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Moral distress in critical care nurses: a phenomenological study Kwisoon Choe, Youngmi Kang & Youngrye Park* Accepted for publication 6 January 2015
Correspondence to Y. Kang: e-mail: [email protected] Kwisoon Choe PhD RN Assistant Professor Department of Nursing, Chung-Ang University, Seoul, Korea Youngmi Kang PhD RN Associate Professor College of Nursing Science, East-West Nursing Research Institute, Kyung Hee University, Seoul, Korea Youngrye Park PhD RN Professor Department of Nursing, Kunsan National University, Kunsan, Korea
*[Correction added on 16 April 2015, after first online publication: the name, title, and affiliation of author Youngrye Park have been corrected.]
C H O E K . , K A N G Y . & P A R K Y . ( 2 0 1 5 ) Moral distress in critical care nurses: a phenomenological study. Journal of Advanced Nursing 71(7), 1684–1693. doi: 10.1111/jan.12638
Abstract Aim. To explore and understand moral distress from the perspective of and as experienced by critical care nurses in Korea. Background. The concept of moral distress among critical care nurses must be more broadly explored using a qualitative approach. Design. Giorgi’s phenomenological research approach was used. Methods. A purposive sampling was used to select 14 critical care nurses. Indepth face-to-face interviews were performed in Korea from March 2012– December 2013. Findings. Five main themes of moral distress emerged: (1) ambivalence towards treatment and care (notably prioritizing work tasks over human dignity, unnecessary medical treatments and the compulsory application of restraints); (2) suffering resulting from a lack of ethical sensitivity; (3) dilemmas resulting from nurses’ limited autonomy in treatments; (4) conflicts with physicians; and (5) conflicts with institutional policy. Conclusion. Staff shortages are aggravated by high staff turnover caused by ethical suffering. The resulting lack of staff can, in turn, give rise to added ethical conflicts as part of a vicious circle, leading to decreased patient satisfaction. Keywords: critical care nurses, moral distress, phenomenological research
Introduction Nurses make morality-based decisions not just in situations concerning life and death, but also in regular, daily issues (Neville 2004). As such, ethics is a major dimension of nursing practice (Kim 2010). Critical care nurses experience frequent moral distress as they face various ethically challenging situations (Corley 2002, Elpern et al. 2005, Kim &
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Ahn 2010). Ethical issues in critical care nurses’ everyday work included end-of-life decisions (e.g. dying with dignity), recognition of the right to privacy, engaging the family in decision-making, assigning/taking on responsibilities in the healthcare team and healthcare access (e.g. limited resources) (Fernandes & Moreira 2012). Critical care nurses care for severely ill patients who are being sustained on a ventilator (Elpern et al. 2005) and unnecessary medical treatments and tests result in high levels of moral distress among critical care nurses (Meltzer & Huckabay 2004, Mobley et al. 2007). Unnecessary medi© 2015 John Wiley & Sons Ltd
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Why is this research or review needed? Moral distress among critical care nurses results in burnout, high turnover and decreased quality of care. A literature review has shown that moral distress among critical care nurses has been insufficiently explored. There is a need to explore and understand moral distress from the perspective of and as experienced by critical care nurses.
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patients (Pendry 2007). Consequently, critical care nurses’ feelings of powerlessness can lead to moral distress (Elpern et al. 2005, Mobley et al. 2007, Pendry 2007). Critical care nurses suffering from moral distress experience burnout, job dissatisfaction and job turnover (Pendry 2007, Rice et al. 2008, Valentine et al. 2011) and ultimately the standard of patients’ care deteriorates (Hamric & Blackhall 2007, Wiegand & Funk 2012). Moral distress among critical care nurses is thus worthy of discussion.
What are the key findings? Critical care nurses experienced ambivalence about prioritizing work tasks over human dignity, unnecessary medical treatments and the compulsory application of restraints. Moral distress resulted from both their own ethical insensitivity and that of co-workers, and from nurses’ limited autonomy in treatments. Moral distress was induced by conflicts with physicians and institutional policy.
How should the findings be used to influence policy/ practice/research/education? The results may help hospital administrators develop and implement strategies and policies capable of reducing moral distress among critical care nurses. Nurse educators may find the study results useful when designing strategies to support nursing students develop good problem-solving skills and the ability to collaborate with other care providers.
cal treatments include those not beneficial to a cure or improving quality of life (e.g. performing unnecessary tests on dying patients, delivery of aggressive treatments to terminal patients, conducting cardiopulmonary resuscitation to prolong life). Most situations that caused moral distress among critical care nurses were related to end of life (Wiegand & Funk 2012). As stress related to ethical dilemmas is considered moral distress (K€alvemark et al. 2004), nurses’ moral distress comes from ethical dilemmas (e.g. critical care vs. unnecessary treatment). For example, Bunch (2001) identified six ethical dilemmas of critical care nurses: end-of-life issues; whether there should be an age limit for coronary surgery; distributing limited resources; resource allocation in terms of better staffing; situations where it more harmful than beneficial to continue treatment; and transferring patients to other facilities. In addition, conflicting role expectations of the organization, physicians and family towards nurses induce moral distress because nurses often lack the autonomy to undertake what they feel is necessary for their
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Background Moral distress is generally defined as the unpleasant feelings when a nurse cannot take an action what he or she perceives as ethically correct because of institutional constraints (Jameton 1984). Due to the limitations in this definition, K€ alvemark et al. (2004) redefined the concept of moral distress as referring to ‘traditional negative stress symptoms that occur due to situations that involve ethical dimensions and where the healthcare provider feels she/he is not able to preserve all interests and values at stake’ (pp. 1082–1083). We used the revised definition (K€ alvemark et al. 2004) while considering Corley’s (2002) theory of moral distress. This theory classifies its impact into three categories: impact on the patient (lack of advocacy and nurse avoids patient), impact on the nurse (suffering) and impact on the organization (high nurse turnover, decreased quality of care and low patient satisfaction). Critical care nurses reported that negative patient consequences of moral distress included suffering, prolonged dying, undignified dying, quantity rather than quality of life, inappropriate care, delayed treatment, prolonged hospitalization, disrespect, unable to be with family and false hope (Wiegand & Funk 2012). Their moral distress is sometimes expressed in terms of stress, burnout, emotional exhaustion and job dissatisfaction (Pendry 2007) and moral distress, compassion fatigue and perceptions about medication errors were correlated (Maiden et al. 2011). As a result, critical care nurses experienced negative emotions, such as frustration, anger, sadness, psychological exhaustion, helplessness, suffering, distress, disappointment, depression and physical exhaustion (Gutierrez 2005, Wiegand & Funk 2012). If nurses do not deal with their moral distress appropriately, they may resign (Nathaniel 2006) because they often recognize that they have little or no power in their institutions and feel that they cannot control the moral distress situation (Ganz et al. 2012). Turnover of critical care nurses is expensive due to recruitment and training costs and has an impact on staff and
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patient satisfaction, quality of care and patient outcomes (Pendry 2007). Previous studies on moral distress in critical care nurses have focused on their perceptions of and responses to moral distress (Gutierrez 2005), including intensity and frequency (Elpern et al. 2005), psychological empowerment (Browning 2013), emotional exhaustion (Meltzer & Huckabay 2004), ethical work environments (Corley et al. 2005, Pendry 2007), structural empowerment (Ganz et al. 2012) and avoidance behaviours (de Villers & de Von 2013). These previous quantitative studies convey some aspects of moral distress, but fail to capture its whole meaning as experienced by critical care nurses from their perspective. Although a qualitative study (Gutierrez 2005) has explored the perceptions of critical care nurses and their responses to moral distress, these findings highlighted moral conflict, moral judgment and moral action rather than moral distress itself. We believe the concept of moral distress in critical care nurses must be explored more exhaustively using a qualitative approach. The study purpose was to examine the concept of moral distress among critical care nurses in Korea and was based on two research questions: ‘How is moral distress experienced in critical care nurses?’ and ‘What kind of moral challenges are connected with moral distress among critical care nurses?’ The study findings will help nurses gain a broader insight into the concept of moral distress and provide a foundation for developing a theory of moral distress.
their units about the study and recommend those who would voluntarily participate. The average age of the sample was 31 years with a range of 24–42 years. The sample had an average of 6.3 years of experience in critical care units (range: 1.1–16 years).
