The concept of moral distress bears important implications for nurses working in neuroscience settings. Over the past two decades, a growing body of research that explores this concept from a nursing perspective, predominantly in the areas of critical care, (Elpern, Covert, & Kleinpell, 2005; McClendon & Buckner, 2007; Mobley, Rady, Verheijde, Patel, & Larson, 2007), neuroscience (Calvin, Kite-Powell, & Hickey, 2007; Silen, Tang, Wadensten, & Ahlstrom, 2008), and end-of-life decision making (Oberle & Hughes, 2001), has emerged. To date, nursing research has focused primarily on clinical situations that give rise to moral distress, as well as the negative implications of such distress (Corley, 2002; Elpern et al., 2005; Mobley et al., 2007). Although the antecedents and consequences of moral distress continue to be uncovered, the unique attributes of this concept remain ambiguous at best. According to Rodgers, when the defining attributes "of a concept are not clear, the ability of the concept to assist in fundamental tasks is greatly impaired" (Rodgers, 1989, p. 330). The current lack of clarity regarding the attributes of moral distress may reflect the relative fluidity of the concept, as the experience of moral distress is largely context dependent (Hardingham, 2004; Oberle & Hughes, 2001; Wilkinson, 1987). The purpose of this study is to distinguish the defining attributes of moral distress from a nursing perspective through the use of Rodgers' evolutionary model of concept analysis. This analysis will clarify the concept of moral distress, contribute new insights about moral distress to nursing as a whole and to the subspecialty of neuroscience nursing in particular, and enhance advancements in nursing knowledge and practice (Rodgers, 1989).

Data Sources

A comprehensive review of the literature was performed to identify nursing research related to the concept of moral distress. The Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1987 to October week 1, 2009) was searched using combinations of the following key terms: moral distress, nursing, critical care, and neuroscience. Initially, a search of moral distress resulted in 236 documents; this cohort was reduced to 168 when nursing was added as a search term. Combining moral distress, nursing, and critical care further reduced the number of documents to 42. Editorials, non-peer-reviewed journals, literature reviews, and commentaries were excluded. Retrievals without full-text versions available online or through the University of Calgary library catalogue were also excluded. The remaining articles were meticulously reviewed and those that best addressed the concept were chosen (Elpern et al., 2005; McClendon & Buckner, 2007; Mobley et al., 2007). This review also revealed three key authors on the basis of repeated citation; their works were retrieved from the CINAHL database and the most frequently referenced were selected (Corley, 2002; Oberle & Hughes, 2001; Wilkinson, 1987).

Three additional articles were selected from the initial cohort of 168 as a means of better understanding the concept within the broader context of nursing, and to distinguish moral distress from the related concepts of moral residue and moral stress (Erlen, 2001; Hardingham, 2004; Lutzen, Cronquist, Magnusson, & Andersson, 2003). The CINAHL database was then searched using moral distress and neuroscience as search terms. Only three articles were retrieved, none of which met the exclusion criteria described above. The Google Scholar database was then searched using the combined terms: moral distress, nursing, and neuroscience. A total of 2,180 documents were retrieved. Upon ranking the documents by relevance, only five articles pertained explicitly to the topic at hand. Each was critically analyzed and the articles that best addressed the concept were chosen (Calvin et al., 2007; Silen et al., 2008). Eleven journal articles were used in the final analysis.

Method

The evolutionary model of concept analysis was first introduced by Rodgers in 1989 (Rodgers, 1989). She states that clearly defined concepts "promote the organization of experience, facilitate communication among individuals, and enable the cognitive recall of a phenomena that may not be immediately present" (p. 330). Many concepts, including moral distress, are assigned meaning on an individual and informal basis; this reflects the situational and temporal dependence of such concepts and perpetuates their vague character (Rodgers, 1989). The evolutionary model of concept analysis pays heed to the dynamic nature of a concept by providing a method of continual concept refinement, which allows new meanings to be introduced over time (Rodgers, 1989). The activities involved in this approach to concept analysis are as follows (Rodgers, 1989, p. 333):

1. Identify and name the concept of interest.

2. Identify surrogate terms and relevant uses of the concept.

3. Identify and select an appropriate realm (sample) for data collection.

4. Identify the attributes of the concept.

5. Identify the references, antecedents, and consequences of the concept, if possible.

6. Identify concepts that are related to the concept of interest.

7. Identify a model case of the concept.

Individual, informal meanings may be assigned to certain concepts, including moral distress, that reflect their situational and temporal dependence. The evolutionary model of concept analysis recognizes this dynamism.

