Perspective: The Moral Distress Debate

The debate

Each speaker presented their interpretation of moral distress (MD). Professor Maben chose to re-examine her own doctoral work through the lens of moral distress. Maben et al. (2007) explored newly qualified nurses’ experiences of implementing their ideals over a period of 2 years. She found that nurses qualified with many ideals instilled in them, often from their nursing curriculum, such as patient-centred holistic care, the pursuit of high-quality care and implementation of evidence-based care. Over time, however, the nurses described difficulties enacting their ideals, often due to professional and organisational constraints. Professor Maben wondered whether, in retrospect, these nurses had been experiencing moral distress. She considered the fact that, ultimately, healthcare is complex and there is often uncertainty regarding the right thing to do, and asked whether the problem is one of moral distress or simply the presence of difficult moral dilemmas.

This is something I have been exploring in my own work. One of the most important criticisms in my mind, of Jameton's definition is put forward by Fourie (2015). Fourie (2015) argues that Jameton's definition of moral distress is too narrow, since stating that the nurse must know the right thing to do in order to experience moral distress appears to rule out cases of moral uncertainty as causes of moral distress. Nonetheless, Professor Maben drew attention to the almost inevitable sense in which ideals are thwarted in our complex healthcare system and instead looked to possible interventions. Mentioning the work of Epstein and Delgado (2010) she discussed some of the suggested strategies for addressing moral distress, such as speaking up, building support networks and creating interdisciplinary strategies, all of which can be developed through the use of Schwartz Rounds. Schwartz Rounds were originally developed in Boston, USA to improve patient care by providing emotional support to staff through reflection and facilitated discussion (Maben et al., 2014). Professor Maben is currently conducting a national evaluation of Schwartz Rounds in order to determine whether they improve staff wellbeing and relationships between staff and patients, and enhance compassion and empathy (Maben et al., 2014). Indeed, this was one of the existing strategies that I have highlighted elsewhere with the potential to reduce moral distress (Morley, 2016), as Schwartz Rounds encourage discussion about clinical ethical issues, creating a forum for nurses to put forward their moral viewpoints. The literature suggests that ‘privileged medical understandings and responsibilities’ continue to pervade healthcare decisions and therefore nurses are encouraged to make explicit the values they hold in order to reduce feelings of moral distress (Peter and Liaschenko, 2004; Peter et al., 2014). I caution, however, that before we can begin to find a solution to moral distress, we first need to better understand the way in which it affects nurses in the UK.

As the editor of the international journal Nursing Ethics, Professor Gallagher receives many papers exploring moral distress from around the globe. As such, she has significant insight into existing moral distress research. In Professor Gallagher’s introductory comments, she outlined what she saw as the strengths, weaknesses, opportunities and threats relating to moral distress. She referred to the first definition from Jameton (1984) and a more recent description by McCarthy (2013), who asserts that:

Moral distress is an umbrella concept that describes the psychological, emotional and physiological suffering that may be experienced when we act in ways that are inconsistent with deeply held ethical values, principles or moral commitments (p. 1).

Professor Gallagher also drew upon the work of Johnstone and Hutchinson (2015), who argue that ‘it is time to abandon a flawed nursing concept’. They criticise moral distress for perpetuating two assumptions: first that nurses’ moral judgements are justified and correct, and second, that they are powerless to take action. Professor Gallagher presented some of the challenges that arise from a focus on moral distress including potential ethical impotence and disempowerment, an unreflective research focus and a potential distraction of attention from organisational responsibilities. She argued that the strengths of the concept of moral distress include the following: it draws attention to ethical aspects of care practices; it suggests ethical sensitivity; it highlights challenges to ethical care and can illuminate the relationship between individual behaviour and organisational culture (particularly when correlated with ethical climate). Moral distress engages international scholars and researchers and draws attention to the importance of ethics as applied to nursing and care more generally. Professor Gallagher argued that, despite the challenges of moral distress, it remains a useful concept and offers opportunities for further research that is inter-professional, interdisciplinary and international. She went on to argue that we should not focus solely on moral distress and we need to widen our lens in order to explore other moral concepts, such as moral residue (the lasting effects of moral distress), moral resilience and moral dilemmas. Ultimately, Professor Gallagher stressed that we need to turn to solution-focused ethics education. She concluded that we need to be wary of quick fixes, that the activity of ethics in care is not fast, and that we must embrace solutions that are long-term as well as ‘slow ethics’ (Gallagher, 2013).

