The process of moral distress development: A virtue ethics perspective

Introduction

Work in healthcare is dynamic, complex, and has characteristics that make professionals face ethical challenges that can culminate in experiences of moral distress, such as futile care, limited resources, moral conflict with the medical team, and a lack of transparent and participative decision-making. ¹ Moral distress can be understood as the reaction to a situation in which healthcare professionals, when faced with a moral problem, make their judgment, but are rendered unable to act in accordance with their values and judgments. ² Moral distress causes feelings of anguish with possible physical and psychological manifestations that compromise their work and can culminate, in more extreme situations, with people leaving their profession. ² Moral distress inhibits moral deliberation that can lead to the distortion of a practice in the eyes of to professionals, their peers, and society. ³

The object of this article is to add understanding to the process of moral distress development proposed by Ramos et al., ² using MacIntyre’s ⁴ work on virtue ethics, along with the work of Van Hooft ⁵ that also draws on MacIntyre. Although the process of moral distress has been studied widely, generally this has occurred without using ethical theory explicitly, resulting in the potential for a more in-depth examination. In particular, a gap in understanding of moral distress in the context of a practice exists. Our goal is not to develop a new framework of moral distress, but to add philosophical elements arising from virtue ethics to increase the depth and understanding of Ramos et al.’s ² framework. We begin by providing an overview of both virtue ethics and Ramos et al.’s ² framework and then describe how identity, social context, beliefs, and tradition shape moral discomfort, uncertainty, and sensitivity. We then describe how virtues inform moral judgments that, if blocked, can lead to moral distress and deprofessionalization. Ultimately, we maintain that moral competence can be developed through the acquisition of virtues.

Background: virtue ethics

Virtue ethics is focused on the moral character of agents as opposed to the acts, circumstances, and consequences of moral events. ⁶ Virtue ethics addresses some important questions that deontological codes, restricted to regulations, neglect. Deontological codes restrict actions by considering them to be “right,” “wrong,” “obligatory,” or “permissible.”^5,7 Instead, in virtue ethics, it is possible to evaluate that an action has different possibilities, once moral agents mobilize virtues that lead them to act morally in pursuing their practice. ⁸ From MacIntyre’s perspective, a practice is “any coherent and complex form of socially established cooperative human activity through which goods internal to that form of activity are realized” (p. 187). ⁴

Internal goods comprise recognized standards of excellence that characterize a practice and distinguish it from other practices. ⁴ The internal good is the purpose of the activity (telos), being associated with the history and tradition of the practice, investing it with significance and legitimacy. While professional autonomy entails the means to carry out a practice, professionals have no control over the overall purpose of their practice, since it is already given historically and traditionally. ⁴ For example, the internal good of the practice of nursing is the care of the patient.^3,9 Armstrong ⁹ (p. 112) explains that nurses should “(1) help the patient to survive and recover from illness; (2) promote the patient’s independence; and (3) in terminal illness, alleviate physical symptoms such as pain and promote dignity.” Although the internal good is unique, it should be highlighted that the means to achieve the practice can change according to context and time, being in line with the moral conscience of individuals in particular circumstances. ⁴ Therefore, professionals shift, over time, in pursuit of excellence in its distinct forms, although the ultimate goal remains the same.

In contrast, external goods can be achieved in any practice, including the social goods of prestige, power, money, and status, ⁴ but they do not legitimize or give significance to a practice because they are obtained as recognition for the virtues expressed in the pursuit of the internal good. What would make the professional unvirtuous is prioritizing the external good to the detriment of the internal good, thus corrupting the practice with losses to its legitimacy and credibility. ⁴ The virtuous exercise of a practice is a moral responsibility that transcends these financial aspects and other external goods. ⁵

Professionals must assess their desires, emotions, and needs, accepting their practices as ethically important, and accordingly must decide to carry out actions autonomously and take responsibility for their actions. ⁵ Therefore, virtue ethics recognizes not only the nature of the moral ambiguity that everyday situations present, but also the responsibility that the individual needs to assume when deciding on a path. It is expected in the development of an action that professionals mobilize their virtues to pursue the primary purpose (telos) of their practice. In this way, they will achieve not only the internal goods of the practice, but also the external ones. In the context of a profession, virtue ethics takes the relation between the virtuous character traits of an agent with the aim of the profession in question, building the notion of professional integrity. ⁸ MacIntyrean virtue ethics is grounded in Aristotle’s view of virtue. Thus, the virtues are agents’ qualities that enable them to reach the telos of a practice, that is, the finality of the practice. ⁴

Nurses require moral virtues in their practice that support them in being sensitive to different perspectives to make the best decisions for patients, taking into consideration the context and circumstances of care.^9–11 Being true to the nature of a practice entails a search for excellence, configuring it in accordance with its origin. ⁴ Professional integrity is related to the way that professionals act to reach the telos of their practice. The development of moral agents as a consequence of their narrative histories ⁴ is important with respect to the virtues because professionals will be motivated to act in line with their practice. ⁵ Therefore, the history of individuals is part of their “professional self” and should not be overlooked in practice since socialization processes, which professionals have undergone and continue to undergo, influence their development as moral agents.