Data collection Qualitative data were obtained from in-depth interviews with 14 Korean critical care nurses. Data were collected between March 2012–December 2013. The authors conducted face-to-face interviews with each participant twice and interviews were conducted either individually or in pairs. To clarify the content of the first interview after the first analysis, participants were met with twice in person and asked to either clarify what was said or respond to additional questions. The interval between the two interviews was about 2–4 weeks. Prior to the interviews, participants were asked to reflect on any moral distress that they might have experienced while working as a critical care nurse. They were asked open-ended questions, such as ‘Can you describe your experiences of moral distress while working as a critical care nurse?’ The interviews were audiotaped with participants’ consent. Each interview lasted from a minimum of one to a maximum of two hours and continued until no new themes were identified. Participants chose the interview venue. With respect to participants’ socio-demographic data, gender, age, job title and years of experience were collected.
The study Data analysis Aim To explore and understand moral distress from the perspective of and as experienced by critical care nurses.
Design A phenomenological research approach (Giorgi 2009) was used to identify and analyse the structure of the experience of moral distress among critical care nurses.
Participants The sample consisted of 14 female critical care nurses from two university hospitals located in Seoul, South Korea; each had at least a year of experience in a critical care unit. Purposive sampling was used to collect qualitative data for the study (Coyne 1997). Head nurses in the critical care units at these university hospitals were asked to inform nurses in 1686
The recorded interview data were transcribed and studied thoroughly to analyse their meaning using phenomenological methodology (Giorgi 2009). While studying the data, significant statements about moral distress were identified and were then combined into meaningful components. Each component was subsequently studied multiple times before participants’ raw data were converted into phenomenologically and psychologically sensitive expressions with imaginative variation in accordance with Giorgi’s (2009) method. Some of these final converted components are ‘Concern over the no resuscitation policy in cases of cardiac/respiratory arrest in the ‘elders,’ ‘Physicians’ indifference towards dying children,’ ‘Refusal of treatment by client’s families due to low socio-economic status or lack of insight,’ ‘Outbursts of clients’ families towards nurses who explain the necessity of therapy,’ and ‘Observing unethical behaviour among colleagues.’ To model the structure of the experience © 2015 John Wiley & Sons Ltd
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of moral distress, these converted components were compared and contrasted and categorized into main themes (e.g. difference in treatment directions among physicians, clients’ families and nurses; a low level of physician ethical competency; moral conflicts among nurses; and observing unethical behaviour among co-workers). Similar subthemes were clustered into main themes related to moral distress.
Rigour To ensure the trustworthiness of phenomenological studies, Giorgi (1997) stressed the importance of bracketing and phenomenological reduction. We tried to bracket past knowledge about moral distress. Thus, we did not concern ourselves with the results of previous studies about moral distress; instead, we listened to what participants said and concentrated on the meanings behind their moral distress experience. For auditability (Hupcey 2010), we tried to match the research questions clearly with phenomenological research design. As ‘it certainly is methodologically and ethically commendable to ask persons who have provided experiential descriptions (through interviews, written accounts and so on) whether the examples or anecdotes derived from these experiential materials are resonant with their original experiences (van Manen 2014, p. 348),’ the results of the data analysis were confirmed by participants and other experienced critical care nurses who had moral distress experience.
Ethical considerations The Institutional Review Board of the Bioethics Committee of the Chung-Ang University approved this study. Participants were informed of the study purpose and process and reminded of their right to withdraw at any time. All participants completed an informed consent form. To safeguard the privacy and confidentiality of participants, each participant was given a number to use in place of her name. Participants understood the significance of the study in terms of improving ethical nursing practice and willingly consented to being interviewed.
Results The moral distress of nurses was expressed through ambivalence towards treatment and care, suffering resulting from a lack of ethical sensitivity, dilemmas resulting from nurses’ limited autonomy in treatments, conflicts with physicians and conflicts with institutional policy. These five themes © 2015 John Wiley & Sons Ltd
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were interrelated in the conceptual understanding of moral distress in critical care nurses and are summarized in Table 1.
Theme 1: ambivalence towards treatment and care Participants reported that they experienced moral distress in treatment and care situations where they felt ambivalent and were unable to respect the human dignity of the patients. Ambivalence towards treatment and care occurred in the following three situations: prioritizing tasks over human dignity, unnecessary medical treatments and compulsory application of restraints. Ambivalence towards prioritizing tasks over human dignity Participants felt uncomfortable when work processes and tasks prevented them from advocating patients’ autonomy or respecting human dignity. For example, participants prepared postdeath paperwork for patients designated as do not resuscitate (DNR) to expedite the procedure. Such situations made nurses feel uncomfortable as they believed that they had processed administrative work without due consideration for human dignity. One nurse shared that she felt gratitude towards the nurse handling the previous shift for finishing the paperwork ahead of time as it reduced her workload. In case of frequent cardiopulmonary resuscitation, some participants felt moral distress resulting from guilt whenever they forgot to mourn or revere the death of patients due to considering the performance of cardiopulmonary resuscitation as an extension of their work, rather than as an act intended to save a life:
Table 1 Moral distress in Korean critical care nurses. Themes
Subthemes
Ambivalence towards treatment and care
Ambivalence towards prioritizing tasks over human dignity Ambivalence towards unnecessary medical treatments Ambivalence towards the compulsory application of restraints
Suffering resulting from a lack of ethical sensitivity Dilemmas resulting from the nurses’ limited autonomy in treatments Conflicts with physicians Conflicts with institutional policy
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K. Choe et al. Very young nurses like DNR statuses because they are so busy . . .
