest of the studies. This is accomplished while also maintaining “the central metaphors and/or concepts of each account in their relation to other key metaphors or concepts in the account” (p. 28).

Translations are synthesized by “making a whole into something more than the parts alone imply” (p. 28).

Expressing the synthesis. While in academia, this is often in the form of written word, and it is also possible to express via music, art, plays, and videos.

During the data analysis phase, key metaphors were extracted from each study. These metaphors were analyzed to see how they were related to each other and were found to have a reciprocal relation.⁴ The author met weekly with a methodological expert to review code development and study translation synthesis for the duration of the data analysis phase. See Table 3 for examples of how key metaphors were translated into the central theme and subsequent subthemes.

Table 3.

Individual study metaphor examples as related to the themes.

Study	Conflict: the battle within	On being a nurse	The weight of institutional values and challenging environments	Symptoms: valley of pain	Relationships: ties that bind	Ways I cope: flourishing & floundering
Caram et al.¹⁶	Experiencing a disjuncture contrary to nurses’ virtues	Lack of anticipated autonomy	Frustrated because I did not even see the patient	Frustration Impotence Sadness	Dominance of the physicians	Mechanized approach to caregiving
Choe et al.¹⁷	Conflicts with institutional policy Uncertain about their boundaries of authority	Limited autonomy in decision-making	Prioritizing tasks over human dignity Heavy workload	Guilt when they forgot to mourn or revere the death of patients	Family members chose to refuse treatment Felt sorry for familial caregivers	Considering the performance of cardiopulmonary resuscitation as an extension of their work
Ford and Austin¹⁸	Conflict of morality Following one’s conscience	Healthy sense of professional and personal functioning	Institutional and professional restrictions	Physical and emotional responses within her	—	Distance themselves from the situation
Forozeiya et al.¹⁹	Difference between what they want and what you think is right Questioning the decisions of others	Advocate for what they believed was right	Contemplated ending their employment in the ICU	Emotional, bodily and social consequences	Connections with people who, in their words, ‘‘get it”	Distract myself Absolved themselves of culpability
Green et al.²⁰	As nurses we don’t agree with this Nurses wanted infants to be free from pain	Passionate about this outcome	Desire to leave the job	Anxiety Frustration	Parents are going to suffer along with them	Rationalizations
Lewis²¹	Cure at all costs Junction between curative and futile care	Commitment to deliver the best care possible	We, as hospital staff, assisted in killing her	Anger Guilt I felt so nauseous	Colleague support Grateful to be part of a team	Purposefully ignoring personal feelings
Molloy et al.²²	Allow an infant to continue to suffer Inconsistencies and differing perspectives	You’re constantly there	Not knowing the long-term outcomes	Frustration Under a significant amount of emotional distress	Empathized with the parents	Avoidance
Page et al.²³	Complicit in the tortureTension in balancing physical survival with psychological needs of patients and their families	Passion for nursing on a 1:1 basis	Caring for people, literally fighting for their life Long-term exposure to critical illness	Emotional challenges Stress and frustration	Getting to know the patient and the family	Efforts to humanize an alien environment
Robinson and Stinson²⁴	Conflict between what they believe is right and decisions made by others Going against a person’s wishes	Nurse gets lost	Desire to leave the job Guilt over not wanting to care for certain patients	Guilt associated with their reactions to stress	Doctor is doing it anyway	Inappropriate jokes Suppressing emotions
Wolf et al.²⁵	Conflicting demands placed on nursing staff So why do I? But I do	You’re intimate with your patient	All about the scores and the numbers Demands of the work environment and administrative decisions	Depression Despair Fatigue	—	I’m turning to alcohol to calm this day I’ve had

ICU: intensive care unit.