Rodgers' model of concept analysis aims to uncover the attributes of a concept by calling attention to its common use in current literature, providing a foundation for further inquiry and promoting continual concept development (Johnson, 2007; Rodgers, 1989). The primary assumption underlying this approach is that concepts "are continually subject to change" (Rodgers, 1989, p. 332). This assumption distinguishes Rodgers' model from other models of concept analysis, namely that offered by Walker and Avant (1995), which is a modified version of that offered by Wilson (1963; Lowey, 2008). The Wilsonian approach to concept analysis is grounded in the positivist paradigm, which is rooted in the philosophical teachings of Descartes and Comte (Johnson, 2007; Rodgers, 1989, 2005). Positivism places value on objectivity, logic, and empiricism; it is largely intolerant of the qualitative, subjective, and transcendental (Rodgers, 1989, 2005). The Wilsonian approach to concept analysis assumes that concepts can be rigidly defined, as they are perceived to be static with respect to time and context (Johnson, 2007; Rodgers, 1989). Moral distress is a relatively fluid concept that has temporal and contextual influences (Hardingham, 2004; Oberle & Hughes, 2001; Wilkinson, 1987). It demands a qualitative lens of inquiry to attain a true appreciation for its richness and complexity. On the basis of the positivist tenants presented above, the philosophical underpinnings of the methods offered by Wilson and by Walker and Avant are incongruent with the nature of this concept. On the contrary, Rodgers' evolutionary model of concept analysis embraces the aforementioned qualities of moral distress and is therefore the most appropriate method to employ when clarifying it.

Definitions and Meanings

The term moral distress is not a word, but rather a phrase that is often given different meanings by different individuals (Hardingham, 2004; Oberle & Hughes, 2001; Wilkinson, 1987). The Merriam-WebsterOnline Dictionary (2011) does not offer a precise definition for this phrase; however, a number of definitions and meanings are offered in the selected literature. These definitions and meanings will be presented below. To add depth to these descriptions, each of the words within this phrase will first be examined separately.

A Definition of Morality

According to the Merriam-Webster Online Dictionary, morality is defined as a moral discourse, statement, or lesson (morality, 2011); the word moral is described as being of or relating to principles of right and wrong behavior (moral, 2011). The Online Etymology Dictionary states that moral pertains to character or temperament (circa 1340); it is traced to the Latin term moralis, meaning the proper behavior of a person in society (moral, 2010); furthermore, it implies conformity to established sanctioned codes or socially accepted notions of right and wrong human conduct (Beauchamp & Childress, 2001; moral, 2011). This term is frequently used when addressing basic tenets of nursing practice. For example, Lutzen et al. write that "nurses are aware of patients' vulnerability[horizontal ellipsis]and feel a moral responsibility to provide care that is in the best interest of the patient" (Lutzen et al., 2003, p. 313). For this reason, the practice of nursing is often referred to as moral work (Corley, 2002; Lutzen et al., 2003; Storch & Kenny, 2007). Surrogate terms include virtuous, righteous, noble, and ethical (moral, 2011). Virtuous implies moral excellence in character and conduct; righteous stresses guiltlessness or blamelessness and often suggests sanctimonious; and noble implies moral eminence and freedom from anything petty, mean, or dubious in conduct and character (moral, 2011).

Whereas a number of authors use the terms moral and ethical interchangeably (Hamric & Delgado, 2009; Oberle & Hughes, 2001; Storch & Kenny, 2007), I will demonstrate that these terms are distinct yet intimately tied. Beauchamp and Childress (2001) suggest that ethics is a generic term used to describe "various ways of understanding and examining the moral life" (p. 1). Ethics is described etymologically as the science of morals (1,602), from the plural of the Middle English term ethik, meaning the study of morals (1,387), which can be traced to the Greek term ethike philosophia, meaning moral philosophy (moral, 2010). The Merriam-Webster Online Dictionary suggests that the word ethical implies the involvement of more difficult or subtle questions of rightness, fairness, or equity than would be associated with the word moral (moral, 2011). For the purposes of this article, moral refers to the socially accepted principles of right and wrong human conduct, and ethics refers to the study of these principles.