John Paley introduced the concept of narratives in his interpretation of moral distress, arguing that moral distress has a ‘narrative reframing’ function. One example he gave was of understaffing. Paley argued that understaffing is essentially an issue that arises from political or economic issues, but when moral distress is applied the narrative is reframed to one in which the ‘virtuous moral agent is thwarted’. Paley argued that moral distress has come to encompass such a broad range of emotions, circumstances and outcomes that it is not a phenomenon, but rather an ‘expression’ that can be utilised within nursing, and one that has significant problems. He used the recent junior doctors’ strike to illustrate the problem, and potentially negative consequences of using moral distress as a political narrative. The strike could arguably have been framed as an issue of moral distress in which doctors were torn between their obligations to patients and their right to fair pay and working hours. Had they chosen this narrative, Paley argued, then it is likely public support would have been reduced, as the moral distress narrative would have framed the doctors both as passive and ineffective, and as making the problem about them as individuals. Furthermore, Paley argued that the range of situations to which moral distress could be applied is so broad that labelling a phenomenon ‘moral distress’ is too ambiguous to be useful, and any attempt to define or explore it as a singular concept is likely to fail.

In a similar vein, Johnstone and Hutchinson (2015) have critiqued moral distress research for the ongoing narrative of nurses as powerless victims, which Paley (2004) has previously argued is a favourite meta-narrative of suffering within the nursing discourse, as they report that nurses feel under-appreciated and oppressed by medicine. I would argue, however, that nurses do find themselves in a unique role, responsible for navigating their own professional integrity whilst expected to carry out others’ decisions; yet I agree that sometimes such narratives play to the image of nurses as victims. One way in which I have seen this within my own practice is through very sad circumstances. A young patient underwent surgery that went tragically wrong. Much of the nursing team were deeply affected by this case due to both questions regarding the clinical decisions made and the fact that the patient was of a similar age to many of us. The team were offered space to reflect with a clinical psychologist and formal debriefing, yet very few nurses actually participated. The team underwent a very difficult few weeks, caring for the patient day after day, often discussing feelings of powerlessness and anger at decisions made, seemingly without regard for the nursing staff. Although these feelings would be aired in the staff room, very few accepted the support provided, continuing to suffer as helpless victims of a tragic case. Whilst we must continue to narrate nurses’ moral suffering, we must be mindful that in doing so we do not perpetuate powerlessness but work towards finding sources of support that are timely, accessible and appealing.

Professor Lesley Baillie rounded off the speakers’ presentations by bringing the conceptual discussion back to the clinical environment. Professor Baillie wondered whether we face more multifaceted ethical issues in nursing today: the technology available is increasingly complex; we are able to sustain life for longer; there is increasing demand, with high expectations and financial constraints. Drawing upon work by Peter and Liaschenko (2004), the question of whether nurses’ proximity to patients causes higher levels of moral distress amongst the profession was raised. It was widely agreed amongst the panel, and indeed the audience, that moral distress is not only an issue faced by nurses but one that affects all healthcare professionals and is likely also to operate outside of healthcare.

Indeed, research exploring moral distress has expanded to the multidisciplinary team (MDT). Evidence shows that all healthcare professionals providing both direct and non-direct care can experience moral distress (Whitehead et al., 2014). However, there is also some evidence suggesting nurses may experience some of the highest levels of moral distress amongst the MDT. For example, in a study by Allen et al. (2013), advanced registered nurse practitioners reported the highest levels of moral distress, with respiratory therapists reporting the second highest; and in the work of Hamric and Blackwell (2007) and Hamric and colleagues (2012), nurses reported higher levels of moral distress when compared to physicians. This suggests that proximity to patients could affect perceived levels of moral distress. It has also been suggested that nurses’ position in the hierarchy, responsible for carrying out the requests of others yet lacking the authority to make ultimate decisions, could affect perceived levels of moral distress. McCarthy and Deady (2008) suggest that nurses’ position in the hierarchy does indeed expose them to greater ‘moral grief’, dominated by decisions driven by their medical colleagues.

Much of the moral distress research has been conducted in intensive care and critical care areas but Professor Baillie drew our attention to an area of everyday nursing, suggesting that difficulties related to admission and discharge of patients may also cause moral distress. For example, this may occur where there are pressures to move patients to different ward areas at inappropriate times or to discharge patients to other hospitals due to lack of beds. Broadly, these issues relate to the institutional constraints faced in healthcare, which force clinicians to choose between equally undesirable options. Responding to this position, Dr Jonathan Ives, University of Bristol, suggested that perhaps this illustrates a problem in the way in which healthcare students are taught to address ethical dilemmas – the implication being that there is a ‘correct’ answer, or a ‘solution’. In fact, ethical dilemmas are often characterised by the very fact that the choice is between two equally undesirable outcomes and therefore the ‘solution’ is rarely an option that is desirable in itself, yet is the one that we can live with (Ives, 2014).

With this salient reminder that in healthcare difficult decisions often involve choosing between options that are undesirable to all involved, the evening was drawn to a close. Although some people may remain unconvinced about whether moral distress is useful, ultimately the concept draws our attention to the multifaceted nature of the healthcare environment and to the ‘complexity of moral agents acting in dynamic contexts’ (Musto and Rodney, 2015: 7).