Findings

The synthesis of studies included in this metaethnography resulted in one central theme and five subthemes. These studies are summarized in Tables 1 and 2. The central theme is entitled conflict: the battle within, and the five subthemes are (1) on being a nurse; (2) the weight of institutional values and challenging environments; (3) symptoms: valley of pain; (4) relationships: ties that bind; and (5) ways I cope: flourishing & floundering. The subthemes are inter-related to the central theme in that each of these subthemes also has an aspect of conflict within it. The inter-relationship of these themes is illustrated in Figure 2 and Table 3. With the exception of relationships: ties that bind, examples of the central theme and all subthemes are found within all 10 studies. Examples of the relationships: ties that bind subtheme occur in eight of the 10 studies.

Figure 2.

Inter-relationship of moral distress themes.

Themes

Central theme—Conflict: the battle within

The battle within emerged as the central metaphor for moral distress as the nurses described their internal conflicts of conscience with doing what they are told to do versus what they feel is the right thing to do. Examples of this internal conflict were consistent in all 10 synthesized studies. Nurses wanted to follow their conscience yet were “forced to admit to a different reality.”²⁰

The difference between harming and saving was difficult to elicit by some nurses who then viewed themselves as torturers.²⁰ These nurses began to question how much suffering their patients were enduring in the quest to keep them alive at all costs.^18,19,21,22 Nurses began to question whether considerations had been made for the value of life,¹⁷ the humanity of the patient,²⁰ or the “benefits and burdens imposed by treatment.”²⁰ This was especially evident when “resuscitating an extremely premature infant”²² or when doing a futile resuscitation for an adult patient.¹⁷ At this point, nurses felt they were “inflicting more harm than good,”²² especially when partaking in painful procedures or procedures intended to prolong life in a patient who would ultimately die.²⁰ One nurse described these situations as “when caring and torture are the same thing.”²⁰

Nurses also described feeling moral distress when “everyone’s not on the same page.”²² This included the family not wanting the patient to know their diagnosis,¹⁷ the physician not telling the patient and/or family the whole story,¹⁹ and the nurse not agreeing with the treatment ordered by the physician.²⁰ This also occurred when care went against the patient’s wishes¹⁹ and when institutional policies were incongruent with the nurses’ ethical morals.¹⁷ Nurses felt this could be prevented by having preset advanced directives and the establishment of goals of care for every patient.¹⁹

A last source of the major internal conflict was when nurses felt as if they had to cover things up. For example, a nurse stated that she had “observed fellow nurses who lacked sensitivity towards ethical care and committed malpractice.”¹⁷ Other nurses reported instances where their colleagues “did not adhere to the principles of standard nursing care”¹⁷ or crossed professional boundaries.²¹

Subtheme 1—On being a nurse

In this subtheme, nurses describe their nursing identity and how it becomes conflicted when suffering from moral distress. Nurses described the positives of being a nurse such as patient advocacy,^22,25 being responsible for patients,¹⁶ being there for patients,¹⁶ and delivering the best care they could.^18,21,23 This gave the nurses a sense of purpose²¹ and made them feel as if they were in a “privileged position.”²³ These characteristics established their personal nursing identity.

Overshadowing this personal nursing identity was the “invisibility of self,”¹⁶ where nurses were in conflict with this identity due to their moral distress. Thoughts of “being dropped in someone else’s nightmare”²¹ or of profound personal failure surfaced.¹⁸ Nurses began to “not recognize themselves in their practice”¹⁶ and began to feel powerless.^{17,18,20,21,24,25} Nurses who previously had described nursing as a spiritual practice²¹ now felt “asking God for forgiveness” necessary for the things they had done to their patients.²⁴

Subtheme 2—The weight of institutional values and challenging environments

Nurses cited organizational constraints such as lack of resources,²⁵ lack of adequate staff,¹⁷ and increased nurse-to-patient ratios.^16,25 In addition, nurses cited needing to “choose between good care and good documentation,”²⁵ a focus on metrics, a focus on performance measures, and lack of managerial support as triggers for the development of moral distress.²⁵