with them, but it is imperative to apply restraints for therapeutic
that does not mean they are ignoring life, but their workload is so
purposes. (Participant C)
heavy that they like DNR itself . . . actually, I felt that I was doing my work rather than feeling pity for the deceased. (Participant A)
Theme 2: suffering resulting from a lack of ethical sensitivity Ambivalence towards unnecessary medical treatments Participants felt ambivalence towards unnecessary medical treatments. Nurses experienced moral distress when unnecessary treatments were given to patients who had a low possibility of recuperation. In the case of older adult patients, nurses’ ambivalence towards care – originating from the belief that it was unnecessary, as the patient’s life expectancy was relatively short – caused moral distress. Participants thought that it would be better if older patients spent their last days at home with their families rather than suffering through unnecessary medical treatments in hospital. This would also benefit family members who would not need to deal with guilt about having been unable to spend time with them before their death. In addition, participants observed the suffering of family caregivers as a result of continued financial difficulties due to the prolongation of the time spent by the patient in the critical care unit: Although we followed the protocol for an 83-year-old male patient with acute respiratory distress syndrome, his saturation was irresponsive to the treatment. In this situation, the physician decided to perform extracorporeal membrane oxygenation (ECMO), but we did not think it would work for the patient. We asked ourselves, ‘Is there any reason why the physician inserted ECMO to prolong the patient’s life?’ (Participant B)
Ambivalence towards the compulsory application of restraints Sometimes, the application of restraints becomes necessary while performing certain procedures, such as intubation, insertion of a central venous pressure monitoring line, or urinary catheter insertion in older adult patients in critical care units. However, unavoidable, critical care nurses could not reduce the guilt resulting from their ambivalent feelings, as they said that the therapeutic purpose of applying restraints had violated the patient’s human dignity, regardless of the fact that the patient had been uncooperative. In addition, participants had psychological conflicts with patients’ families who wanted them to release the patients: When a patient needs to be restrained for special treatments, such as intubation, I feel like it is a violation of human rights. In addition, family members often request us to loosen the restraints, complaining that the patient’s hands are swollen. Sometimes, I agree 1688
Participants experienced ethical anguish when either they or a fellow nurse did not adhere to the principles of standard nursing care, even in situations where they were not expected to lie or give excuses for the behaviour. Participants experienced moral distress when they observed fellow nurses who lacked sensitivity towards ethical care and committed malpractice, or covered up the unethical behaviour of fellow nurses (e.g. attributing her/his mistake to others, ignoring the opinion of younger nurses, or leaving their work to junior nurses): I found that a senior nurse administered the wrong dosage of an inotropic agent. It is quite different mixing three ampules in 500 ml and mixing one ampule in 500 ml. She was indifferent all the time. (Participant D)
Some participants experienced moral distress after realizing that they had acted indifferently in relation to ethical care. The more experienced nurses were, the more they excelled in healthcare provision and the more indifferent they became towards ethical nursing practice. This manifested itself in bitterness when reflecting on their behaviour. Moreover, they felt remorse when treating patients mechanically and with a cool manner. Most participants considered their heavy workload the main cause of ethical insensitivity, although participants’ ethical concerns about patients were influenced by the patient’s age, illness and other extraneous factors, such as the existence of a DNR order. Participants were more empathetic to paediatric patients than to older adult patients and most felt at ease with patients living with DNR orders: To be honest, when a patient was admitted to the unit with a DNR order, we, the nurses, felt less stress. I know it is not right as a professional, but we tend to provide less care to the patient with a DNR. When I was a new nurse, I was not that way. I became less and less interested in patients with DNR. (Participant E)
Theme 3: dilemmas resulting from nurses’ limited autonomy in treatments Participants sometimes experienced moral distress when they were provided with limited autonomy in decision-making during situations where they disagreed with patients’ familial caregivers and/or physicians over a course of © 2015 John Wiley & Sons Ltd
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treatment. Some patients’ family members chose to refuse treatment due to financial hardship or because of the burden of caring for a patient, even if he/she had a high possibility of recovery. The cost of care in the critical care unit is high and families often found it difficult to sustain the expense of extended treatment. In such cases, physicians often agreed to discontinue treatment without trying to convince patients’ families. Participants felt frustrated that they had no control over this situation: Treatment was being administered to a patient with cancer, but the
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ferent to professional ethics, provided incorrect treatment (e.g. physician providing incompetent care, administering medications during a code with no compressions or intubation) to patients, or caused treatment to be delayed due to initially providing the wrong treatment. Participants also felt bitter when doctors displayed excessive confidence in the treatment while downplaying patients’ pain, which was vented on the nurses. Nurses experienced pain when they encountered dishonesty and a lack of perceived responsibility in the physicians:
patient only knew that he had to be admitted due to vomiting and
The doctor gave up on the patient too fast without any consider-
abdominal pain. Family members requested that the patient not be
ation for the value of life. I thought that if the doctor is able to do
informed about his diagnosis. (Participant F)
something then they should; for example, if a patient’s respiration
Physicians sometimes provide patients and their families with incomplete or inaccurate information. In many cases where critical care was no longer required and physicians recommended transfer to a different hospital unit (such as a general care unit or rehabilitation), patients’ families tended to reject the option because intensive care ensured that they did not need to take care of the patient on their own and because medical expenses were quite low due to insurance reimbursement. Participants often felt helpless in such situations. They also experienced ethical conflicts when they were either unable to share their opinions proactively or when their opinions were ignored or not accepted due to their lack of authority. Furthermore, because participants were uncertain about their boundaries of authority and afraid of providing incorrect information, they agonized over how to respond to family members when asked about the patient’s current medical condition or the future direction of treatment: As nursing staff, we cannot help family when an attending physician insists on transferring the patient to a critical care unit. The physician explained to the family that the patient’s condition would be getting better if in intensive care. The patient with liver cirrhosis was in the terminal stage. No, no way for him to be discharged to his home. I am pretty sure that the physician knew it. I don’t understand why he did it. It may depend on the physician’s ethical
pattern is not stable then they would obtain ABGA and administer SOBI (sodium bicarbonate), but the doctors are not proactive in treating patients at all. (Participant H)
Another participant (I) commented as follows: A doctor prescribed an antacid eight times for a patient with chronic renal failure. The patient was likely to receive haemodialysis, so I asked him to give the antacid just once because the antacid could produce toxic effects in the patient. The doctor said, ‘The order is mine, so you have to follow it.’
Even in this situation, where the nurse thought that the physician’s prescription – including the use of unnecessary, expensive drugs for research – was not reasonable, she could not raise her voice and had to accept the prescription.
Theme 5: conflicts with institutional policy Administrative policy that was deemed ethically misguided often caused participants moral distress. In the case of hospital administrative processes, participants suffered from moral distress when the economic benefits to the hospital were prioritized ahead of respecting human life and human rights (e.g. patients were forced to be discharged or transferred without consideration for their condition):
qualification. This is my dilemma, ‘should I tell the family my per-
The patient was homeless and needed to be transferred to another
sonal opinion?’ (Participant G)
facility. We could not guarantee that the patient would be safe during transfer. This has happened a few times when the hospital considered that the patient could not afford to pay medical bills and
Theme 4: conflicts with physicians Ethically misguided behaviour of physicians (e.g. discontinuing treatment when the patient or family is unable to pay or not being truthful with patients) often caused participants moral distress. Participants experienced ethical conflicts when they worked with physicians who were indif© 2015 John Wiley & Sons Ltd
that this would affect the income of the hospital. They forced the patient to transfer. I felt sorry at that time. (Participant J)
Another major conflict that participants experienced was the inability to provide comprehensive care due to staff shortages, which made them feel powerlessness and resentful towards the hospital. The nurses were unconvinced that 1689
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the hospital’s healthcare services were designed to help patients (e.g. delay in providing financial assistance and unavailability of healthcare services or support during weekends). They felt sorry for familial caregivers when it took a long time to issue relevant documents after the patient’s death due to inefficient administrative procedures.
