533124 research-article2014
CNRXXX10.1177/1054773814533124Clinical Nursing ResearchBernhofer and Sorrell
Article
Nurses Managing Patients’ Pain May Experience Moral Distress
Clinical Nursing Research 2015, Vol. 24(4) 401–414 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1054773814533124 cnr.sagepub.com
Esther I. Bernhofer, PhD, RN-BC1 and Jeanne M. Sorrell, PhD, RN, FAAN1
Abstract Bedside nurses care for patients with pain every day but the task is often challenging. A previous qualitative study that investigated nurses’ experiences as they treated patients with pain suggested that nurses may suffer from moral distress if they are unsuccessful in providing adequate pain relief. As 20 of the original 48 nurses interviewed described frustration and distress when constrained from doing the right thing to provide pain relief for their patients, the purpose of this secondary qualitative analysis was to answer new research questions on nurse moral distress related to managing pain. Findings indicated that difficulties in nurse/physician communication and lack of pain education were contributors to nurses’ frustrations and provided barriers to optimal pain management. Many participants indicated a need for interprofessional pain management education. Further investigation is needed to clarify the impact of moral distress on nurses managing hospitalized patients’ pain. Keywords pain, moral distress, nursing, qualitative study, secondary analysis
1The
Cleveland Clinic, OH, USA
Corresponding Author: Esther I. Bernhofer, Principal Investigator, Nurse Researcher, Office of Research and Innovation, Nursing Institute, The Cleveland Clinic, 9500 Euclid Avenue, T3-16, Cleveland, OH 44195, USA. Email: [email protected]
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Hospitalized patients often experience pain providing an ongoing challenge for nurses who care for them. Bedside nurses, many of whom have had little or no formal education in pain management (Polomano, Dunwoody, Krenzischek, & Rathmell, 2008), must do their best to help alleviate their patients’ suffering. Depending on their experience and resources, nurses may find providing optimal pain management for their patients to be a frustrating and sometimes insurmountable task (Siedlecki et al., 2014). Regardless of their condition or prognosis, some patients remain in unacceptable pain, whether it is acute post-operative pain, acute medical pain, chronic nonmalignant pain, or malignant pain. Despite the nurse’s best efforts, sometimes suffering is not resolved thus distressing the nurse as well as the patient. Moral distress may occur when nurses experience an inability to do what they believe to be the right thing. Moral distress in nurses is a phenomenon described by Jameton (1993) as “Feelings that are painful . . . disequilibrium that occurs when nurses find themselves in situations where they feel unable to do the right thing” (p. 542), and alleviating a patient’s pain and suffering is usually perceived as the right thing to do. Although moral distress has been studied in other nurse populations (Rice, Rady, Hamrick, Verheijde, & Pendergast, 2008; Rittenmeyer & Huffman, 2009), no studies could be found on moral distress in bedside nurses specifically related to the struggles of helping all patients with pain in the general hospital setting. This article describes a secondary analysis study that was implemented to investigate feelings of moral distress described by nurses who felt they were constrained in providing their hospitalized patients with optimal pain management regardless of the origins of their pain.
