Introduction: peers or ethicists, rely on identifying


Conflicts of one’s morality with external factors
are inevitable, however these conflicts are often at a level that is easily
resolved internally, by accommodation or assimilation, or externally by
successful efforts to change the situation. The phenomenon of moral distress,
the primary focus of this discussion, occurs when these conflicts are not fully
resolvable, and become a threat to one’s moral integrity. Its occurrence has been
described in the medical field, primarily in nurses caring for vulnerable
patient groups such as neonates, the terminally ill, and the elderly, but also
in physicians and other medical professionals.

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of moral distress by care takers can result in mental damage (such as feelings
of guilt, pain, and suffering), lack of job satisfaction, and higher turnover
rates in the field (2,3,9). Moral distress in the medical field has been
posited as a risk factor for not only care providers but also patients, with
warnings that care provider stress could lead to callousness or aversion
towards patients’ or their needs (2,3). It has further been used to explain the
potential danger of the erosion of “care providers’ moral integrity, resulting
in desensitization to the moral aspects of care”, and the impairment of care
providers’ ability to be compassionate (5).


of definition and perspective:

Many methods of attempting to resolve
moral distress, whether by individual introspection, or seeking discussion with
peers or ethicists, rely on identifying when moral distress is being
experienced. To do this, a clear understanding and definition of what
constitutes moral distress is necessary. Furthermore, any definition will have
a clear impact on how the topic is perceived and how it should be approached.
The question at hand is: how should moral distress be defined and perceived in
the context of efforts to manage and resolve it?

Moral Distress:

            The first step in attempting to
manage moral distress is how to define it clearly and identifiably, in a way
that it can be properly addressed. Many of the techniques for individuals to
tackle morally distressing situations, or to seek help, rely on identifying
when there is ethical conflict, and examining why this is distressing on a
case-by-case basis (10,11). However, this can be confusing as the definition of
moral distress has undergone gradual change and broadening over the years, and
remains a divisive topic.

Early writers on the topic distinguished
moral distress from feelings arising from moral

or purely emotional distress, describing it as “negative feelings that arise
when one

the morally correct response to a situation but cannot act accordingly” (1).

the correct course of action is unknown, or where emotional distress is
salient, but without

moral component, were omitted.

Many writers draw a line between moral
distress and ethical dilemmas because in an ethical dilemma, there are “two or
more ethically justifiable but mutually opposing actions that can be taken… both
of which are ethically justifiable, and neither of which is optimal”, implying
that there is uncertainty in the correct decision, as opposed to the assumption
of confidence in an ethical course of action based on an individual’s sense of
morality (10). Therefore, what may be a morally distressing situation to one
person, may not be for another. Instead of discussing ethical elements, early writing
on moral distress focused on the “identification of social and organization
issues, and questions of accountability and responsibility” (10). This is
closely tied to the history of moral distress, which was first identified in
nurses in a frequently cited work from 1984 by Jameton (10,12). Moral distress
in nursing has been the most well documented in the medical field, where constrains,
such as conflicts with institutional policy and physician orders, tackled in
the context of the autonomy of nurses and role relationships, are commonly
found (10,12).

One of the most frequent scenarios,
leading to moral distress in nurses, is in end-of-life care, with the
appearance of two predominant scenarios. One scenario is where a nurse
disagrees with the treatment plan. Usually this is because he or she feels a
treatment is futile, improper, or will contribute to unnecessary suffering of
the patient, but reverse is also possible, where he or she may feel that not
enough is being done for the patient. The other is from reports of distress
when patient condition fails to improve despite best treatment efforts, and
thoughts of futility emerge (4). This calls into question the initial
definition of moral distress as arising when the right course of action is
known but cannot be acted on. Rather, this scenario is where the perceived
right course of action was known and was acted on, but ultimately failed. Both
scenarios are closely linked in that the experiences of futile treatment were likely
necessary for a nurse to oppose the action in a future case, and that moral
distress is perhaps not truly realized until a nurse acts against his or her
moral beliefs and then observes a negative outcome to reinforce the initial
distress. Feelings of powerlessness and frustration appear to pervade the moral
distress discussion.