The Meaning of Distress

Distress is defined as a state of great pain or suffering affecting the body, a bodily part, or the mind (distress, 2011). This word is etymologically rooted in the Old French term destresse (circa 1280), from Gallo-Romance districtia, meaning restraint or affliction (distress, 2010). It implies an external and usually temporary cause of great physical or mental strain and stress (distress, 2011). Distress is frequently used in illness narratives, for example, "I was in great distress after being diagnosed with cancer." Surrogate terms include suffering, agony, anguish, misery, pain, torment, torture, tribulation, and woe (distress, 2011). Suffering implies a conscious endurance of pain or distress; misery stresses the unhappiness associated with loss; and agony is suggestive of a pain too intense to be borne (distress, 2011). Near antonyms include comfort, consolation, and solace; alleviation, assuagement, ease, and relief; peace and security (distress, 2011).

Tracing the Description of Moral Distress Over Time

Jameton (1984) first defined moral distress as the suffering that ensues when the right course of action is known but cannot be carried out because of institutional constraints. Building upon this definition, Wilkinson (1987) described moral distress as "the psychological disequilibrium and negative feeling state experienced when a person makes a moral decision but does not follow through by performing the moral behavior indicated by that decision" (p. 16). Webster and Baylis (2000) further developed this definition, suggesting that moral distress arises when an error in judgment, a personal failing, or some external and uncontrollable circumstance prevents an individual from doing the right thing.

Uses of the Concept: A Literature Review

The hallmark definitions offered by Jameton (1984), Wilkinson (1987), and Webster and Baylis (2000) continue to guide nursing research in the area of moral distress. Although understandings of this concept have evolved over time, these definitions now appear timeless when viewed within the context of more recent nursing literature. In this section, current uses of the concept of moral distress will be presented with reference to the selected literature. In addition, the continued influence of each hallmark definition will be highlighted throughout.

It is most appropriate to begin this review by discussing the research contributions of Wilkinson herself. In her magnum opus, Wilkinson (1987) offers her revised definition of moral distress and argues that moral distress threatens the delivery of good patient care. Using a constant-comparative, phenomenological approach, Wilkinson investigated the experience of moral distress among staff nurses working in tertiary care settings, hoping to uncover the relationship between moral distress and the quality of nursing care delivered. She found that moral distress occurs most frequently in situations involving the prolongation of life in dying patients, the infliction of harm or inability to reduce pain and suffering, and the dehumanization of patients (Wilkinson, 1987). Powerlessness and conflicting loyalties were identified as key contributors to moral distress in nursing (Wilkinson, 1987). Anger, frustration, and guilt were predominantly associated with the experience of moral distress (Wilkinson, 1987). Moral distress was shown to negatively affect physical well-being, personal relationships, job satisfaction, and self-worth (Wilkinson, 1987). Although the impact of moral distress on patient care was not clearly ascertained, this investigation led to the development of a moral distress model (Wilkinson, 1987); furthermore, it brought awareness to the concept and laid the foundation for further work in the area.

The definitions of moral distress offered by Jameton (1984) and Wilkinson (1987) are by and large the most frequently referenced with respect to the selected literature. Utilizing these definitions, Elpern et al. (2005) evaluated the extent to which moral distress was experienced by nurses working in a medical intensive care unit. In this exploratory, descriptive, nonexperimental, questionnaire study, the authors identified situations that gave rise to significant moral distress (Elpern et al., 2005). They also examined the consequences of morally distressing experiences and investigated the relationship between moral distress and demographic characteristics (Elpern et al., 2005). Situations involving the provision of heroic interventions to save terminal and dying patients were associated with the highest levels of moral distress (Elpern et al., 2005). Feelings of anger, anxiety, depression, powerlessness, and hopelessness characterized the experience of moral distress among participants (Elpern et al., 2005). Physical symptoms and changes in job satisfaction, self-image, spirituality, and health-related behavior were attributed to moral distress (Elpern et al., 2005). A positive correlation between moral distress and years of nursing experience was also found (Elpern et al., 2005). Many of these findings are in agreement with those offered by Wilkinson and are further substantiated by the research of McClendon and Buckner (2007), as well as Mobley et al. (2007).

McClendon and Buckner (2007) employed a mixed methods approach to study how critical care nurses describe moral distress. Drawing from the American Association of Critical Care Nurses' definition of moral distress, which is reminiscent of those offered by Jameton (1984) and Wilkinson (1987), the personal and professional implications of moral distress were examined (McClendon & Buckner, 2007). Methods of coping with morally distressing situations were also identified (McClendon & Buckner, 2007). Again, the continuation of aggressive treatment in patients who would not likely benefit was most frequently linked to moral distress (McClendon & Buckner, 2007). In addition, the authors found that moral distress can be detrimental to family relationships and professional performance, culminating in a loss of focus, reduced patience, and burnout (McClendon & Buckner, 2007).