Discussion The experiences of moral distress among critical care nurses in South Korea were explored. Ambivalence towards treatment and care was the first theme to emerge. This form of moral distress is consistent with the findings reported in previous qualitative studies (Gutierrez 2005, Heland 2006, Shorideh et al. 2012, Wiegand & Funk 2012); however, in contrast, participants in this study did not know how to deal with their feelings. Critical care nurses encounter many unethical moments in their profession and this causes them to experience moral conflict between what they want to do and what they have to do. This study revealed that critical care nurses felt ambivalence when they prioritized task completion over patient care. The concept of ambivalence has emerged as a form of moral distress for the first time in this study. Interestingly, while previous qualitative (Gutierrez 2005) and quantitative (Corley 1995, Meltzer & Huckabay 2004, Elpern et al. 2005, Rice et al. 2008, Valentine et al. 2011) research has shown that burnout, job dissatisfaction and turnover are attributable to moral distress, respondents in this study did not relate moral distress to emotional exhaustion and resignation. Rather, these nurses reported that they experienced ambivalence as a result of prioritizing work tasks over human dignity or the advocacy of patients’ rights and that this prevented them from completing their work efficiently. Participants further reported that their moral distress was a consequence of their heavy workload, a suggestion that may be supported by the findings of previous qualitative (K€alvemark et al. 2004) and quantitative (Pauly et al. 2009, Wilson et al. 2013) studies. As was reported, numerous earlier quantitative studies have demonstrated that critical care nurses experience high levels of moral distress when providing treatments that are perceived as unnecessary (Pendry 2007, Rice et al. 2008, Faith & Chidwick € 2009, Radzvin 2011, Haq 2012, Ozden et al. 2013, Wilson et al. 2013). Radzvin (2011) reported that aggressive or unnecessary treatment of terminal patients and the neglect of patient and family autonomy were major sources of moral distress. The third subtheme of ambivalence towards treatment and care – the use of compulsory treatments, such as the compulsory application of restraints – is also 1690
consistent with existing findings among quantitative studies (Meltzer & Huckabay 2004, Elpern et al. 2005, Mobley et al. 2007, Rice et al. 2008, Wilson et al. 2013). The second theme to emerge was suffering caused through the observation of unethical care. This finding is consistent with previous quantitative (Epp 2012) and qualitative (Shorideh et al. 2012) studies. This study revealed that the effects of moral distress on nurses include the development of negative attitudes towards their care recipients. Critical care nurses typically expressed negative ethical aspects rather than positive ones (e.g. demonstrated little motivation exposure themselves to ethical issues that would stimulate ethically critical thinking). Critical care nurses experienced different kinds of distress compared with nurses in other settings, and higher levels of moral distress due to the nature and complexity of their work and the critical condition of their patients (Fernandes & Moreira 2012). It is essential for critical care nurses to be aware of ethical standards, be sensitive to ethical issues, think ethically and take appropriate action. This finding is consistent with Corley’s (2002) moral distress theory as applied to nurses (suffering). The third theme of moral distress drawn from this research was dilemmas resulting from nurses’ limited autonomy in treatments. These results are consistent with those of previous qualitative studies (K€ alvemark et al. 2004, Fernandes & Moreira 2012, Karanikola et al. 2014) in that participants felt frustrated when they were unable to control unethical situations. Main themes identified in the study centred on a lack of collaboration between nurses and physicians in relation to decision-making in patient care and the subsequent negative impact that this has on nurses’ empowerment, the communication between nurses, patients and physicians and nurses’ ability to find meaning in patient and family suffering. As a result of this powerlessness, nurses tend to feel unable to influence the outcome of ethical dilemmas and to prevent themselves from acting unethically (K€ alvemark et al. 2004, Varcoe et al. 2004, Tsaloglidou et al. 2007). This may have resulted in the demonstrated ambivalence among nurses in this study and the increased feelings of guilt resulting from being unable to protect patients’ dignity and act in their best interests. Ethical conflicts with misguided physicians comprised the fourth theme. Radzvin (2011) demonstrated that working with incompetent nurses and physicians interferes with patients’ needs and is a major cause of moral distress among critical care nurses. Intensive care settings often involve situations that call for critical care nurses to overcome interprofessional conflicts on ethical issues. © 2015 John Wiley & Sons Ltd
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The final theme was the identification of conflicts between ethical actions and institutional policies. This finding is supported by existing quantitative studies that show that nurses experience moral distress when staffing levels are deemed ‘unsafe’ (Corley 1995, Varcoe et al. 2004, Radzvin 2011, Ganz et al. 2012, Wilson et al. 2013). Workload and a lack of organizational support are seen as major causes of moral distress among critical care nurses (Wilson et al. 2013) and those in the professional often find themselves torn between the patient and physician (Varcoe et al. 2004). Shorideh et al. (2012) reported that institutional barriers and constraints are one of the themes addressed among clinical nurses and nurse educators in Iran. No negative impacts on the healthcare organization, such as a high turnover of nurses, decreased quality of care, or low patient satisfaction, were identified in this study, which is inconsistent with the findings of earlier qualitative (Gutierrez 2005) and quantitative (Corley 1995, Elpern et al. 2005, Valentine et al. 2011) studies. Participants in this current study did not mention a desire to leave their job, but reported that one of the factors that most affected their ethical distress was a shortage of staff. Consistent with the findings of previous qualitative (Shorideh et al. 2012) and quantitative (Corley et al. 2005, Zuzelo 2007) studies, nurses further attributed their moral distress to nursing administration and hospital policy. Most findings in this study supported Jameton’s (1984) and K€alvemark et al.’s (2004) definitions of moral distress, with an interesting exception; participants in this study sometimes felt moral distress in ethically challenging situations both when they were confident of their actions and when they did not know how to act. This suggests that the definition of moral distress needs to be redefined more broadly to include the cognitive state of nurses. In this respect, K€alvemark et al.’s (2004) concept of moral distress seems more appropriate as it defines moral distress as representing the negative stress symptoms involved in ethical dilemmas.
Limitations This qualitative study had some limitations. Participants were all Korean female nurses and were selected from two university hospitals located in the capital, Seoul. The results should therefore be interpreted cautiously when applying them to other populations. We did not examine the influence of educational background (e.g. degree, ethical education or special training with regard to critical care) on moral distress among participants. The nature of © 2015 John Wiley & Sons Ltd
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qualitative research may make it difficult for other researchers to transfer the results using the same research methods.
Conclusion Five themes of moral distress were identified and the results indicated that moral distress is a common ethical issue among Korean critical care nurses. The findings of this study have implications for policy, education and practice. Participants reported that ethical insensitivity was a primary cause of moral distress. Regarding policy, the results will help hospital administrators develop strategies that reduce the proliferation of moral distress among critical care nurses. For example, increased moral education, such as workshops or seminars for critical care nurses and discussing moral struggling with colleagues and other health professionals through seminars or forums may be helpful to foster collegial relationships and interprofessional collaboration between critical care nurses and other healthcare professionals. In addition, hospital administrators may consider encouraging nurses’ involvement in the development of policies and guidelines of ethical decision-making in unnecessary medical care. In nursing education and practice, nurse educators may find the study results useful to help build strategies that support nursing students to develop good problem-solving skills and collaboration with other care providers. Nurse educators should focus on developing a bioethics curriculum to empower students to cultivate professional ethical awareness and adopt individual ethical values in patient care. Introducing students to different types of scenarios that require ethical decision-making and encouraging their participation may also help to address this issue. Such exercises would enable nursing students to cope with subsequent ethical challenges in their clinical practice.
Funding This research was supported by the Chung-Ang University Research Grant, Seoul, Republic of Korea.
Conflict of interest No conflict of interest has been declared by the authors.
Author contributions All authors have agreed on the final version and meet all of the following criteria [recommended by the International 1691
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Committee of Medical Journal Editors (ICMJE)] (http:// www.icmje.org/recommendations/browse/roles-and-responsi bilities/defining-the-role-of-authors-and-contributors.html):
• •
substantial contributions to the conception, or design of the work; the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content.
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Haq A. (2012) Medical ethics in ICU patients: conflicts and their resolution. Anaesthesia, Pain & Intensive Care 16, 232–236. Heland M. (2006) Fruitful or futile: intensive care nurses’ experiences and perceptions of medical futility. Australian Critical Care 19, 25–31. Hupcey J.E. (2010) Measurement issues in qualitative research. In Measurement in Nursing and Health Research (Waltz C.F., Strickland O.L. & Lenz E.R., eds), Springer, New York, pp. 225–240. Jameton A. (1984) Nursing Practice: The Ethical Issues. PrenticeHall, Englewood Cliffs, NJ. K€alvemark S., H€ oglund A.T., Hansson M.G., Westerholm P. & Arnetz B. (2004) Living with conflicts-ethical dilemmas and moral distress in the health care system. Social Science & Medicine 58, 1075–1084. Karanikola M.N.K., Albarran J.W., Drigo E., Giannakopoulou M., Kalafati M., Mpouzika M., Tsiaousis G.Z. & Papathanassoglou E.D.E. (2014) Moral distress, autonomy and nurse-physician collaboration among intensive care unit nurses in Italy. Journal of Nursing Management 22, 472–484. Kim H.S. (2010) The Nature of Theoretical Thinking in Nursing. Springer Publishing Company, New York, NY. Kim H.R. & Ahn S.H. (2010) Moral sensitivity and moral distress among Korean Hospital nurses. Korean Journal of Medical Ethics 13(4), 321–336. Maiden J., Georges J.M. & Connelly C.D. (2011) Moral distress, compassion fatigue and perceptions about medication errors in certified critical care nurses. Dimensions of Critical Care Nursing 30(6), 339–345. van Manen M. (2014) Phenomenology of Practice. Left Coast Press, Walnut Creek, CA. Meltzer L. & Huckabay L. (2004) Critical care nurses’ perceptions of futile care and its effect on burnout. American Journal of Critical Care 13(3), 202–208. Mobley M.J., Rady M.Y., Verheijde J.L., Patel B. & Larson J.S. (2007) The relationship between moral distress and perception of futile care in the critical care unit. Intensive and Critical Care Nursing 23(5), 256–263. Nathaniel A.K. (2006) Moral reckoning in nursing. Western Journal of Nursing Research 28(4), 419–438. Neville L. (2004) Moral difficulties in nursing practice: reflections on the practice of a nurse educator. Nurse Education in Practice 4, 128–134. € Ozden D., Karag€ ozoglu S. & Yildirim G. (2013) Intensive care nurses’ perception of futility: job satisfaction and burnout dimensions. Nursing Ethics 20(4), 436–447. Pauly B., Varcoe C., Storch J. & Newton L. (2009) Registered nurses’ perceptions of moral distress and ethical climate. Nursing Ethics 16, 561–573. Pendry P.S. (2007) Moral distress: recognizing it to retain nurses. Nursing Economics 25(4), 217–221. Radzvin L. (2011) Moral distress in certified registered nurse anesthetists: implications for nursing practice. AANA Journal 79, 39–45. Rice E.M., Rady M.Y., Hamrick A., Verheijde J.L. & Pendergast D.K. (2008) Determinant of moral distress in medical and surgical nurses at an adult acute tertiary care hospital. Journal of Nursing Management 16, 360–373.