Feeling and morality are inseparable in
discussing moral distress, as all moral distress has an emotional distress
component, although the converse is not true. Individuals’ feelings about what
is right or wrong are generally reflective of their beliefs in what is right or
wrong, but whether the emotional or moral aspects dominate response is unclear.
Due to the complex nature of moral distress, and reliance on self-reporting in
studies, characterization of moral distress in terms of emotional outcomes such
as feelings of frustration, anger, guilt, and sadness has been inevitable (7),
especially in cases were observations are made based on data collection not
aimed specifically at obtaining reports of moral distress. As such, uncoupling
moral distress from emotional distress proves to be challenging. Whether
emotional distress alone could have resulted in the same reports of patient
aversion, burn-out, loss in job satisfaction, and desire to leave the profession
as reported in moral distress cases is worthy of study, and should be
considered when attempting to address drops in medical professionals’ welfare
and functionality.


Moral Distress:

            The assumption of a clear ethical
course of action, for there to be moral distress, strongly limits the
experience to a narrow range of cases. A broader view can be seen by looking beyond
the field of nursing, where the definition of moral distress sometimes exists
in stark contrast to these definitions. In an article published in the journal
Business Horizons, moral distress is described as discomfort felt when being
forced to confront ethical dilemmas, stating that it is not about ‘right versus
wrong’ but “right v. right” (11). The goal of the article is to outline a
step-by-step process to assess and resolve ethical dilemmas defensibly and in a
manner, that minimizes the potential for personal regret (11). The authors
describe a 5-step process: “pay attention to your gut, gather the facts, engage
your moral imagination, interrogate your options, act and review” (11).
Ignoring for a moment the key difference in definition, one of the most
powerful perspectives taken in the article is that an individual can consider
many options and act on them, instead of feeling that they are forced into one
singular action. This is not to say that, in the case of nursing, that a nurse
should make a unilateral decision on patient care, but that they should
introspect on why they may ultimately desire to override a gut feeling that
what he or she is doing may be wrong, or to consider other options and maintain
a mindset of being able to choose a course of action.   

Yet unmentioned, is how an ethical course
of action is decided on. This requires narrowing of the topic to the field of
nursing, where moral distress is more specifically thought to occur “when the
nurse knows what is best for the patient but that course of action conflicts
with what is best for the organization, other providers, other patients, the
family, or society as a whole” (10). From this we can see that moral distress
is closely tied to the role of nurses as patient advocates, however is
necessarily viewed through personal senses of morality and proper care. This
and other views of moral distress as stemming from pitting one’s moral values against
external factors, such as the interests of other parties, is additionally
problematic as it fails to consider that these other parties are likely to also
be trying to act in an ethical and morally congruent manner, therefore
consideration of moral distress in the context of an ethical dilemma is
seemingly necessary to the discussion. This is perhaps most striking when the
decision of a patient, or their surrogate decision maker, conflicts with a
nurse’s personal perspective, from which the moral nature of the distress is

Perhaps more salient is the fact that
decisions regarding patient care are not solely dependent on a moral interest
in a patient’s wellbeing, but include considerations to efficacy, legality, and
cost, to name a few. These are far reaching external factors that can result in
moral distress, but whose ethics has not largely been considered in moral
distress discussions.


of Moral Distress and the Crescendo Effect:

The evolution of moral distress is an
ongoing process, with successive incidents leading to moral distress not
necessarily being independent of one another. While a single incidence is
distressing, it is insufficient to explain significant changes in attitude
towards patients and towards the field. Given this, there is a need to model
care provider response to successive morally distressing situations over time.
The predominant view on this was described in 2009 by Epison and Hamric in
their paper “Moral Distress, Moral Residue, and the Crescendo Effect” where
they model the phenomenon of moral distress overtime (4). Briefly, it claims
that there is a crescendo (rise) in moral distress levels overtime, explaining
that morally distressing incidents leave behind moral residue that causes
following incidents to be more distressing. While the effects of moral distress
and moral residue are made distinct in these papers, in this paper moral
residue is considered a component of changing moral distress levels and not a
catalyst for change independent of moral distress itself. The crescendo model’s
framework supports the proposition that moral distress leads to job
dissatisfaction and ultimately higher turnover rates, that eventually the
buildup in moral distress becomes too much to handle. It has also been used to
explain the potential danger of the erosion of “care providers’ moral
integrity, resulting in desensitization to the moral aspects of care”, and the impairment
of care providers’ ability to be compassionate (5). This can be seen reflected
in a study of psychiatric nurses experiencing moral distress which found that
nurses employed strategies such as compartmentalizing the problem by adopting
“a dual moral code of behavior: one for home and one for work”, or distancing
themselves from the problem either intellectually or physically, confirming
worries of a harmful response to moral distress (8). However implicit to this
should be the observation of a diminished moral distress experience.

Responses to moral distress, did not all
follow this trend, however with several reports of

reflection with family or other
trusted confidants. Perhaps most surprising was the observance of several
positive reactions to experiences of moral distress including “taking courses to gain further education or training,
acting professionally, reassuring patients, and empathizing with patients”
suggesting that moral distress can serve as a catalyst for self-reflection,
increased awareness, and improved patient care contrary to the view of moral
distress as inherently harmful (8).

To help better understand the evolution of
moral distress over time, changes in moral distress with practitioner age and
years of experience can be examined. A recent study (2016) of clinical
personnel in 13 ICUs in British Columbia, Canada revealed that moral distress
was lower with older age in non-nurse-non-physician professionals, but higher
with more years of experience in nurses (7). While a study of physicians in
hospitals affiliated with medical science universities (2014) found moral
distress was lower with both age and years of experience among surveyed
physicians (6). Together, the findings further suggest that there is not a
broadly generalizable progression of moral distress, and that moral distress
does not necessarily rise over time. Clues into why this is the case are found
in a 2015 study examining moral distress in ICU professionals which concluded
that moral distress was “driven more by the level of disturbance than by the
frequency of disturbances for all professional groups” (7).

Potentially this means that highly morally
distressing situations lead to a crescendo effect, and that less morally
distressing situations lead to a buildup of tolerance and lower reported moral


questions and relevance

            Moral distress is an ongoing
phenomenon of negative feelings by health professionals in the medical field. Current
definitions of moral distress in medicine, particularly in nursing, attempt to
separate it from ethical dilemmas and emotional distress, however this can be
problematic when attempting to identify the experience of moral distress to resolve
it on an individual or small group level. Situations leading to moral distress
are by nature ethically complex, involving conflicts between personal feelings,
morality, professionalism, and obligations to patients. This requires reflection
not only on the morality of the distressed, but how attempts at moral decision
making by others is present. In a morally diverse environment, conflicts are
inevitable and unanimous agreement is unlikely. Conflicts between the multiple
roles of any one individuals means that compromise will need to be a necessary
component of any solution. Increased understanding of the situation and sensitivity
to the view of others is likely to lessen discomfort in morally challenging
situations, however being overly accepting of the existence of moral conflict
could gradually erode individuals’ moral integrity and dampen warning bells
that may need to be sounded in case of unethical or immoral behavior.  

Moral distress, despite being described as
distinct from emotional distress, appears to be disproportionately a very emotional
experience, that disentangling an identifiable impact of harmed moral integrity,
even in moral distress, is very challenging. Even when an individual cannot
clearly identify a moral component to emotional distress, utilizing strategies
and resources targeted at resolving moral distress should still be promoted: not
only because a moral aspect may not initially be evident, but because there is
a need to address the distress regardless, and these techniques have been shown
to ultimately be helpful in resolving negative feelings.

Finally, there exists the question of whether
the attempts at managing moral distress should aim to avoid and/or eliminate it
from occurring, instead of trying to address it after the fact. Regularly
facing morally challenging situations does not necessarily lead to negative
outcomes for care providers and patients. Sophisticated handling of limited
amounts of moral distress has the potential be positive in improving moral
awareness, understanding of moral complexities, and empathy with patients.