Specific patients provided nurses with challenging work environments that led to moral distress. For example, nurses expressed guilt for wanting to avoid caring for certain patients such as patients who came to the emergency department for nonemergent problems,²⁵ behavioral health and substance users,²⁵ and patients with delirium.²³ An additional patient population the nurses felt led to feelings of moral distress were patients that needed restraints applied for therapeutic purposes as it then violated the patient’s sense of dignity.¹⁷ The inability to know the eventual outcomes for their patients once they left the emergency department or critical care unit also contributed to moral distress.^22,23 In addition, “confronting mortality on a regular basis” and working in close proximity to death contributed to moral distress.²³ The weight of these constraints and environments led to nurses contemplating leaving their current roles.^18,20,24

Subtheme 3—Symptoms: valley of pain

Given the metaphor “valley of pain” due to the symptomatic lows surrounded by morally challenging events, this subtheme describes physical and emotional symptoms felt by the nurses suffering from moral distress. Examples such as anger,^{16

–22,25} stress,^{17,19,20,22,23,25} depression,^17,22,25 despair,^20,25 guilt,^17,18,21,25 sadness,¹⁶ and frustration^{16

–23,25} are evident within the synthesized studies. The emotional challenges, costs, fallout, and withdrawal are described in detail.^{17

–25} The most common physical symptoms included nausea and high blood pressure^18,21,25 and were blamed as reactions to the stress the nurses felt.

At times, these symptoms manifested as a reaction toward others. Nurses felt guilt after reacting to their stress as if they were not allowed to feel stressed with their caregiving duties.²⁴ Guilt was also expressed when a nurse moved on from a death too quickly and did not mourn.¹⁷ Nurses became angry with family members when they made patient care decisions the nurse did not morally agree with.^18,21 Nurses also felt stress when they had to repeatedly support family members on top of caring for dying patients.^20,22,23

Subtheme 4—Relationships: ties that bind

The metaphor “ties that bind” is used to describe the relationships the nurses develop with nursing colleagues, physicians, parents, and family members. Despite the alliances and alienations within these relationships, the nurses felt bound to these relationships. In many instances, these relationships contributed to the moral distress felt by the nurses.

While mostly positive, relationships with nursing colleagues did lead to an inner conflict as described in the central theme. While that describes the alienation aspect, the alliance aspect is described through examples of supportive relationships.^19,21 Nurses described their nursing colleagues being the only ones who “get it”¹⁹ when they are feeling distressed. The nurses leaned on these nursing colleagues for support.

Nurses described their relationships with physicians more often in a negative light. Nurses often felt alienated by physicians who withheld information from parents or family members,¹⁹ who were indifferent to professional ethics,¹⁷ who were not proactive in treatment strategies or gave up on patients too quickly,¹⁷ and who expressed distrust with the nurses’ ability to make patient care decisions.¹⁶ Nurses described physicians as dominant¹⁶ and at times questioned the physicians’ decisions.^19,21 While nurses did not feel supported by physicians overall, some nurses did describe being grateful for their interdisciplinary team^18,21 and supportive physicians who asked the nurses for their opinions on end-of-life care.²¹

Synthesis of the relationships with families averaged equally positive and negative. Nurses often felt empathy for families²² and helped to empower them.²¹ Nurses helped to console family members in times of crisis.²⁰ Nurses cared for the family members along with the patient.^21,22,23 Nurses also felt that family-centered care was important as patients received better overall care when family was present.^23,24

Subtheme 5—Ways I cope: flourishing & floundering

The metaphor “flourishing & floundering” was used for this subtheme because of the nature of the coping strategies the nurses described. Nurses who are flourishing despite feeling moral distress used adaptive coping strategies such as exercise,²⁵ focusing on their patient care,¹⁶ psychological counseling,²⁵ and looking at things with a different perspective.¹⁹ Nurses who are floundering in their moral distress are using maladaptive coping strategies such as alcohol and substances,^24,25 avoidance of their feelings,^19

–22 and becoming numb.²⁴ Some nurses “actively acknowledge their moral distress,”¹⁹ while others become ambivalent¹⁷ or put blinders on.²⁴ One nurse used the metaphor “Like Grass in the Wind” to describe the way she felt stating that this grass is “flattened in the wind but that it is able to get back up.”¹⁹

