Determinants of moral distress in daily nursing practice: A cross sectional correlational questionnaire survey
Introduction
Moral distress consists of negative stress symptoms that occur in situations that involve ethical dimensions and where the nurse feels (s)he is not able to preserve all interests and values at stake (Kälvemark et al., 2004). Changes in the health care system leading to, for instance, an increased number of legal rules, clinical guidelines and protocols, a strong emphasis on accountability, inadequate staffing and job pressure and higher societal demands have been associated with more moral distress (Table 1, Ulrich et al., 2003). Health care organisations may aim to reduce moral distress by helping employees to adequately deal with ethical dilemmas. The objective of this research is to determine individual and job characteristics that are related to moral distress experiences of nursing staff.
Jameton (1984) is often cited as the philosopher and ethicist who introduced the concept of moral distress into nursing practice (e.g. Corley et al., 2001, Corley et al., 2005, Pendry, 2007). According to Jameton moral distress is the painful psychological disequilibrium that results from recognising an ethically appropriate action that is difficult to take because of institutional obstacles such as a lack of time, supervisory reluctance, an inhibiting medical power structure, institutional policy, or legal considerations (Corley et al., 2001). In practice, however, health care workers did not always know the ethically appropriate action (as Jameton suggested), and yet experienced moral distress (Kälvemark et al., 2004). For instance, they also experienced moral distress when they had to make difficult choices between institutional rules and what they thought was morally right. Kälvemark et al. therefore suggested a broader definition of moral distress referring to negative stress symptoms that occur due to situations that involve ethical dimensions and where the health care provider feels not to be able to preserve all interests at stake. So individual and structural factors play a role in moral distress (Pauly et al., 2012).
It is meaningful to distinguish moral distress from emotional distress and other kinds of distress (McCarthy and Deady, 2008). A nurse may, for example, be emotionally distressed while restraining a patient, but is likely to become morally distressed only if the nurse believes that restraining the patient is morally wrong. Similarly a nurse may be stressed because of long working hours but is likely to become morally distressed only when worrying that this impacts negatively on the quality of care. This requires moral reflection, reasoning, and agency. In the literature there is a controversy about the actual meaning of moral distress and to which it is an accurate presentation of wrong doing (see for example Repenshek, 2009). A further elaboration of this controversy is beyond the scope of our study.
Nurses associate moral distress with feelings of frustration, anger and guilt (Wilkinson, 1988). Moral distress affects both their personal life, for example, causing short temper and irritability, and their professional life, for example, leading to difficulty in concentrating, and feelings of ineffectiveness (McClendon and Buckner, 2007). Moral distress is often mentioned in association with decreased job satisfaction, burnout, and nurse turnover (e.g. Hart, 2005, Meltzer and Huckabay, 2004, Pendry, 2007), but there still are limited empirical data that reliably support these assertions (Schluter et al., 2008).
No relationships were found between moral distress and gender (e.g. Corley et al., 2001, Elpern et al., 2005, Meltzer and Huckabay, 2004) and religion (Meltzer and Huckabay, 2004, Van der Arend and Remmers-Van den Hurk, 1999). The relationship with age is not clear, with studies finding negative (e.g. Corley et al., 2005, Kälvemark Sporrong et al., 2006), positive (e.g. Rice et al., 2008) and no relationship between age and moral distress (e.g. Corley et al., 2001, Elpern et al., 2005, Meltzer and Huckabay, 2004). Mixed results were also found in research on the relationship between moral distress and years of professional experience and educational level (e.g. Corley et al., 2001, Corley et al., 2005, Elpern et al., 2005, Meltzer and Huckabay, 2004).
It is concluded that in the available studies moral distress seems not to be related to gender or religion, whereas the relationship with age, years of experience and educational level is still not clear. However, most research on moral distress is descriptive, and still limited knowledge exists about determinants of moral distress.
There are indications that some health care settings more easily trigger moral distress than other settings. Corley et al. (2001) did not find differences in moral distress levels between different kinds of hospitals, but there are some studies that did find a relationship between health care setting and moral distress. Within a hospital, nurses who cared for oncology and transplant patients experienced more moral distress than other nurses (Rice et al., 2008). Community nurses were found to report less moral distress than hospital nurses (Eizenberg et al., 2009) or nurses in psychiatric hospitals (Van der Arend and Remmers-Van den Hurk, 1999).
Few researchers also looked at possible influences of the work environment. Based on a literature review of moral problems experienced by nurses in terminal care, Georges and Grypdonck (2002) concluded that because of a lack of autonomy, nurses are sometimes unable to act in accordance with their own values, which causes moral distress.
There is also evidence that moral distress is influenced by peer support (Schluter et al., 2008), supervision (Magnussen et al., 2002), and ethical climate, that is the nursing staffs’ perception of the way in which the organisation views and handles ethical issues (Corley et al., 2005, Pauly et al., 2009).
So far research on moral distress has often been focussed on what moral distress is, the prevalence of moral distress, and possible individual determinants. Little research has been done on what job characteristics contribute to whether or not a situation causes moral distress and further investigation of the ways job factors contribute to moral distress is needed (Pauly et al., 2009).
The aim of this study was twofold. First, to give insight into nurses’ moral distress in several work settings, in acute as well as chronic care and in inpatient as well as outpatient care. Most previous research on moral distress concentrates on nurses in hospitals, working in acute care or critical care settings (e.g. Corley et al., 2001, Corley et al., 2005, Elpern et al., 2005, McClendon and Buckner, 2007, Meltzer and Huckabay, 2004, Mobley et al., 2007, Rice et al., 2008). The second aim was to explore individual as well as job characteristics that influence moral distress.
The questions were:
- 1.
What kinds of situations are likely to trigger moral distress?
- 2.
Is intensity of moral distress related to job satisfaction?
- 3.
Which individual and job characteristics are associated with intensity of moral distress?
Section snippets
Design and setting
This cross sectional correlational study was based on two datasets:
- (1)
a dataset on individual characteristics and job characteristics of nurses, gathered in the Netherlands in June 2009;
- (2)
a dataset on the frequency and intensity of moral distress, gathered in September 2009.
It was a secondary analysis since the data on individual and job characteristics were originally not gathered to explain moral distress.
Sample
A total of 365 Dutch nursing staff members completed the questionnaires of both datasets. All
Morally distressing situations
Table 2 shows ten situations with the highest mean scores on intensity of moral distress. The most morally distressing situation occurred when a discrepancy was perceived between the wishes of the family and patient. Also the treatment policy of doctors triggered considerable moral distress if the nurse did not agree with it or perceived that the policy was not in accordance with what the patient wanted. Other items reflected the sense of responsibility the nursing staff member had towards the
Strengths and weaknesses of this study
In this study the intensity of moral distress has been measured that may occur when nursing staff members have to deal with a number of interests and values in daily care. This study is one of the first to examine job determinants of moral distress. Another strength of this study is that the intensity of moral distress in different health care settings has been studied. There is only a small amount of research done on long term care, such as nursing homes and home care and from this viewpoint
Acknowledgements
The research on moral distress is financed by the Dutch Centre for Ethics and Health. The Nursing Staff Panel is financed by the Dutch Ministry of Health.
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