What is “moral distress” in nursing? How, can and should we respond to it?

Abstract

Interest in moral distress (MD) as a research topic has soared in recent years. What is it about this concept that makes it so intriguing? Why does it create such debate amongst healthcare professionals? Why has there been so much conceptual confusion regarding the concept? And why do nurses, in particular, seem to feel this concept so accurately captures their experiences? These are some of the questions that I have been thinking about over the course of my doctoral studies and I would like to consider here. As it was originally conceived, MD was believed to arise "when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action" (Jameton, 1984, p. 6). On this understanding, all that is required for MD to occur is a moral judgement and the presence of an external constraint which prevents that judgement from being carried out. This notion that nurses are constrained by external forces and are "not free to be moral" (Yarling & McElmurry, 1986, p. 63) has according to critics, such as Paley (2004), perpetuated a favourite metanarrative of nurses suffering within nursing discourse. Others, such as Johnstone and Hutchinson (2015), argue that the entire concept ought to be abandoned because it undermines the process of moral deliberation by perpetuating the notion that nurses' moral judgements are correct and justified. They argue that MD, as it is currently understood (according to Jameton (1984, 1993)), risks nurses failing to nurture the skills required for ethical discussion and damages their integration into moral decision-making because of the "assumed rightness of [their] moral judgements" (Johnstone and Hutchinson, 2015). Indeed, Weinberg (2009) highlights how Jameton's conception of MD fails to acknowledge the possibility that there might not even be a "correct" course of action. So, does Jameton's (1984) conception of MD perpetuate epistemic arrogance, or worse perhaps, epistemic laziness, when it comes to decision-making? Should we, as Johnstone and Hutchinson (2015) argue, abandon the concept of MD altogether? Despite criticism of the concept, the notion of MD continues to attract research attention from healthcare professionals and, in particular, nurses, suggesting that it appeals to individuals lived experiences. I was first drawn to exploration of this phenomenon through my own experiences working as a nurse in the National Health Service (NHS). I was surprised to find a distinct lack of empirical research had been conducted in the United Kingdom (UK). Since Jameton (1984) first defined MD, hundreds of qualitative, quantitative and theoretical studies exploring MD have been published, but very few are from the UK. In a recent review of this literature, Morley et al. (2017) identified twenty key definitions from the extensive MD literature, each made up of various necessary and/or sufficient conditions required for MD to occur (Morley, Ives, Bradbury-Jones, & Irvine, 2017). However, a lack of engagement within the empirical literature with these various suggested definitions of MD has caused conceptual confusion which has complicated attempts to study the phenomenon. For example, there are many studies which purport to measure MD using variations of the Moral Distress Scale, one of the most commonly used measures of MD, but many of these studies use different definitions of MD to underpin their research which makes comparisons between studies problematic. The first aim of my research project was therefore to establish a definition of MD that was plausible within the UK setting. As with other recent theoretical efforts, I argue that Jameton's (1984) original definition of MD needs to be broadened and postulated a definition that comprises three core criteria: This much broader understanding of MD allows for other potentially relevant causes of MD to be captured within the "umbrella" term of MD (McCarthy & Deady, 2008), which can then be further subcategorised, as suggested by Fourie (2015), into, for example, "moral-constraint distress" or "moral-conflict distress." I hypothesize that broadening the definition of MD and subcategorising into these constituent pieces will allow for more specific measurements and targeted interventions to help address MD. Arguably, only once the conceptual fog has cleared can healthcare professionals, researchers and policy-makers can begin to gain further clarity regarding what, if anything, can be done to mitigate MD? Indeed, it has been suggested that MD is simply a natural response to morally troubling experiences that should be welcomed and that getting rid of MD is not only impossible but undesirable (personal communication with Tigard; hinted at in Tigard (2017) and Howe (2017)). MD may be a natural consequence of the messiness of moral life but when one experiences MD everyday due to their occupation, which seems to be the case for nurses and other healthcare professionals, then it may instead