While some nurses are unable to build adaptive coping skills from the start, other nurses start with adaptive coping and then cross into the maladaptive with time and subsequent morally distressing episodes. For example, nurses start to distance themselves from their patients, their feelings, and the morally distressing situations.^{16,18
–20,24} One nurse stated, “every death takes a little part of me.”²¹ Other nurses reported making changes to their nursing practice as a result of their morally distressing situations.²¹

Discussion

This metaethnography illustrates the lasting inner conflict emergency and critical care nurses feel due to moral distress. The stressors of the workplace, interpersonal professional relationships, end of life, prematurity, emergent situations, and critical illness result in the nurses questioning their nursing identity, the development of physical and emotional symptoms, and the potential for inadequate coping. These effects are complex and long lasting for the nurse potentially impacting their future patient care.²

“The battle within” emerged as the central theme due to the inner conflict the nurses described. Each nurse in each qualitative study described this inner conflict and how it made them feel. Nurses began to question whether the care they were giving was actual care versus a form of torture for the patient and occurred across the life span from premature infants to the elderly. This inner conflict also was present when communication was not consistent, when care was considered futile, when institutional policies were morally questionable, and when nurses had to cover for the questionable moral compass of their nursing colleagues.

Subtheme 1 describes the conflict nurses feel about their nursing identity in regard to morally distressing episodes. Nurses described what they thought nursing would be versus what they felt nursing actually was. Subtheme 2 describes how the organizational culture and work environment, especially in the emergency department and critical care units, can result in moral distress. Nurses describe feeling conflicted in the following policy while providing moral care and inner conflicts that become present when taking care of certain patient populations. Subtheme 3 describes the symptoms nurses develop as a result of morally distressing episodes. In this subtheme, conflict is present in the form of the nurses’ guilt for their stress reactions. Subtheme 4 describes conflicting relationships the nurses develop with nursing colleagues, physicians, and family members. Finally, subtheme 5 describes the nurses’ coping strategies. The conflict within this subtheme is in regard to both the positive and negative coping strategies used by the nurses. Some nurses stayed positive or negative while other nurses used both types of coping adding to their inner conflict.

The results of this metaethnography are consistent with the crescendo effect of moral distress as described by Epstein and Hamric³⁶ where each additional morally distressing episode adds to the previous ones (see Figure 2). Each of the subthemes is interrelated to the central theme and each contributes to this crescendo effect. While nurses may initially be able to adaptively cope, over time, with repeated morally distressing situations, the nurses’ coping strategies may turn maladaptive.^{16,18,19,20,24} Nurses come into nursing with an idea of their personal nursing identity. This identity potentially changes once they undergo morally distressing situations. Professional relationships impact the nurse both positively and negatively, with each type contributing to the moral distress of the nurse. Together these inter-related subthemes result in inner conflict for the nurse with additive effects each time the nurse finds themselves in a morally distressing situation.

Conclusion and recommendations

This metaethnography highlights the seriousness of moral distress. As moral distress has been found to be mixed in emergency nurses and high in critical care nurses, nursing management needs to be aware of the potential for the presence of moral distress in their nurses. Nurse managers need to be cognizant of morally distressing situations that are occurring on their units and the resultant effects on their nurses. When nurses show signs of maladaptive coping mechanisms or show changes in the way they give patient care, such as “faking an attitude”¹⁹ or shutting themselves off during patient care situations,²⁴ nurse managers need to be aware this may be a manifestation of moral distress rather than a behavior that should be disciplined. In addition, nurse managers may use screening tools such as the Moral Distress Scale-Revised (MDS-R)³⁷ or the Measure of Moral Distress for Healthcare Professionals (MD-HP)³⁶ to screen their nurses for the effects of moral distress and intervene as necessary. As this metaethnography and previous qualitative research have given rise to the effects of moral distress on the nurse, further research is necessary to develop interventions to lessen the impact and residual effects of moral distress on the nurse. This research should focus on strategies that can be used in real time as the morally distressing episode occurs to lessen the known crescendo effect of moral distress.

Footnotes

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Tracey C Arnold

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