The morally distressing situations described by Wilkinson (1987), Elpern et al. (2005), and McClendon and Buckner (2007) speak directly to the notion of futile care. The American Medical Association Council on Ethical and Judicial Affairs (1999) describes futile care as that which involves aggressive treatment to sustain life in individuals that are not likely to survive or achieve a successful outcome. Mobley et al. (2007) prospectively examined the relationship between moral distress and perceptions of futile care among critical care nurses using a cross-sectional survey. Their results suggest that moral distress is most often preceded by incidents of futile care (Mobley et al., 2007). Futile care was perceived by 66% to 89% of participants, and the frequency with which it was perceived increased with participant age, years in critical care, and years of nursing practice (Mobley et al., 2007). Support groups, collaboration between healthcare providers, and educational programs related to the management of distressing situations emerged as important strategies to alleviate moral distress and perceptions of futile care in nursing (Elpern et al., 2005; McClendon & Buckner, 2007; Mobley et al., 2007; Wilkinson, 1987).

Medical futility and end-of-life care are intimately tied and represent unique circumstances that can potentiate moral distress. Using a qualitative, descriptive approach based on grounded theory methodology, Oberle & Hughes, (2001) explored doctors' and nurses' perceptions of ethical problems related to end-of-life decisions. This investigation shed light on the relationship between moral distress and powerlessness, which was initially introduced by Wilkinson (1987) and later clarified by Elpern et al. (2005). The authors also provided evidence to support that moral distress is associated with the inability to reduce pain and suffering (Oberle & Hughes, 2001). In addition, uncertainty and competing values emerged as important qualities of moral distress in nursing (Oberle & Hughes, 2001).

In a similar study conducted by Calvin et al. (2007), perceptions of end-of-life care among critical care neuroscience nurses were investigated. The conclusions offered by Calvin et al. (2007) support many of those offered by Wilkinson (1987), relating moral distress to patient dehumanization, powerlessness, and conflicting loyalties. Advocacy was identified as an important nursing role that is complicated by perceptions of powerlessness and conflicting loyalties in morally distressing situations (Calvin et al., 2007). Feelings of frustration, helplessness, and uncertainty were found to characterize the experience of moral distress (Calvin et al., 2007).

Silen et al. (2008) examined the experience of workplace distress and ethical dilemmas in neuroscience nursing; they argue that neuroscience nurses must be particularly proficient in managing life-threatening situations, rehabilitation, and long-term palliative care. Although the focus of their study was not on moral distress specifically, the concept of moral distress emerged upon inductive analysis of qualitative interviews (Silen et al., 2008). Drawing from the definition of moral distress offered by Jameton (1984) and the research contributions of Wilkinson (1987), the authors described the physical manifestations of moral distress, as well as the associated feelings of frustration and worthlessness (Silen et al., 2008). Institutional factors were brought to the forefront as key contributors to moral distress in neuroscience nursing (Silen et al., 2008).

Hardingham (2004) refers to the work of Jameton (1984) and Webster and Baylis (2000) to distinguish moral distress from the related concept of moral residue. She also calls attention to the institutional factors that can foster moral distress in nursing, arguing that these factors impede autonomous nursing practice and professional integrity (Hardingham, 2004). The notion of the moral community is introduced as a method of supporting moral integrity and reducing instances of moral distress and moral residue (Hardingham, 2004). According to Hardingham (2004), the formation of such a community requires a shift in attention toward the social relations that influence power dynamics in healthcare and instigate conflicting loyalties within nursing practice.

A number of nurse scholars and theorists have taken up the concept of moral distress to bring clarity to the complex moral matrix of nursing (Lutzen et al., 2003). As a result, many of the topics covered within this literature review have been revisited and expanded upon. Erlen (2001) explored ethical practice, moral distress, the moral community, and power dynamics in healthcare. She offers new insights about the relationships between moral distress and patient dehumanization, perceptions of powerlessness, conflicting loyalties, advocacy, competing values, and institutional factors (Erlen, 2001). Lutzen et al. summarized the works of Jameton (1984) and Wilkinson (1987) when distinguishing the concept of moral stress from that of moral distress. Interestingly, powerlessness, institutional factors, and moral sensitivity emerged as important preconditions to moral stress (Lutzen et al., 2003). Corley (2002) offers a theory of moral distress that is largely informed by Jameton and Webster and Baylis (2000). She explores nursing as a moral endeavor, highlighting many of the attributes, antecedents, and consequences of moral distress to be described herein (Corley, 2002). Corley (2002) addresses the related concepts of moral residue, moral integrity, and moral sensitivity; she also identifies strategies to minimize moral distress at both the personal and the institutional level (Corley, 2002). Corley's (2002) moral distress model was integral in crafting this analysis.