A practice is composed of standards of excellence, and the achievement of its internal good. In healthcare, the internal good translates as the patient good. However, when we consider that each professional group pursues its own internal good, conflicts may emerge due to the specificities of their training, the exercise of their professional responsibilities, and their particular interests. With the existence of different professional groups in healthcare, sometimes there is a lack of clarity as to the scope of their specific duties and responsibilities. This situation is aggravated if we consider the various histories and traditions of professions that are highlighted in nursing and medicine and often culminate in hostile relations, negatively impacting the quality of care and leading to a failure to achieve what is good for patients.

It is expected, then, that professionals seek to achieve a practice directed to its internal good, which at the same time benefits fellow citizens and legitimizes the professional practice. ⁴ Practice, therefore, must be inclusive, providing benefits to society and legitimizing the professions and their social relevance. Professionals need to find ways to express their virtues for the sake of a practice and conduct themselves with excellence, achieving its social relevance and legitimacy. However, professionals find problems of a moral nature in their daily practice that can render them incapable of pursuing the internal goods of their practices, triggering distress and, consequently, a distortion of the practices. ³

Recognizing the constraints to the exercise of virtues is important because without this recognition professionals could be blamed for the problems they encounter. For instance, Tong ¹² regards caring as a virtue but specifies that certain conditions need to be present for this virtue to be exercised in healthcare, namely, the absence of oppression and the requirement of healthcare services not to be viewed as a commodity. Moreover, it is important to acknowledge that many nurses cannot fully engage in a practice because their work is task-oriented as a result of the conditions of their employment. ¹³ These nurses, like others who are not engaged in a practice, also make moral judgments and are also not immune from experiencing moral distress.

The process of moral distress

Jameton was the first to define moral distress in nursing, describing it as a painful feeling or a psychological imbalance resulting from the inability to act according to one’s moral judgment due to institutional constraints. ¹⁴ He distinguishes two stages of moral distress, the initial and the reactive, with the initial being represented by feelings of anguish, frustration, and anger, and the reactive being delineated by the inability to face the obstacle and act according to one’s values and the impossibility of overcoming the initial feelings. Nurses may experience moral distress as a result of the inconsistency between their actions and their moral judgments, which generates distress and even the abandonment of their profession. ² Moral distress manifests itself in distinct forms, comprising feelings such as frustration, guilt, depression, anxiety, humiliation, anguish, grief, anger, and impotence, and also through physical responses, such as crying, insomnia, loss of appetite, nightmares, tachycardia, headaches, tremors, gastrointestinal disorders, and stress.^4,15–17 Nurses are vulnerable to moral distress given the complexity and particular circumstances of the work they carry out. Such experiences can result in a crises of values, with real and deleterious consequences on the quality of care and with ethical implications for all those involved. ¹⁸

Ramos et al. ² have proposed a framework to analyze moral distress. The framework conceptualizes moral distress as part of a process that constitutes moral experience (see Figure 1). The moral problem in this framework is central because the outcomes, such as moral deliberation and/or moral distress, flow from it. Ramos et al. ² acknowledge that the framework will continually evolve as new studies and healthcare issues, along with different theoretical and ethical perspectives, influence the development of its elements.

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Figure 1.

The process of moral distress.

The voices of nursing professionals are often silenced and obstructed when they wish to express moral concerns inherent in their work, which contributes to experiences of moral distress and to the disruption of their sense of identity as nurses, resulting in their invisibility to themselves. ³ Gallagher ¹⁶ notes that in addition to nurses having little space to expose problems, there are everyday situations that generate apprehension, such as having the responsibility to inform patients and their families about the patient’s prognosis. Apprehension can be a factor that prevents nurses from acting on their values, thus causing moral distress, unless they possess moral courage and are able to act despite their fear. Gallagher ¹⁶ believes that moral courage is a professional virtue that stimulates nurses to assume a position contrary to unacceptable practices and policies as a form of resistance and protection. However, she points out that it is not always possible to exercise courage because institutions may become barriers.

