Why we need to reconsider moral distress in nursing

One of the most discussed phenomenon in nursing ethics is moral distress. Such a pervasive phenomenon, or, as we should soon ask, ‘concept’ is allegedly well established, agreed and assumed in many of the studies investigating nurses' management of ethical dilemmas, conflicts and concerns. It is so much emphasized in the literature and training programs or curriculums that it also enjoys from verified and credible measurement, developed through tools which have been translated and applied in many countries.

However, other than asking ourselves the interesting question of what has contributed to this large (conceptual) acknowledgement and endorsement, it is time for us to thoroughly explore the question of what, exactly, is moral distress? We should then engage in more than repeating its mantric definitions according to which it is the situation when one knows the right thing to do but institutional constrains make it nearly impossible to pursue the right course of action,^1–3 involving, in addition, the experience of negative feelings, ⁴ anguish and suffering. ³ We should ask about its theoretical components, their justifications in being included in such a “concept”, the relationship between them, and their connection to ethical decision-making and its subjective experience by the moral agent.

Defined as a situation of moral constraint, the concept of moral distress assumes that nurses' management of ethical dilemmas and conflicts is passive. It is shaped mostly, if not exclusively, by external factors which, at the end, outweigh nurses' moral agency and capacity to act, if the latter exist at all. As a result of this uneven competition of forces, nurses suffer from serious distress which could also lead to compromised well-being, sub-optimal care and attrition.

Such an assumption must be contested. As more literature develops the ideas of moral resilience ⁵ and critical resilience ⁶ to refer to the positive (and active) capacity to provide a response to moral complexity, to sustain or restore one’s integrity in response to such complexity, and, at times, to resist the external constrains that jeopardize the very nature of the nursing profession, it is imperative to associate these situations not with distress and depletion, but with solutions and possibilities. ⁷ This also calls into emphasis on learning to self-identify, name and frame ethical issues, discuss them (relationally) with others ⁸ and appreciate the different values and attitudes in order to advance one’s moral agency but also – and through - setting limits to one’s moral integrity and professional obligations. ⁹ Most of all, it requires a narrative and conceptual shift: from one that regards nurses as powerless to one that sees nurses as capable and competent to direct themselves and flourish as autonomous moral agents. ¹⁰ These ideas need to be foregrounded in discussions of moral distress.

In recent years, some questions have been raised with regard to the concept of moral distress. ¹¹ Queries have been raised e.g. with regard to whether moral constraint is a necessary condition of moral distress, ¹² whether a direct causal relation should exist between the moral event and the experience of the psychological distress ¹³ and what else is involved in moral distress that it differs from the emotional states of frustration, anger, anxiety etc., which are associated with it? ¹¹

A recent systematic literature review and narrative synthesis of the 20 definitions of moral distress in 34 articles suggests that there is still little agreement as to the conditions that cause moral distress, and their classification as sufficient or necessary. ¹³ It is of no big surprise then that if the concept of moral distress indeed rests on shaky grounds, or, at least, is far than being settled, that reviews of studies referring to it found conflicting findings and inconsistencies in its measurement, as well as problems with its practice environment and conditions. ¹⁴ They also referred to the scientific challenge of evaluating the impact of its various interventions aimed at mitigating it. ¹⁵

Recent calls to abandon the concept of moral distress ¹⁶ or to revise it conceptually ¹⁷ represent some attempts to manage this conceptual gap. After all, it is the natural course of scientific development that models and theories are proposed, tested, and re-planned to better fit those elements they are missing and to adequately respond to their critique. Yet, it seems that the case of moral distress is special and justifies a more thorough investigation than usual. Given its broad influence on the field of nursing ethics, researchers, reviewers and editors must work together to rethink this concept, its premises and consequences. Nursing Ethics should and will lead the journey for this theoretical investigation not just as in light of ethical obligation stemming from its mandate to publish top scientific research in the field, but resulting from its commitment to reflect upon and refine the core constituents upon which the profession and the art of nursing rest.