Attributes of Moral Distress

By analyzing, synthesizing, and critiquing the selected literature, four comprehensive attributes were formulated to describe the concept of moral distress: negative feelings, powerlessness, conflicting loyalties, and uncertainty. A number of secondary attributes were also identified: ineffective advocacy, the inability to reduce pain and suffering, patient dehumanization, and competing values. These secondary attributes will be addressed within the broader context of the four comprehensive attributes.

Negative Feelings

Anger, frustration, and guilt are the predominant negative feelings associated with moral distress (Calvin et al., 2007; Elpern et al., 2005; Oberle & Hughes, 2001; Silen et al., 2008; Wilkinson, 1987). According to Wilkinson (1987), feelings of anger and frustration often arise during resuscitation events; feelings of guilt arise when the truth is withheld from patients. One nurse declared, "I was really angry and very frustrated[horizontal ellipsis]I felt real guilty, too. I kept thinking, 'Do I need to push this. What will be the outcome if I don't? Will the child live?'" (Wilkinson, 1987, p. 22). Subsequent research revealed that feelings of anxiety, depression, hopelessness (Elpern et al., 2005), worthlessness (Silen et al., 2008), sadness, and helplessness (Calvin et al., 2007) also accompany the experience of moral distress.

Powerlessness

Owing to the hierarchical structure of healthcare, nurses often occupy a position of powerlessness and are increasingly susceptible to moral distress (Erlen, 2001; Oberle & Hughes, 2001; Wilkinson, 1987). According to Erlen (2001), powerlessness in nursing reflects the longstanding power imbalance between doctors and nurses and between men and women. Although great strides have been made toward autonomy in nursing and gender equality, this unjust power structure remains (Erlen, 2001). Consequently, many fundamental nursing roles are violated, including that of patient advocate (Corley, 2002; Erlen, 2001; Oberle & Hughes, 2001). Nurses often see themselves as ineffective patient advocates, as they are not able to influence decision-making processes and instigate change within their institutions (Corley, 2002; Erlen, 2001; Oberle & Hughes, 2001). One nurse explains that "it is extremely difficult to be in a situation you know is hopeless, but all available measures are being implemented to prolong a patient's life and you're powerless to do otherwise" (Elpern et al., 2005, p. 528).

Nurses' perceptions of powerlessness can exacerbate the negative feelings associated with moral distress and are often related to the inability to reduce pain and suffering (Elpern et al., 2005; Wilkinson, 1987). This notion is illustrated in the following excerpt: "We're very frustrated. I think we hurt a lot for the patients. It doesn't matter what we tell most of the physicians, about the pain or suffering[horizontal ellipsis]about how miserable they are with all the treatments they're getting, etc. It's almost like it's falling on deaf ears" (Oberle & Hughes, 2001, p. 711).

In addition, nurses may feel powerless when forced to treat patients as objects rather than holistic beings (Erlen, 2001; Wilkinson, 1987). In recounting one such scenario, a nurse describes a man that was nearly a century old, "he would probably have gone in peace and would not have had to spend his last days this way-he has decubitus, an open sore. He's been on the ventilator, comatose, in this state forever" (Wilkinson, 1987, p. 20).

Calvin et al. (2007) offer a unique but related perspective on powerlessness in healthcare. They suggest that nurses, physicians, family members, and clergy are all powerless when faced with impending death (Calvin et al., 2007). Such powerlessness was expressed by one nurse in stating that "at some point, no matter what we do, nature will finally take over" (Calvin et al., 2007, p. 148).