The explication of Ramos et al.’s moral distress framework using virtue ethics

Ramos et al.’s ² moral distress framework, however, focuses only on the process of moral distress itself without exploring in depth the process of moral distress in the context of a practice. The professionals’ moral judgment and moral deliberation process are not described as related to the search for the telos of a practice, but instead is unspecified. It could be related to a telos, but it also could be related to deliberations that are related to rules, consequences, or the context of a moral event.

From a virtue ethics perspective, moral judgment occurs through virtuous moral agents who pursue their practice, ⁴ aiming and making choices to realize the internal good of their practice. When using the concept of practice, it is understood that professionals will make the best possible decisions if they are guided by their virtues and the internal good.

The moral experience depicted in Figures 1 and 2 is initiated by the existence of a moral problem, which requires professionals, like nurses, to be morally sensitive. Moral sensitivity, moral uncertainty, and moral discomfort are required first to recognize a moral problem. Moral sensitivity is “a distinguished ability to perceive” that something of moral significance is present. ² Moral sensitivity corresponds to a nurse’s perception with regard to the values in the conflict situation and the awareness of their responsibility through the moral motivation to do good. ¹⁹ Moral sensitivity is not just about emotion and knowledge to identify the conflict, but it is also about the professional’s capacity to differentiate the common problem from a moral problem, as well as their experiences and values. Moral sensitivity occurs in environments that are permeated by moral discomfort and uncertainties that can lead professionals to perceive a specific situation, leading to the possibility of moral discomfort and uncertainty. ²

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Figure 2.

The process of moral distress: an adaptation of Ramos et al.’s moral distress framework using virtue ethics.

For example, nurses experience moral uncertainty related to their own ways of being a nurse and when they must face specific circumstances related to the daily life and death of patients and their communication with professionals and families about the best care for patients. The moral uncertainty is productive in the sense of making the nurse perceive, question, and be critical of moral problems in the face of moral discomfort, even in apparently everyday circumstances.

The place of identity, social context, beliefs, and tradition

The components of moral discomfort, uncertainty, and sensitivity, according to MacIntyrean virtue ethics, ⁴ can be understood as belonging to the moral character of a professional, comprising a set of tendencies, as opposed to others, which are part of the narrative history of a person. The agent’s behaviors are intelligible when it is possible to understand the context of how actions occur, meaning that actions are a result of the interactions between intentions and the social and historical context of the agent.

Narrative history is composed of the traditions, beliefs, and identity, belonging to individuals and situating them in a social context, which gives intelligibility to a practice. ⁴ Because the context in which a practice develops is defined by traditions that include institutional, social, and historical influences, ²⁰ by engaging in a particular practice, individuals inherit a tradition, learn from it, and at the same time build it. ⁴ Consequently, it is not just the historical dimensions that constitute the tradition of a practice, but also the identities of individuals developed in the course of their socialization.

The process of socialization occurs relationally, providing individuals with the construction and knowledge of themselves and others that result in the construction of their identity. ²¹ MacIntyre also recognizes that the identities of individuals are relationally composed and that through them they are able to be a part of a social space. ⁴ Professionals experience a sense of belonging to the community through their work that contributes to their legitimacy and to the intelligibility of their practice in society, thus revealing the social character of identity development that occurs in the dynamics of life in which relationships and experiences are not static, but are a part of a narrative history.

MacIntyre recognizes that the role of narrative history is necessary to understand moral discomfort, uncertainty, and sensitivity since they arise from the relational processes of socialization. Thus, decisions are not centered only on individuals, but are part of a context, ²² and, for this reason, narrative history confers intelligibility to a practice, since the actions come to be situated and understood as a whole. ⁴ These components are part of a moral agent’s experience, ² since even before making their judgments and choices, there are narrative histories that will influence them in the way they face the moral problem and make their decisions. Such influences occur in the expression of virtues in situations that require moral judgment.

