Moral Distress, Moral Residue, and the Crescendo Effect

Abstract

First defined by Jameton in 1984 as a phenomenon that occurs when nurses cannot carry out what they believe to be ethically appropriate actions because of institutional constraints, moral distress has recently gained attention as an important problem experienced by multiple healthcare disciplines.1 Although it is not a new topic, recent attention to moral distress (specifically, an article in the New York Times by surgeon Pauline W. Chen, “When doctors and nurses can’t do the right thing,”2 and a fourfold increase in articles on the topic in MEDLINE in the past two years) has highlighted its presence and effect on healthcare providers and on the delivery of healthcare. While the majority of published research has been in nursing journals, current work has expanded to other disciplines, including medicine, psychology, pharmacy, and respiratory therapy.3 It is increasingly clear that moral distress is not solely a nursing issue, but one that potentially influences all healthcare professionals. Jameton described moral distress as having two parts: initial distress and reactive distress.4 Initial distress occurs in the moment, as a situation unfolds (from this point forward, we will use the phrase moral distress to refer to this acute phase). After the situation that elicited moral distress ends, reactive distress (now referred to as moral residue) remains. Hence, moral distress and moral residue are closely related but separate concepts. Thus far, distinctions between the two have largely not been addressed empirically or conceptually; however, the two phenomena have differing characteristics and their interrelationship poses important implications for members of healthcare teams. The aim of this article is to propose a preliminary model that we call the crescendo effect, which describes the interrelationship between moral distress and moral residue. Our intent is to spark debate, encourage further study, and provide additional insight for ethics consultants as they analyze clinical situations. While the crescendo effect model arose from an empirical study of experienced nurses and physicians in a neonatal intensive care unit (NICU),5 mounting evidence from other disciplines and settings indicates that the phenomenon is shared across many specialties. We will provide examples from these sources and settings in this article.