Background A primary focus of nursing has always been to help patients with their pain. Although great strides have been made in the science of pain management, patients often report that they experience moderate to severe pain that is not adequately controlled during their hospital stay (Apfelbaum, Chen, Mehta, & Gan, 2003; Dix, Sandhar, Murdoch, & MacIntyre, 2004). Most bedside nurses are well prepared to deal with the medical needs of their patients but they may find themselves less equipped to understand and treat complex pain issues (Blondal & Halldorsdottir, 2008; Lewthwaite et al., 2011). Even nurses who have some understanding of pain management may run into challenges when trying to meet patients’ pain needs in a complex hospital system (Giordano, Engebretson, & Benedikter, 2009; Wang & Tsai, 2010). When a patient continues to suffer despite the nurse’s best efforts, the nurse may feel as though he or she is unable to meet the ethical standard of
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providing the best pain relief possible for a patient. While moral distress may sometimes occur when an ethical dilemma is being considered, facing a dilemma is not always an essential element of moral distress. When the nurse knows and understands how to provide pain relief, yet is powerless to do so, a threat to the nurse’s own moral integrity is the cause of the distress (Epstein & Delgado, 2010). Moral distress is more than an uncomfortable, frustrating feeling; it can be wholly detrimental to the nurse who suffers from it. Frequent call-offs, illness, and burnout have been traced back to nurses experiencing moral distress (Coles, 2010). It may also be that nurses who must deal with many morally distressing episodes could experience lasting long-term personal and professional harm due to having to repeatedly act against one’s own moral values (Epstein & Delgado, 2010). Although little research has been done on the effect of nurse moral distress on patient outcomes, in an early writing, Wilkinson (1988) noted that patient care may be directly and negatively affected by nurses suffering from moral distress since nurses may avoid patients in an effort to deal with their own ethical turmoil. In 2002, Corley, writing about a proposed nursing theory on moral distress, noted that moral distress among nurses could lead to longer hospital stays and increased pain in patients. In the primary study on which this article is based, researchers used a grounded theory methodology to investigate how nurses made decisions when dealing with chronic and acute pain in their hospitalized patients (Siedlecki et al., 2014). Forty-eight nurses were individually interviewed. The research team met regularly to listen to the audio recordings of the interviews, carefully noting and comparing recurring themes; four core concepts emerged from the data analysis: (1) taking ownership of the problem, (2) nurse tenacity, (3) nurse frustration, and (4) moral distress. Figure 1 shows the model of the primary study, culminating in what was labeled moral distress for some nurses. The question for this study focused on what elements are described by nurses in the transition between frustration and moral distress. Although no nurse participant used the phrase “moral distress” during the interviews, fully 42% of respondents described distress at not being able to do what was right (Siedlecki et al., 2014), compelling the researchers to further explore this phenomenon.
Conceptual Framework The conceptual framework on which this secondary analysis is based is the nursing middle-range theory of Moral Reckoning (Nathaniel, 2006). This theory describes how nurses experience and work through times when their
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Figure 1. Model of how nurses make decisions when dealing with chronic and acute pain. Source. Reprinted from Siedlecki et al. (2014). Copyright 2014 by Elsevier. Reprinted with permission.
core moral beliefs are in direct conflict with external forces over which they have no control. Nathaniel proposed that institutional health care is a major trigger for moral conflict in nurses. Since a core concept from the primary study is moral distress among nurses who work in an institutional setting (the hospital) and must contend with many external forces, the researchers believe that the theory of Moral Reckoning provides a valuable framework for findings in this secondary analysis.
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Purpose of the Study The purpose of this secondary analysis study was to further investigate the experience of moral distress described by nurses interviewed in the primary study who felt they were constrained in providing their patients with optimal pain management.
Research Questions The research questions were as follows: (1) How do nurses describe their experience when unable to successfully manage their patient’s pain? and (2) What do nurses describe as the reasons for or barriers to successfully managing their patient’s pain that may potentially result in their own moral distress?
Study Design The study design is a qualitative secondary analysis of an original grounded theory study. A secondary analysis of qualitative data is used when new research questions emerge from the data. A subset of cases are extracted and analyzed to provide answers to the new research questions (Hinds, Vogel, & Clarke-Steffen, 1997).
Setting and Sample Forty-eight registered nurses from medical-surgical units and the emergency department in a large single tertiary care hospital in the Midwest participated in the primary study from which the data for this analysis are derived. These nurses were originally recruited through their nurse managers who were asked to recommend nurses who had previously discussed their experiences in caring for patients with acute and chronic pain (purposive sampling). The nurses were individually interviewed (Siedlecki et al., 2014). Original interview data from the same purposive sample of nurses were reviewed and no new data were obtained. Table 1 describes the sample.
Methods Institutional review board approval was obtained for the primary study prior to data collection and interviews. Informed consent was obtained from every nurse participant and included a statement that the recorded interviews would be digitally stored and reviewed for purposes of any analysis related to their experiences in the assessment and management of chronic and acute pain in the acute care setting.
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Table 1. Sample Characteristics of Nurse Participants in Primary Study (N = 48). Range Age (in years) Length of practice (in years)
23-59 1-37
n (%)
Gender Female Male Race Caucasian African American Specialty Medical/surgical Other Education Diploma Associate BSN MSN Did not respond
42 (87.5) 6 (12.5) 43 (89.6) 5 (10.4) 41 (85.4) 7 (14.6) 1 17 25 4 1
Source. Reprinted from Siedlecki et al. (2014). Copyright 2014 by Elsevier. Reprinted with permission.