Moral deliberation and judgments

Moral judgments, according to MacIntyre, ⁴ correspond with factual statements that moral agents understand as having the characteristics deemed necessary to achieve a purpose. Since this judgment is conducted in the development of a practice, it is understood that the purpose is to achieve an internal good. The virtues used for a moral judgment are related to the structure of the social context of which the individual is part, being something particular and at the same time socially interconnected, since it is part of an inherited tradition. ⁴ The idea of virtue is related to the excellence of character that guides an agent toward certain ends and purposes, as an excellence of reason and not just of emotion, centered on practical judgment being apprehended in the practice itself. ⁶ The expression of virtue involves thinking about the practice and about the patient, in addition to involving self-reflection on what kind of professional one would like to be and what one should do. ²³

Thus, as represented in the framework (Figure 2), when nurses are faced with a moral problem, they need to utilize their virtues to make moral judgments and act in line with the telos of their practice. Ramos et al. ² proposed three possible outcomes that will be analyzed from the perspective of virtue ethics, namely, the process of moral deliberation, moral distress, and stagnation in uncertainty (non-deliberation/deprofessionalization). The process of moral deliberation occurs when professionals, faced with a moral problem, make their judgment and utilize the virtues that will guide them to act in line with their moral judgment, accomplishing the pursuit of the internal good of their practices (telos). Thus, moral distress should not exist if moral agents are able to engage in practical wisdom and morally deliberate to accomplish needed actions based on their judgment. This process can reinforce the intelligibility of practice, since when there is a moral judgment in line with moral deliberation, there is the pursuit of an internal good. Practical wisdom (phronesis), as understood by Aristotle, ²⁴ is the ability to perceive that which can be the object of deliberation, with virtue being central and, thus, the means that will lead to the end or telos of practice. Ultimately, with practical wisdom, people are able to carry out moral judgments and make appropriate choices for the activity in which they are engaged, ⁶ because the expression of virtues involves the ability to judge the right thing to do, at the right place, and at the right time. ⁴

However, the development of moral distress occurs over time, and constant exposure to it can lead moral agents to no longer defend their practice and to lose their ability to mobilize practical wisdom. This is characterized by Ramos et al. ² as “stagnation in uncertainty,” which is an unfavorable outcome because the search for internal good (telos) is no longer pursued.

Obstacles leading to moral distress

Hodkinson questions if practical wisdom always leads individuals to make the morally adequate decision and argues that in the course of action, they may feel uncomfortable with the decision made, although they initially used practical wisdom. ²⁰ Accordingly, the assessment of the moral deliberation process can be a source of moral distress, as pointed by Ramos et al., ² because the assessment of the deliberation entails a new process of moral judgment followed by its possible outcomes. Regarding the outcome associated with moral distress, according to Figure 2, an individual uses their practical wisdom, but encounters obstacles in performing the action, leading to an inability to act. Thus, the professional is faced with a moral problem, makes their judgment, and draws on their practical wisdom, but is rendered unable to act in accordance with their judgment, resulting in moral distress. In this case, the moral deliberation process is interrupted due to obstacles preventing the ethical-moral positioning of the professional. ²

It is worth emphasizing the inclusion of moral outrage as an obstacle to the implementation of practical wisdom. Moral outrage occurs when individuals witness a situation of deep moral concern in the workplace, but are rendered unable to act, since it is related to the decision and conduct of another. ⁷ As nursing practice is not performed in isolation, but instead occurs with other interprofessional practices and organizational mandates, some decisions may not occur in conjunction or with the consensus of others, which may cause differences with respect to moral judgment and, consequently, moral distress.

Finally, the outcome of stagnation in uncertainty (non-deliberation) can be one of the effects of moral distress, when the prolonged experience of moral distress and moral residue can lead the nurse to not assume a moral position. Prolonged and repeated exposure to moral distress gradually ravages the moral integrity of the professional, resulting in moral residue. Distress, due to the damage of moral integrity, remains dormant in the thoughts and conscience, and in every situation involving a moral issue with the moral distress experienced being intensified due to moral residue. ²⁵ The relationship between moral distress and moral residue can reach the point of producing important ruptures. Epstein and Hamric ²⁶ describe two consequences of such ruptures that are possible to identify in Figure 2. The first refers to the “dormancy” of the professional in relation to the experience of moral conflict, that is, they no longer recognize or get involved in morally significant situations, that is, the outcome of stagnation in uncertainty. The second concerns the professional opposing the situation vigorously and seeking a means to overcome the constraints, that is, the mobilization of practical wisdom for the process of moral deliberation.

Consequently, “stagnation in uncertainty” occurs when the professional is rendered unable to assume a position according to their moral values, ² leading to the conduct of their practice in a mechanical and uncritical manner. In the work of Pellegrino, ⁶ this posture is characterized as deprofessionalization, in which a profession loses their commitment to the character traits that are particular to it and necessary for protection of the well-being and interests of patients. Deprofessionalization is part of the reason that professionals can become invisible to themselves, ³ because when they cannot conduct their practice in a way that would allow them to reach its telos, they cannot recognize themselves as engaged in their practice.