Conflicting Loyalties

Nurses are primarily accountable to patients; however, they are also accountable to families, nurse colleagues, allied health professionals, physicians, employing institutions, licensing bodies, and society as a whole (Corley, 2002; Erlen, 2001; Hamric & Delgado, 2009; Hardingham, 2004; Wilkinson, 1987). Moral distress arises when the best course of action for a patient is known but cannot be taken, because it conflicts with what is best for any or all of these secondary groups (Corley, 2002; Erlen, 2001; Wilkinson, 1987). Conflicting loyalties and hierarchical processes impede autonomous nursing practice and patient advocacy, thus perpetuating the negative feelings associated with moral distress (Erlen, 2001; Hardingham, 2004; Oberle & Hughes, 2001; Silen et al., 2008). One nurse confessed that staffing shortages and financial restrictions forced her to lower her standard of care, stating that "I can't meet needs the way I used to. It's physically and emotionally impossible, on the majority of my shifts, to meet those needs, which leads to a lot of frustration" (Oberle & Hughes, 2001, p. 711).

Conflicting loyalties may also force nurses to act as mediators, being caught between the competing values of patients and families, patients and physicians, families and physicians, and so forth (Calvin et al., 2007; Oberle & Hughes, 2001). This is increasingly apparent when nurses become involved in end-of-life decisions, which are intrinsically value laden; this is further complicated when patients are unable to speak for themselves (Calvin et al., 2007; Oberle & Hughes, 2001). As vocalized by one respondent, "nurses cry a lot. You're pushed in different directions, and you ask yourself, 'Is this what that person wanted?'" (Calvin et al., 2007, p. 148).

Uncertainty

Uncertainty permeates many end-of-life experiences, prompting considerable deliberation and reflection about the most appropriate actions to take as death approaches (Calvin et al., 2007; Oberle & Hughes, 2001). Decisions related to the initiation, continuation, and termination of life-sustaining interventions rely heavily on outcome predictions, which are of uncertain reliability at best (Oberle & Hughes, 2001). Prognostication is problematic in many disease states; however, it is especially challenging in critically ill neuroscience patients because of a lack of significant empirical evidence in the area (Winslade, 2007). As a result, physicians and nurses are often forced to draw from personal experiences when attempting to predict patient outcome and inform end-of-life decisions. Tensions arise when these predictions differ among healthcare providers. Because of their position within the healthcare power structure, nurses are often not given a voice; consequently, they feel helpless when they believe that wrong decisions have been made (Calvin et al., 2007; Oberle & Hughes, 2001). Nurses frequently experience moral distress in these uncertain end-of-life situations, feeling as though they are contributing to a patient's misery by prolonging their life (Oberle & Hughes, 2001; Wilkinson, 1987). One nurse shared, "it sickens me when we pull out all the stops on a patient who will never have any quality of life"; another added, "I'm scared that I'm causing undue pain and suffering, and this causes me great distress" (Elpern et al., 2005, p. 527).

Related Concepts

Oberle and Hughes argue that the concept of moral distress is unique to nursing. They found that experiences surrounding end-of-life decisions represent moral dilemmas for doctors and moral distress for nurses (Oberle & Hughes, 2001). A moral dilemma occurs when there is an obligation to pursue two or more mutually exclusive courses of action, when there is no obvious reason to prefer one over the other (Hamric & Delgado, 2009; Hardingham, 2004; Oberle & Hughes, 2001). Moral distress, on the other hand, arises when the right course of action is known but cannot be pursued (Jameton, 1984; Wilkinson, 1987).

Hardingham (2004) distinguishes moral distress from the related concept of moral residue. Moral residue is "that which each of us carries with us from those times in our lives when in the face of moral distress we have seriously compromised ourselves or allowed ourselves to be compromised" (Webster & Baylis, 2000, p. 218). When moral distress compromises moral integrity, moral residue develops (Hardingham, 2004). Moral integrity implies a wholeness or conformity between actions and values (Corley, 2002; Hardingham, 2004). On the basis of these definitions, it appears that moral integrity is always compromised in morally distressing situations. The distinction between moral distress and moral residue rests on the understanding that moral distress is an acute emotional response whereas moral residue is a chronic manifestation of this acute emotional response (Hardingham, 2004).

Lutzen et al. (2003) differentiate the concept of moral stress from that of moral distress; they also identify moral sensitivity as an important precondition of the former. Moral stress involves being aware of the moral principles that are at stake and being unable to make a decision that would rectify the conflict between competing principles (Lutzen et al., 2003). On the contrary, moral distress requires an awareness of the morally correct action to take. Moral sensitivity has been described as the intuitive faculty and virtuous capacity that compels an individual to act in the best interest of another (Corley, 2002; Lutzen et al., 2003). It constitutes the ability to recognize moral dilemmas and assess the moral implications of a given action on behalf of vulnerable persons (Corley, 2002; Lutzen et al., 2003). Nursing is thus a morally sensitive act.