The secondary analysis was conducted by members of the original research team of the primary study. The process included listening to all of the original 48 audio-recorded, digitally saved interviews and reviewing written notes (existing data) taken by the interviewers and researchers. Special attention was paid to themes of frustration, moral distress, and barriers to successful pain management.
Data Analysis In this secondary analysis, researchers focused on the concept of moral distress and commonalities between participants’ descriptions of their experiences related to this concept. An important aspect of assuring credibility in analysis of qualitative data is the value of shared dialogue between researchers in the data analysis process (Graneheim & Lundman, 2004). For this study, researchers listened to each audio-recording while writing memos that reflected their ideas and insights that evolved as they interacted with the data (Starks & Trinidad, 2007).
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Memos also served as an audit trail to document emerging impressions of meaning in the data and the interrelationships between these ideas. At the end of each data analysis session, researchers discussed the emerging core concepts to arrive at consensus in the sorting and labeling of the data. Graneheim and Lundman note that there is no single correct meaning in qualitative data. Trustworthiness relies on establishing arguments for the most probable interpretations and is enhanced by presentation of findings in a way that allows readers to look for alternative interpretations, which is the intent of the following section.
Findings Unable to Manage Patients’ Pain The most common words that nurses used to describe their experience when unable to help manage a patient’s pain were “frustrating” or “frustrated.” Frustration is often based on perceiving a lack of power or control, a classic element of moral distress (Wilkinson, 1988). Nurses’ comments suggested that moral distress may be related to the frustrating feelings of being powerless that build and continue over time. Twenty respondents described their frustration with being unable to help their patients with their pain: For example, “It’s hard for me with pain patients because I feel like we are never going to make it better” and “no one is paying attention to our requests [for help in controlling the patient’s pain].” Distress is evident in the following quote: “ . . . we couldn’t do much about it [patient’s chronic pain]. It was sad and he expired.” Two nurses stated, “I couldn’t do anymore” and “I tried and tried.” Notably distressed voice intonation, sighs, and pauses were heard on the audio recordings of the nurses interviewed. Written memos from the interviewer describing dejected-looking body language also suggested a sense of moral distress in a nurse who stated, . . . nothing I was doing was relieving his [the patient’s] pain . . . I contacted the doctor . . . again I called . . . he told me he [the physician] can’t do anything now. At the end of the day, they did increase his [patient’s] pain medicine but it still wasn’t adequate . . . there was no resolution and I just don’t know how to deal with this . . .
Barriers to Managing a Patient’s Pain Nurses described experiences that centered on difficulty communicating with or obtaining the necessary orders from the physician, nurse/physician hierarchy issues, and a lack of pain management education.
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A few nurses stated that throughout their efforts to help a patient with pain, the doctor “didn’t call,” “doesn’t understand,” or “isn’t educated.” A common problem (barrier) was expressed by one nurse who stated, “reaching the doc and how they respond is an issue,” and, “The nurse always needs to be an advocate to get the right medications . . . [but] we shouldn’t have to fight like we do . . . ” Noting that moral distress arises when one knows the right thing to do, but it is nearly impossible to pursue the right course of action (Gallagher, 2010), one nurse described her distress due to nurse/physician hierarchy this way: I just truly felt we weren’t treating this patient appropriately and I was not sure where else to go . . . this patient was basically in medical purgatory. [The doctor] refused to see him . . . I am so upset . . . we did a very poor job of giving him the medical support he needed . . . this was not fair to the patient or [the nurse caring for him].
Lack of physician collaboration led one nurse to express: You just can’t let [a patient] suffer like that! It’s inhumane! The man was dying and I made 10 calls to residents and staff . . . His wife was crying, “Just make him comfortable!” It’s so wrong and there’s nothing else we [nurses] could do.
And I had a patient with pulmonary hypertension . . . I called . . . I called again . . . his pain medication still wasn’t adequate . . . he was still waiting the next day . . . I don’t know . . . Some nurses are a lot more verbal and being more assertive with the doctor and some are not comfortable at all.
A lack of pain management education was expressed as a barrier that may lead to moral distress: “We need more education, “the doctor’s aren’t educated on it,” and “I think education of doctors is a huge thing.” When pain management education is lacking, common myths and biases toward patients with pain may remain and contribute to frustration and distress: . . . doctors are more hesitant to order the amount of the medications they need. They’re like, they shouldn’t have that much pain from the surgery . . . I’ve had doctors tell me that they’re just drug-seeking . . . A lot of times the doctors have a hard time with it, you know, they’ll only prescribe so much . . . they’re afraid to prescribe as much as the patient was
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taking. That’s the biggest barrier . . . it can be a big problem . . . even if the patient’s been on it at home, they think the patient is seeking drugs. I called the Ombudsman . . . my intent was to say that I did not feel this physician was treating this patient very appropriately or fair . . . the patient was very upset.