Thus, stagnation in uncertainty and moral distress are unexpected outcomes as they go against the pursuit of an internal good, with professionals no longer defending their practice and losing the ability to draw on their practical wisdom. Such a circumstance, as depicted in Figure 2, weakens the intelligibility of a practice and, consequently, the moral perception of professionals who become influenced by vices and the pursuit of external good. Professionals, due to being unable to exercise their practice with excellence, break with their system of values and lose moral sensitivity as an effect of moral distress, resulting in deprofessionalization.

The development of moral competence

In summary, the process of moral distress proposed by Ramos et al. ² was further explicated using virtue ethics, in which the process occurs in the context of a practice. Individuals involved in a practice have a narrative history and a purpose (telos) that guide them in every step of the process, especially in moral judgment. It is worth emphasizing that the process described is supported by the formation of moral competence. Ramos et al. ² argue that moral competence is developed throughout life and encourage individuals to acknowledge and face moral problems. In addition, they express that the development of moral competence is bound to pedagogical and professional discourses as important attributes of nursing.

It is possible to explore moral competence development using virtue ethics. Virtue, in general, is the character disposition that allows a person to perform their activity with excellence, since it involves choice of action. ⁴ In this regard, MacIntyre ⁴ believes that virtues are habits can be developed and learned, including both the intellectual virtues and moral virtues. From an Aristotelian perspective, an intellectual virtue is the result of the acquisition of wisdom ²⁴ such as practical wisdom, while moral virtue refers to the exercise of virtues, such as freedom, pleasure, justice, and courage, among others. Intellectual virtue is the result of education that requires the expenditure of time and the acquisition of experiences, while moral virtue is acquired through habit, as in “learning by doing.” ²⁴

The dynamic process of moral distress can lead professionals to self-reflect and criticize professional practice, and therefore, it should not be considered only negatively. Corley ¹⁷ clarifies that moral distress is a source of experience that professionals can use to position themselves in the face of future trouble to avoid distress. Ramos et al. ² also discuss the productivity of moral distress as influencing the development of professionals, since it takes them out of their comfort zone. Thus, although the trigger is a conflict, it can contribute to the construction and transformation of the moral agent. From the perspective of virtue ethics, moral distress can be a source for the development of moral virtues, contributing to the formation of practical wisdom toward internal goods and also to the construction of traditions, since it occurs in conflict. ¹¹ It is important, therefore, to highlight the role of virtues in the development of practices as responsible for guiding the attitudes and behaviors of professionals in pursuing the excellence of the internal good of their practices.

The virtues are acquired human qualities ⁴ that are developed in the narrative histories of professionals, that is, in the processes of socialization and in their relationships with others. Thus, the construction of the moral agent when engaged in a practice involves the relationship among current professionals and those who preceded them, with tradition being a source of learning and also comparison, including the recognition of oneself and of the other, of what one is supposed to do and what one wants to be. ⁴

Final reflections

The explication of Ramos et al.’s ² conceptual framework of moral distress using virtue ethics began with considering the relationship between the concept of practice and moral distress. Such a relationship is revealed when the moral deliberation of nurses is curtailed in developing their practice, due to their inability to act in a way that is consistent with their moral judgments when they are faced with the experience of moral constraints. Moral distress can estrange nurses from the ideals of the profession, leading them at times to abandon the profession. ² This problem requires the development of strategies involving education so that individuals are able to deal with the ethical dimensions while working in healthcare and also develop their virtues. In addition, it is important that institutions work with professional organizations to create appropriate conditions for the practice of nursing. Therefore, studying moral distress goes beyond the measurement and perception of the impact on the lives of professionals, but also involves the profession, institutions, and healthcare systems, since moral distress has broad repercussions when it affects professionals both individually and collectively. From a general perspective, the strategies discussed should focus on the preservation of the moral sensitivity and moral integrity of professionals, through discussion and reflection on their practice, relationships, and working environment, as well as on the training process.

It is worth highlighting that the adoption of virtue ethics as an ethical perspective for Ramos et al. ’s ² conceptual framework aims to broaden the perspective of the complexity of experiences of healthcare professionals, since it is impossible to create a ready model that can cover all possibilities. Therefore, in this analysis, virtues are assumed to be a guide of conduct for a practice, and practical wisdom is assumed to be necessary for moral competence, since the moral agent will make their judgment based on virtues that are appropriate to each situation experienced. Since we are considering the practice of a profession, the internal good is considered to be equal to the telos, as it is not just about a pursuit of a purpose that human beings desire, but about a practice built over time with history and traditions.