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JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUALITATIVE Shorideh F.A., Ashktorab T. & Beheshti S. (2012) Iranian intensive care unit nurses’ moral distress: a content analysis. Nursing Ethics 19, 464–478. Tsaloglidou A., Rammos K., Kiriklidis K., Zourladani A. & Matziari C. (2007) Nurses’ ethical decision-making role in artificial nutritional support. British Journal of Nursing 16(16), 996–1001. Valentine S., Godkin K., Fleischman G.M. & Kidwell R. (2011) Corporate ethical values, group creativity, job satisfaction and turnover intention: the impact of work context on work response. Journal of Business Ethics 98, 353–372. Varcoe C., Doane G., Pauly B., Rodney P., Storch J., Mahony K., McPherson G., Brown H. & Starzomski R. (2004) Ethical practice in nursing: working the in-between. Journal of Advanced Nursing 45, 316–325.
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de Villers M.J. & de Von H.A. (2013) Moral distress and avoidance behavior in nurses working in critical care and noncritical care units. Nursing Ethics 20(5), 589–603. Wiegand D.L. & Funk M. (2012) Consequences of clinical situations that cause critical care nurses to experience moral distress. Nursing Ethics 19, 479–487. Wilson M.A., Goettemoeller D.M., Bevan N.A. & McCord J.M. (2013) Moral distress: levels, coping and preferred interventions in critical care and transitional care nurses. Journal of Clinical Nursing 22, 1455–1466. Zuzelo P.R. (2007) Exploring the moral distress of registered nurses. Nursing Ethics 14, 344–359.
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Moral distress in critical care nurses: a phenomenological study Kwisoon Choe, Youngmi Kang & Youngrye Park* Accepted for publication 6 January 2015
Correspondence to Y. Kang: e-mail: [email protected] Kwisoon Choe PhD RN Assistant Professor Department of Nursing, Chung-Ang University, Seoul, Korea Youngmi Kang PhD RN Associate Professor College of Nursing Science, East-West Nursing Research Institute, Kyung Hee University, Seoul, Korea Youngrye Park PhD RN Professor Department of Nursing, Kunsan National University, Kunsan, Korea
*[Correction added on 16 April 2015, after first online publication: the name, title, and affiliation of author Youngrye Park have been corrected.]
C H O E K . , K A N G Y . & P A R K Y . ( 2 0 1 5 ) Moral distress in critical care nurses: a phenomenological study. Journal of Advanced Nursing 71(7), 1684–1693. doi: 10.1111/jan.12638
Abstract Aim. To explore and understand moral distress from the perspective of and as experienced by critical care nurses in Korea. Background. The concept of moral distress among critical care nurses must be more broadly explored using a qualitative approach. Design. Giorgi’s phenomenological research approach was used. Methods. A purposive sampling was used to select 14 critical care nurses. Indepth face-to-face interviews were performed in Korea from March 2012– December 2013. Findings. Five main themes of moral distress emerged: (1) ambivalence towards treatment and care (notably prioritizing work tasks over human dignity, unnecessary medical treatments and the compulsory application of restraints); (2) suffering resulting from a lack of ethical sensitivity; (3) dilemmas resulting from nurses’ limited autonomy in treatments; (4) conflicts with physicians; and (5) conflicts with institutional policy. Conclusion. Staff shortages are aggravated by high staff turnover caused by ethical suffering. The resulting lack of staff can, in turn, give rise to added ethical conflicts as part of a vicious circle, leading to decreased patient satisfaction. Keywords: critical care nurses, moral distress, phenomenological research
Introduction Nurses make morality-based decisions not just in situations concerning life and death, but also in regular, daily issues (Neville 2004). As such, ethics is a major dimension of nursing practice (Kim 2010). Critical care nurses experience frequent moral distress as they face various ethically challenging situations (Corley 2002, Elpern et al. 2005, Kim &
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Ahn 2010). Ethical issues in critical care nurses’ everyday work included end-of-life decisions (e.g. dying with dignity), recognition of the right to privacy, engaging the family in decision-making, assigning/taking on responsibilities in the healthcare team and healthcare access (e.g. limited resources) (Fernandes & Moreira 2012). Critical care nurses care for severely ill patients who are being sustained on a ventilator (Elpern et al. 2005) and unnecessary medical treatments and tests result in high levels of moral distress among critical care nurses (Meltzer & Huckabay 2004, Mobley et al. 2007). Unnecessary medi© 2015 John Wiley & Sons Ltd
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Why is this research or review needed? Moral distress among critical care nurses results in burnout, high turnover and decreased quality of care. A literature review has shown that moral distress among critical care nurses has been insufficiently explored. There is a need to explore and understand moral distress from the perspective of and as experienced by critical care nurses.
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patients (Pendry 2007). Consequently, critical care nurses’ feelings of powerlessness can lead to moral distress (Elpern et al. 2005, Mobley et al. 2007, Pendry 2007). Critical care nurses suffering from moral distress experience burnout, job dissatisfaction and job turnover (Pendry 2007, Rice et al. 2008, Valentine et al. 2011) and ultimately the standard of patients’ care deteriorates (Hamric & Blackhall 2007, Wiegand & Funk 2012). Moral distress among critical care nurses is thus worthy of discussion.
What are the key findings? Critical care nurses experienced ambivalence about prioritizing work tasks over human dignity, unnecessary medical treatments and the compulsory application of restraints. Moral distress resulted from both their own ethical insensitivity and that of co-workers, and from nurses’ limited autonomy in treatments. Moral distress was induced by conflicts with physicians and institutional policy.
How should the findings be used to influence policy/ practice/research/education? The results may help hospital administrators develop and implement strategies and policies capable of reducing moral distress among critical care nurses. Nurse educators may find the study results useful when designing strategies to support nursing students develop good problem-solving skills and the ability to collaborate with other care providers.