Antecedents of Moral Distress

For moral distress to occur, a nurse must demonstrate some degree of moral sensitivity (Corley, 2002). Moreover, there must be a moral conflict, which involves a clashing of values regarding the morally correct action to take (Corley, 2002). Nurses who experience moral distress make a moral decision but cannot act according to that decision (Jameton, 1984; Wilkinson, 1987). Competing values take precedence over the values of the nurse and dictate the actions that he or she will take. This is particularly apparent in situations where futile care is suspected, or when institutional constraints impede the delivery of quality nursing care (Elpern et al., 2005; McClendon & Buckner, 2007; Mobley et al., 2007; Wilkinson, 1987). Medical futility involves the prolongation of life in individuals that are not likely to survive or achieve a successful outcome (American Medical Association Council on Ethical and Judicial Affairs, 1999). These situations are often dehumanizing, causing nurses to feel as though they are inflicting undue pain and suffering (Elpern et al., 2005; McClendon & Buckner, 2007; Mobley et al., 2007; Wilkinson, 1987). Because nurses occupy a position of powerlessness within the hierarchical structure of healthcare, they have few avenues of recourse when forced to engage in futile interventions. Likewise, nurses are seldom able to influence the institutional factors that necessitate a reduction in their standard of care; such institutional factors include policies and procedures, staffing shortages, routines, and economic constraints (Erlen, 2001; Hardingham, 2004; Oberle & Hughes, 2001; Silen et al., 2008). Powerlessness is therefore an attribute and an antecedent of moral distress in nursing. Without the longstanding power imbalance between doctors and nurses, the current struggle for autonomy in nursing would not exist; furthermore, nurses would have a voice.

Consequences of Moral Distress

Moral distress has been shown to affect physical well-being, self-image, spirituality, personal relationships, and job satisfaction (Elpern et al., 2005; Silen et al., 2008; Wilkinson, 1987). Physical symptoms associated with moral distress include heart palpitations, diarrhea, headaches, fatigue, and insomnia (Elpern et al., 2005; Silen et al., 2008; Wilkinson, 1987). A loss of self-worth has also been associated with moral distress, along with changes in religious practices and health-related behaviors (Elpern et al., 2005; Wilkinson, 1987). One nurse explains, "my personality has changed to cynical, suspicious, unhelpful, lacking enthusiasm, unwilling to help others" (Elpern et al., 2005, p. 527). Another confesses, "I no longer donate blood after 'wasting' blood products on patients who are terminal" (Elpern et al., 2005, p. 528). Moral distress can be detrimental to family relationships and professional performance, culminating in a loss of focus, reduced patience, and burnout (McClendon & Buckner, 2007). Elpern et al. suggest that moral distress negatively impacts interactions with coworkers and patients, contributing to a reduction in job satisfaction. Moral distress has also been linked to absenteeism, increasing staff turnover, and low workplace morale, leading to compromised patient care and rising healthcare costs (Meltzer & Huckabay, 2004; Pendry, 2007).

An Exemplar Case in the Form of a Personal Vignette

I arrive on the nursing unit at 7:00 am and glance quickly at the whiteboard where the patient names are listed. On most days, none of these names are familiar to me; however, today my attention is immediately drawn to one name. It is the name of an adolescent girl who was admitted to the hospital nearly six months ago following a single vehicle rollover, which left her with a severe diffuse axonal injury. This type of traumatic brain injury (TBI) is the most common cause of long-term morbidity in the TBI population (Vinters, Farrell, Mischel, & Anders, 1998). Since the time of the accident, she has been resuscitated six times and has undergone three emergency operations to relieve fatal increases in intracranial pressure. One such operation involved the complete removal of her frontal cranial bone, a procedure known as a decompressive hemicraniectomy, leaving her permanently disfigured. It has been 3 weeks since she was last transferred from this unit to a less acute ward. I reckon that deterioration in her condition has prompted her return to one of the critical care neuroscience beds here. Upon receiving report from the night nurse, I learn that cerebrospinal fluid is oozing from her multiple cranial incisions, putting her at high risk for meningitis. I also learn that she is in increasing respiratory distress because of worsening pneumonia. Her mother continues to insist that all life-sustaining interventions be carried out; she is not open to discussing a reduction in her daughter's level of care.