cal treatments include those not beneficial to a cure or improving quality of life (e.g. performing unnecessary tests on dying patients, delivery of aggressive treatments to terminal patients, conducting cardiopulmonary resuscitation to prolong life). Most situations that caused moral distress among critical care nurses were related to end of life (Wiegand & Funk 2012). As stress related to ethical dilemmas is considered moral distress (K€alvemark et al. 2004), nurses’ moral distress comes from ethical dilemmas (e.g. critical care vs. unnecessary treatment). For example, Bunch (2001) identified six ethical dilemmas of critical care nurses: end-of-life issues; whether there should be an age limit for coronary surgery; distributing limited resources; resource allocation in terms of better staffing; situations where it more harmful than beneficial to continue treatment; and transferring patients to other facilities. In addition, conflicting role expectations of the organization, physicians and family towards nurses induce moral distress because nurses often lack the autonomy to undertake what they feel is necessary for their
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Background Moral distress is generally defined as the unpleasant feelings when a nurse cannot take an action what he or she perceives as ethically correct because of institutional constraints (Jameton 1984). Due to the limitations in this definition, K€ alvemark et al. (2004) redefined the concept of moral distress as referring to ‘traditional negative stress symptoms that occur due to situations that involve ethical dimensions and where the healthcare provider feels she/he is not able to preserve all interests and values at stake’ (pp. 1082–1083). We used the revised definition (K€ alvemark et al. 2004) while considering Corley’s (2002) theory of moral distress. This theory classifies its impact into three categories: impact on the patient (lack of advocacy and nurse avoids patient), impact on the nurse (suffering) and impact on the organization (high nurse turnover, decreased quality of care and low patient satisfaction). Critical care nurses reported that negative patient consequences of moral distress included suffering, prolonged dying, undignified dying, quantity rather than quality of life, inappropriate care, delayed treatment, prolonged hospitalization, disrespect, unable to be with family and false hope (Wiegand & Funk 2012). Their moral distress is sometimes expressed in terms of stress, burnout, emotional exhaustion and job dissatisfaction (Pendry 2007) and moral distress, compassion fatigue and perceptions about medication errors were correlated (Maiden et al. 2011). As a result, critical care nurses experienced negative emotions, such as frustration, anger, sadness, psychological exhaustion, helplessness, suffering, distress, disappointment, depression and physical exhaustion (Gutierrez 2005, Wiegand & Funk 2012). If nurses do not deal with their moral distress appropriately, they may resign (Nathaniel 2006) because they often recognize that they have little or no power in their institutions and feel that they cannot control the moral distress situation (Ganz et al. 2012). Turnover of critical care nurses is expensive due to recruitment and training costs and has an impact on staff and
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patient satisfaction, quality of care and patient outcomes (Pendry 2007). Previous studies on moral distress in critical care nurses have focused on their perceptions of and responses to moral distress (Gutierrez 2005), including intensity and frequency (Elpern et al. 2005), psychological empowerment (Browning 2013), emotional exhaustion (Meltzer & Huckabay 2004), ethical work environments (Corley et al. 2005, Pendry 2007), structural empowerment (Ganz et al. 2012) and avoidance behaviours (de Villers & de Von 2013). These previous quantitative studies convey some aspects of moral distress, but fail to capture its whole meaning as experienced by critical care nurses from their perspective. Although a qualitative study (Gutierrez 2005) has explored the perceptions of critical care nurses and their responses to moral distress, these findings highlighted moral conflict, moral judgment and moral action rather than moral distress itself. We believe the concept of moral distress in critical care nurses must be explored more exhaustively using a qualitative approach. The study purpose was to examine the concept of moral distress among critical care nurses in Korea and was based on two research questions: ‘How is moral distress experienced in critical care nurses?’ and ‘What kind of moral challenges are connected with moral distress among critical care nurses?’ The study findings will help nurses gain a broader insight into the concept of moral distress and provide a foundation for developing a theory of moral distress.
their units about the study and recommend those who would voluntarily participate. The average age of the sample was 31 years with a range of 24–42 years. The sample had an average of 6.3 years of experience in critical care units (range: 1.1–16 years).
Data collection Qualitative data were obtained from in-depth interviews with 14 Korean critical care nurses. Data were collected between March 2012–December 2013. The authors conducted face-to-face interviews with each participant twice and interviews were conducted either individually or in pairs. To clarify the content of the first interview after the first analysis, participants were met with twice in person and asked to either clarify what was said or respond to additional questions. The interval between the two interviews was about 2–4 weeks. Prior to the interviews, participants were asked to reflect on any moral distress that they might have experienced while working as a critical care nurse. They were asked open-ended questions, such as ‘Can you describe your experiences of moral distress while working as a critical care nurse?’ The interviews were audiotaped with participants’ consent. Each interview lasted from a minimum of one to a maximum of two hours and continued until no new themes were identified. Participants chose the interview venue. With respect to participants’ socio-demographic data, gender, age, job title and years of experience were collected.
The study Data analysis Aim To explore and understand moral distress from the perspective of and as experienced by critical care nurses.
Design A phenomenological research approach (Giorgi 2009) was used to identify and analyse the structure of the experience of moral distress among critical care nurses.
Participants The sample consisted of 14 female critical care nurses from two university hospitals located in Seoul, South Korea; each had at least a year of experience in a critical care unit. Purposive sampling was used to collect qualitative data for the study (Coyne 1997). Head nurses in the critical care units at these university hospitals were asked to inform nurses in 1686
The recorded interview data were transcribed and studied thoroughly to analyse their meaning using phenomenological methodology (Giorgi 2009). While studying the data, significant statements about moral distress were identified and were then combined into meaningful components. Each component was subsequently studied multiple times before participants’ raw data were converted into phenomenologically and psychologically sensitive expressions with imaginative variation in accordance with Giorgi’s (2009) method. Some of these final converted components are ‘Concern over the no resuscitation policy in cases of cardiac/respiratory arrest in the ‘elders,’ ‘Physicians’ indifference towards dying children,’ ‘Refusal of treatment by client’s families due to low socio-economic status or lack of insight,’ ‘Outbursts of clients’ families towards nurses who explain the necessity of therapy,’ and ‘Observing unethical behaviour among colleagues.’ To model the structure of the experience © 2015 John Wiley & Sons Ltd
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of moral distress, these converted components were compared and contrasted and categorized into main themes (e.g. difference in treatment directions among physicians, clients’ families and nurses; a low level of physician ethical competency; moral conflicts among nurses; and observing unethical behaviour among co-workers). Similar subthemes were clustered into main themes related to moral distress.
Rigour To ensure the trustworthiness of phenomenological studies, Giorgi (1997) stressed the importance of bracketing and phenomenological reduction. We tried to bracket past knowledge about moral distress. Thus, we did not concern ourselves with the results of previous studies about moral distress; instead, we listened to what participants said and concentrated on the meanings behind their moral distress experience. For auditability (Hupcey 2010), we tried to match the research questions clearly with phenomenological research design. As ‘it certainly is methodologically and ethically commendable to ask persons who have provided experiential descriptions (through interviews, written accounts and so on) whether the examples or anecdotes derived from these experiential materials are resonant with their original experiences (van Manen 2014, p. 348),’ the results of the data analysis were confirmed by participants and other experienced critical care nurses who had moral distress experience.
Ethical considerations The Institutional Review Board of the Bioethics Committee of the Chung-Ang University approved this study. Participants were informed of the study purpose and process and reminded of their right to withdraw at any time. All participants completed an informed consent form. To safeguard the privacy and confidentiality of participants, each participant was given a number to use in place of her name. Participants understood the significance of the study in terms of improving ethical nursing practice and willingly consented to being interviewed.
Results The moral distress of nurses was expressed through ambivalence towards treatment and care, suffering resulting from a lack of ethical sensitivity, dilemmas resulting from nurses’ limited autonomy in treatments, conflicts with physicians and conflicts with institutional policy. These five themes © 2015 John Wiley & Sons Ltd
Moral distress
were interrelated in the conceptual understanding of moral distress in critical care nurses and are summarized in Table 1.
Theme 1: ambivalence towards treatment and care Participants reported that they experienced moral distress in treatment and care situations where they felt ambivalent and were unable to respect the human dignity of the patients. Ambivalence towards treatment and care occurred in the following three situations: prioritizing tasks over human dignity, unnecessary medical treatments and compulsory application of restraints. Ambivalence towards prioritizing tasks over human dignity Participants felt uncomfortable when work processes and tasks prevented them from advocating patients’ autonomy or respecting human dignity. For example, participants prepared postdeath paperwork for patients designated as do not resuscitate (DNR) to expedite the procedure. Such situations made nurses feel uncomfortable as they believed that they had processed administrative work without due consideration for human dignity. One nurse shared that she felt gratitude towards the nurse handling the previous shift for finishing the paperwork ahead of time as it reduced her workload. In case of frequent cardiopulmonary resuscitation, some participants felt moral distress resulting from guilt whenever they forgot to mourn or revere the death of patients due to considering the performance of cardiopulmonary resuscitation as an extension of their work, rather than as an act intended to save a life:
Table 1 Moral distress in Korean critical care nurses. Themes
Subthemes
Ambivalence towards treatment and care
Ambivalence towards prioritizing tasks over human dignity Ambivalence towards unnecessary medical treatments Ambivalence towards the compulsory application of restraints
Suffering resulting from a lack of ethical sensitivity Dilemmas resulting from the nurses’ limited autonomy in treatments Conflicts with physicians Conflicts with institutional policy
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K. Choe et al. Very young nurses like DNR statuses because they are so busy . . .