As I stand outside the patient's room I try to envision what she will look like now, some 3 weeks since I have seen her last. I want to believe that she will be alert, that she will make eye contact with me, and that she may even squeeze my hand; but I know that this is highly unlikely. I recall that her status had not improved over the course of her nearly 6-month stay. At the best of times she would grind her teeth, open her eyes to painful stimulation, and abnormally extend all four limbs-a phenomenon associated with poor prognosis (Magee, 2008). At the worst of times she was completely unresponsive, but able to breathe on her own. I reflect on the understanding that the greatest amount of functional improvement generally occurs within the first 6 months after TBI, and that the possibility of regaining independence decreases exponentially thereafter (Marion, 1999). However, at such a young age, her prognosis remains unclear. I resign myself to the idea that she will probably not exhibit neurological improvement today and despairingly enter the room.

She is laying on her right side, facing the door, with the head of the bed slightly elevated. She is like an infant; her head and neck are held in a neutral position by pillows and a hard cervical collar, as she cannot support them herself. Her wrists and ankles are bound by rigid braces to prevent contractures. As I get closer, I can see the cerebrospinal fluid trickling from her cranial incisions beneath the hair that is slowly starting to regrow. Like most adolescent girls, she has braces and her skin is spotted with acne; however, her forehead is deeply sunken-in because of the decompressive hemicraniectomy. I can see the pulse of her damaged brain just below the thin skin where her frontal cranial bone once resided. Upon assessment, I find that she does not open her eyes for me, nor does she abnormally extend her limbs to painful stimulation; she hardly resembles the vibrant young woman I see in her bedside pictures. She is tachypnic, it sounds as if she is drowning in her own respiratory secretions, and her oxygen saturation is struggling to stay above 85%. With the possibility of respiratory failure fast approaching, I find myself in a state of moral distress. I wonder if engaging in life-sustaining interventions is truly in her best interest, if prolonging her life will only prolong her suffering, if aggressive interventions will deprive her of a peaceful end-of-life experience, and if death is a more favorable outcome than living. Does attempting to save her life constitute futile care?

Limitations and Future Directions

Eleven journal articles were chosen to guide this concept analysis; these articles were drawn exclusively from the discipline of nursing. Rodgers (1991) suggests a minimum of 30 journal articles when conducting this type of analysis and encourages that literature be drawn from more than one discipline. To maintain a high level of detail and substantiveness in this analysis, such expectations were not fulfilled. The literature search and selection process employed herein reflects my intention to understand the concept of moral distress in relation to nursing as a whole and in relation to the subspecialty of neuroscience nursing in particular. Despite great efforts to maintain objectivity, it is impossible to bracket all preunderstandings when conducting such an analysis. Therefore, it is not unreasonable to assume that additional attributes may be identified once different articles are examined by different investigators, as each investigator brings unique intentions and preunderstandings to their analyses. In addition, because moral distress is a relatively fluid concept that has temporal and contextual influences, new attributes will emerge as different contexts are explored over time. As a result, this analysis will serve as a starting point for further concept development.

Further research is needed to substantiate our understanding of moral distress in nursing. More specifically, moral distress and the related concepts of moral integrity and moral sensitivity should be investigated in various nursing subspecialties, including neuroscience nursing. Given that this analysis is based on literature from Western society, further research is needed to explore how moral distress is experienced by nurses in other cultures. It will also be important to examine how moral distress is viewed by other allied health disciplines. These initiatives will bring breadth and depth to our understanding of moral distress, beyond that which has been attained to date.

Conclusions and Nursing Implications

This concept analysis explores moral distress from a nursing perspective, demonstrating its fluidity, complexity, and multifacetedness. By calling attention to its common use in the literature, four comprehensive attributes were formulated to describe moral distress: negative feelings, powerlessness, conflicting loyalties, and uncertainty. Ineffective advocacy, the inability to reduce pain and suffering, patient dehumanization, and competing values were identified as secondary attributes. These attributes are not mutually exclusive but intimately related, holding true meaning only when viewed within the context of one another and with respect to the historical and philosophical underpinnings of nursing praxis. This analysis offers clarification, provides new knowledge and insight about moral distress in relation to nursing as a whole, as well as in relation to the subspecialty of neuroscience nursing in particular, and promotes efforts toward continual concept development. Awareness of the attributes of moral distress presented herein will facilitate recognition and validation of personal experiences within the neuroscience nursing community, which may have otherwise gone overlooked. Such awareness is necessary to begin to remedy the antecedents of moral distress, in an effort to minimize its consequences.

References