with them, but it is imperative to apply restraints for therapeutic
that does not mean they are ignoring life, but their workload is so
purposes. (Participant C)
heavy that they like DNR itself . . . actually, I felt that I was doing my work rather than feeling pity for the deceased. (Participant A)
Theme 2: suffering resulting from a lack of ethical sensitivity Ambivalence towards unnecessary medical treatments Participants felt ambivalence towards unnecessary medical treatments. Nurses experienced moral distress when unnecessary treatments were given to patients who had a low possibility of recuperation. In the case of older adult patients, nurses’ ambivalence towards care – originating from the belief that it was unnecessary, as the patient’s life expectancy was relatively short – caused moral distress. Participants thought that it would be better if older patients spent their last days at home with their families rather than suffering through unnecessary medical treatments in hospital. This would also benefit family members who would not need to deal with guilt about having been unable to spend time with them before their death. In addition, participants observed the suffering of family caregivers as a result of continued financial difficulties due to the prolongation of the time spent by the patient in the critical care unit: Although we followed the protocol for an 83-year-old male patient with acute respiratory distress syndrome, his saturation was irresponsive to the treatment. In this situation, the physician decided to perform extracorporeal membrane oxygenation (ECMO), but we did not think it would work for the patient. We asked ourselves, ‘Is there any reason why the physician inserted ECMO to prolong the patient’s life?’ (Participant B)
Ambivalence towards the compulsory application of restraints Sometimes, the application of restraints becomes necessary while performing certain procedures, such as intubation, insertion of a central venous pressure monitoring line, or urinary catheter insertion in older adult patients in critical care units. However, unavoidable, critical care nurses could not reduce the guilt resulting from their ambivalent feelings, as they said that the therapeutic purpose of applying restraints had violated the patient’s human dignity, regardless of the fact that the patient had been uncooperative. In addition, participants had psychological conflicts with patients’ families who wanted them to release the patients: When a patient needs to be restrained for special treatments, such as intubation, I feel like it is a violation of human rights. In addition, family members often request us to loosen the restraints, complaining that the patient’s hands are swollen. Sometimes, I agree 1688
Participants experienced ethical anguish when either they or a fellow nurse did not adhere to the principles of standard nursing care, even in situations where they were not expected to lie or give excuses for the behaviour. Participants experienced moral distress when they observed fellow nurses who lacked sensitivity towards ethical care and committed malpractice, or covered up the unethical behaviour of fellow nurses (e.g. attributing her/his mistake to others, ignoring the opinion of younger nurses, or leaving their work to junior nurses): I found that a senior nurse administered the wrong dosage of an inotropic agent. It is quite different mixing three ampules in 500 ml and mixing one ampule in 500 ml. She was indifferent all the time. (Participant D)
Some participants experienced moral distress after realizing that they had acted indifferently in relation to ethical care. The more experienced nurses were, the more they excelled in healthcare provision and the more indifferent they became towards ethical nursing practice. This manifested itself in bitterness when reflecting on their behaviour. Moreover, they felt remorse when treating patients mechanically and with a cool manner. Most participants considered their heavy workload the main cause of ethical insensitivity, although participants’ ethical concerns about patients were influenced by the patient’s age, illness and other extraneous factors, such as the existence of a DNR order. Participants were more empathetic to paediatric patients than to older adult patients and most felt at ease with patients living with DNR orders: To be honest, when a patient was admitted to the unit with a DNR order, we, the nurses, felt less stress. I know it is not right as a professional, but we tend to provide less care to the patient with a DNR. When I was a new nurse, I was not that way. I became less and less interested in patients with DNR. (Participant E)
Theme 3: dilemmas resulting from nurses’ limited autonomy in treatments Participants sometimes experienced moral distress when they were provided with limited autonomy in decision-making during situations where they disagreed with patients’ familial caregivers and/or physicians over a course of © 2015 John Wiley & Sons Ltd
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treatment. Some patients’ family members chose to refuse treatment due to financial hardship or because of the burden of caring for a patient, even if he/she had a high possibility of recovery. The cost of care in the critical care unit is high and families often found it difficult to sustain the expense of extended treatment. In such cases, physicians often agreed to discontinue treatment without trying to convince patients’ families. Participants felt frustrated that they had no control over this situation: Treatment was being administered to a patient with cancer, but the
Moral distress
ferent to professional ethics, provided incorrect treatment (e.g. physician providing incompetent care, administering medications during a code with no compressions or intubation) to patients, or caused treatment to be delayed due to initially providing the wrong treatment. Participants also felt bitter when doctors displayed excessive confidence in the treatment while downplaying patients’ pain, which was vented on the nurses. Nurses experienced pain when they encountered dishonesty and a lack of perceived responsibility in the physicians:
patient only knew that he had to be admitted due to vomiting and
The doctor gave up on the patient too fast without any consider-
abdominal pain. Family members requested that the patient not be
ation for the value of life. I thought that if the doctor is able to do
informed about his diagnosis. (Participant F)
something then they should; for example, if a patient’s respiration
Physicians sometimes provide patients and their families with incomplete or inaccurate information. In many cases where critical care was no longer required and physicians recommended transfer to a different hospital unit (such as a general care unit or rehabilitation), patients’ families tended to reject the option because intensive care ensured that they did not need to take care of the patient on their own and because medical expenses were quite low due to insurance reimbursement. Participants often felt helpless in such situations. They also experienced ethical conflicts when they were either unable to share their opinions proactively or when their opinions were ignored or not accepted due to their lack of authority. Furthermore, because participants were uncertain about their boundaries of authority and afraid of providing incorrect information, they agonized over how to respond to family members when asked about the patient’s current medical condition or the future direction of treatment: As nursing staff, we cannot help family when an attending physician insists on transferring the patient to a critical care unit. The physician explained to the family that the patient’s condition would be getting better if in intensive care. The patient with liver cirrhosis was in the terminal stage. No, no way for him to be discharged to his home. I am pretty sure that the physician knew it. I don’t understand why he did it. It may depend on the physician’s ethical
pattern is not stable then they would obtain ABGA and administer SOBI (sodium bicarbonate), but the doctors are not proactive in treating patients at all. (Participant H)
Another participant (I) commented as follows: A doctor prescribed an antacid eight times for a patient with chronic renal failure. The patient was likely to receive haemodialysis, so I asked him to give the antacid just once because the antacid could produce toxic effects in the patient. The doctor said, ‘The order is mine, so you have to follow it.’
Even in this situation, where the nurse thought that the physician’s prescription – including the use of unnecessary, expensive drugs for research – was not reasonable, she could not raise her voice and had to accept the prescription.
Theme 5: conflicts with institutional policy Administrative policy that was deemed ethically misguided often caused participants moral distress. In the case of hospital administrative processes, participants suffered from moral distress when the economic benefits to the hospital were prioritized ahead of respecting human life and human rights (e.g. patients were forced to be discharged or transferred without consideration for their condition):
qualification. This is my dilemma, ‘should I tell the family my per-
The patient was homeless and needed to be transferred to another
sonal opinion?’ (Participant G)
facility. We could not guarantee that the patient would be safe during transfer. This has happened a few times when the hospital considered that the patient could not afford to pay medical bills and
Theme 4: conflicts with physicians Ethically misguided behaviour of physicians (e.g. discontinuing treatment when the patient or family is unable to pay or not being truthful with patients) often caused participants moral distress. Participants experienced ethical conflicts when they worked with physicians who were indif© 2015 John Wiley & Sons Ltd
that this would affect the income of the hospital. They forced the patient to transfer. I felt sorry at that time. (Participant J)
Another major conflict that participants experienced was the inability to provide comprehensive care due to staff shortages, which made them feel powerlessness and resentful towards the hospital. The nurses were unconvinced that 1689
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the hospital’s healthcare services were designed to help patients (e.g. delay in providing financial assistance and unavailability of healthcare services or support during weekends). They felt sorry for familial caregivers when it took a long time to issue relevant documents after the patient’s death due to inefficient administrative procedures.
Discussion The experiences of moral distress among critical care nurses in South Korea were explored. Ambivalence towards treatment and care was the first theme to emerge. This form of moral distress is consistent with the findings reported in previous qualitative studies (Gutierrez 2005, Heland 2006, Shorideh et al. 2012, Wiegand & Funk 2012); however, in contrast, participants in this study did not know how to deal with their feelings. Critical care nurses encounter many unethical moments in their profession and this causes them to experience moral conflict between what they want to do and what they have to do. This study revealed that critical care nurses felt ambivalence when they prioritized task completion over patient care. The concept of ambivalence has emerged as a form of moral distress for the first time in this study. Interestingly, while previous qualitative (Gutierrez 2005) and quantitative (Corley 1995, Meltzer & Huckabay 2004, Elpern et al. 2005, Rice et al. 2008, Valentine et al. 2011) research has shown that burnout, job dissatisfaction and turnover are attributable to moral distress, respondents in this study did not relate moral distress to emotional exhaustion and resignation. Rather, these nurses reported that they experienced ambivalence as a result of prioritizing work tasks over human dignity or the advocacy of patients’ rights and that this prevented them from completing their work efficiently. Participants further reported that their moral distress was a consequence of their heavy workload, a suggestion that may be supported by the findings of previous qualitative (K€alvemark et al. 2004) and quantitative (Pauly et al. 2009, Wilson et al. 2013) studies. As was reported, numerous earlier quantitative studies have demonstrated that critical care nurses experience high levels of moral distress when providing treatments that are perceived as unnecessary (Pendry 2007, Rice et al. 2008, Faith & Chidwick € 2009, Radzvin 2011, Haq 2012, Ozden et al. 2013, Wilson et al. 2013). Radzvin (2011) reported that aggressive or unnecessary treatment of terminal patients and the neglect of patient and family autonomy were major sources of moral distress. The third subtheme of ambivalence towards treatment and care – the use of compulsory treatments, such as the compulsory application of restraints – is also 1690
consistent with existing findings among quantitative studies (Meltzer & Huckabay 2004, Elpern et al. 2005, Mobley et al. 2007, Rice et al. 2008, Wilson et al. 2013). The second theme to emerge was suffering caused through the observation of unethical care. This finding is consistent with previous quantitative (Epp 2012) and qualitative (Shorideh et al. 2012) studies. This study revealed that the effects of moral distress on nurses include the development of negative attitudes towards their care recipients. Critical care nurses typically expressed negative ethical aspects rather than positive ones (e.g. demonstrated little motivation exposure themselves to ethical issues that would stimulate ethically critical thinking). Critical care nurses experienced different kinds of distress compared with nurses in other settings, and higher levels of moral distress due to the nature and complexity of their work and the critical condition of their patients (Fernandes & Moreira 2012). It is essential for critical care nurses to be aware of ethical standards, be sensitive to ethical issues, think ethically and take appropriate action. This finding is consistent with Corley’s (2002) moral distress theory as applied to nurses (suffering). The third theme of moral distress drawn from this research was dilemmas resulting from nurses’ limited autonomy in treatments. These results are consistent with those of previous qualitative studies (K€ alvemark et al. 2004, Fernandes & Moreira 2012, Karanikola et al. 2014) in that participants felt frustrated when they were unable to control unethical situations. Main themes identified in the study centred on a lack of collaboration between nurses and physicians in relation to decision-making in patient care and the subsequent negative impact that this has on nurses’ empowerment, the communication between nurses, patients and physicians and nurses’ ability to find meaning in patient and family suffering. As a result of this powerlessness, nurses tend to feel unable to influence the outcome of ethical dilemmas and to prevent themselves from acting unethically (K€ alvemark et al. 2004, Varcoe et al. 2004, Tsaloglidou et al. 2007). This may have resulted in the demonstrated ambivalence among nurses in this study and the increased feelings of guilt resulting from being unable to protect patients’ dignity and act in their best interests. Ethical conflicts with misguided physicians comprised the fourth theme. Radzvin (2011) demonstrated that working with incompetent nurses and physicians interferes with patients’ needs and is a major cause of moral distress among critical care nurses. Intensive care settings often involve situations that call for critical care nurses to overcome interprofessional conflicts on ethical issues. © 2015 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUALITATIVE
The final theme was the identification of conflicts between ethical actions and institutional policies. This finding is supported by existing quantitative studies that show that nurses experience moral distress when staffing levels are deemed ‘unsafe’ (Corley 1995, Varcoe et al. 2004, Radzvin 2011, Ganz et al. 2012, Wilson et al. 2013). Workload and a lack of organizational support are seen as major causes of moral distress among critical care nurses (Wilson et al. 2013) and those in the professional often find themselves torn between the patient and physician (Varcoe et al. 2004). Shorideh et al. (2012) reported that institutional barriers and constraints are one of the themes addressed among clinical nurses and nurse educators in Iran. No negative impacts on the healthcare organization, such as a high turnover of nurses, decreased quality of care, or low patient satisfaction, were identified in this study, which is inconsistent with the findings of earlier qualitative (Gutierrez 2005) and quantitative (Corley 1995, Elpern et al. 2005, Valentine et al. 2011) studies. Participants in this current study did not mention a desire to leave their job, but reported that one of the factors that most affected their ethical distress was a shortage of staff. Consistent with the findings of previous qualitative (Shorideh et al. 2012) and quantitative (Corley et al. 2005, Zuzelo 2007) studies, nurses further attributed their moral distress to nursing administration and hospital policy. Most findings in this study supported Jameton’s (1984) and K€alvemark et al.’s (2004) definitions of moral distress, with an interesting exception; participants in this study sometimes felt moral distress in ethically challenging situations both when they were confident of their actions and when they did not know how to act. This suggests that the definition of moral distress needs to be redefined more broadly to include the cognitive state of nurses. In this respect, K€alvemark et al.’s (2004) concept of moral distress seems more appropriate as it defines moral distress as representing the negative stress symptoms involved in ethical dilemmas.
Limitations This qualitative study had some limitations. Participants were all Korean female nurses and were selected from two university hospitals located in the capital, Seoul. The results should therefore be interpreted cautiously when applying them to other populations. We did not examine the influence of educational background (e.g. degree, ethical education or special training with regard to critical care) on moral distress among participants. The nature of © 2015 John Wiley & Sons Ltd
Moral distress
qualitative research may make it difficult for other researchers to transfer the results using the same research methods.
Conclusion Five themes of moral distress were identified and the results indicated that moral distress is a common ethical issue among Korean critical care nurses. The findings of this study have implications for policy, education and practice. Participants reported that ethical insensitivity was a primary cause of moral distress. Regarding policy, the results will help hospital administrators develop strategies that reduce the proliferation of moral distress among critical care nurses. For example, increased moral education, such as workshops or seminars for critical care nurses and discussing moral struggling with colleagues and other health professionals through seminars or forums may be helpful to foster collegial relationships and interprofessional collaboration between critical care nurses and other healthcare professionals. In addition, hospital administrators may consider encouraging nurses’ involvement in the development of policies and guidelines of ethical decision-making in unnecessary medical care. In nursing education and practice, nurse educators may find the study results useful to help build strategies that support nursing students to develop good problem-solving skills and collaboration with other care providers. Nurse educators should focus on developing a bioethics curriculum to empower students to cultivate professional ethical awareness and adopt individual ethical values in patient care. Introducing students to different types of scenarios that require ethical decision-making and encouraging their participation may also help to address this issue. Such exercises would enable nursing students to cope with subsequent ethical challenges in their clinical practice.
Funding This research was supported by the Chung-Ang University Research Grant, Seoul, Republic of Korea.
Conflict of interest No conflict of interest has been declared by the authors.
Author contributions All authors have agreed on the final version and meet all of the following criteria [recommended by the International 1691
K. Choe et al.
Committee of Medical Journal Editors (ICMJE)] (http:// www.icmje.org/recommendations/browse/roles-and-responsi bilities/defining-the-role-of-authors-and-contributors.html):
• •
substantial contributions to the conception, or design of the work; the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content.
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