What about those who were interviewed in the primary study and did not describe frustration or potential moral distress? Their comments appeared to indicate a lack of understanding of the importance of pain care for a patient. For example, the response of one nurse illustrates how pain care can receive low-level priority: If a patient can’t speak with you, we just kind of ignore the chronic pain. We work in the here and now . . . brush it under the rug . . . we’ll fix that some other time . . . it’s not as pressing a matter as if you’re here for cardiac issues. (Siedlecki et al., 2014)
Another nurse indicated a lack of knowledge regarding pain treatment and biases against patients with chronic pain issues: We need to make sure that the patients are really honest. [And,] The hugest barrier is the drug-seeking behaviors and manipulation of the patients. It tends to make them less trustworthy if they are drug seeking at every moment . . .
Discussion Moral distress is not a phenomenon solely relegated to nurses who care for critically ill patients or those at the end of their lives with a certain type of pain such as malignant pain; the phenomenon of moral distress may also extend to medical-surgical bedside nurses who are unable to successfully care for their patients with many types of suffering. Responses from nurses in this study suggest that frustration with their inability to provide appropriate pain care for a patient, no matter the source of the pain, may turn into personal suffering over the patient’s suffering, leading to feelings of moral distress. Nurses who knew what to do but encountered barriers seemed to suffer the most, suggesting that those with more knowledge about pain management were more inclined to move from frustration to moral distress as they knew what could potentially help the patient, yet felt powerless to act on what they knew. In fact, nurses who reported any type of extra education in pain management more often described this frustration/moral distress phenomenon: Of the 20 (42%) participants of the primary study who described words or
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frustration/moral distress, 13 (65%) had extra pain management education somewhere in their nursing career (Siedlecki et al., 2014). In similar findings, a literature review by Schluter, Winch, Holzhauser, and Henderson (2008) identified a significant relationship between educational level/experience and moral distress, suggesting that nurses with more education and experience have higher levels of moral distress. Although effective pain care for inpatients requires that nurses become more educated in pain management strategies (Blondal & Halldorsdottir, 2008; Wang & Tsai, 2010), it may be that educating nurses in the mechanisms, theories, and optimum methodologies of pain management without educating their physician colleagues may not be enough to help patients and may lead to unintended stressors, rather than optimal pain care for patients. Unfortunately, just like nurses, many physicians have had minimal instruction in pain management resulting in their own frustrations and less than optimal pain care for their patients (Pizzo & Clark, 2012).
Study Limitations There were two noteworthy limitations to this study. First, although there were a large number of participants in the primary qualitative study, nurses from only one hospital were interviewed. Therefore, it is not known if the experience of nurses who care for patients with chronic and acute pain is similar in other hospital settings. Also, as the study design was a secondary analysis and the only data available were what was included in the primary study, investigators could not ask specifically about “moral distress” or its components. The research questions were answerable only through analysis of recorded responses obtained from the interviewees in the primary study. Therefore, saturation of the concepts/ themes was unable to be determined as moral distress questions were not explicitly asked in the primary study interviews. Any follow-up qualitative studies should include interview questions specific to the experience of moral distress to achieve the goal of saturation of themes.
Application Findings from this secondary analysis of data provide a foundation for considering several applications to nursing practice. Participants’ responses to the first research question, How do nurses describe their experience when unable to successfully manage their patient’s pain? reflected their appreciation for the opportunity to describe how their inability to manage their patient’s pain affected them. Nathaniel (2006) noted the importance of
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“telling the story,” as emotions triggered by troubling patient situations linger for years. She emphasized that the process of remembering and reflecting is iterative and that moral reckoning can continue indefinitely as the nurse tries to make sense of the experience. One wonders how nurses like those in this study will make sense of feelings that “I tried and tried” but “I couldn’t do anymore.” Implementing changes in the institutional environment to encourage shared dialogue and reflection about troubling aspects of pain management could help nurses come to terms with their feelings and explore options to improve pain management and diminish moral distress. Responses to the second research question, What do nurses describe as the reasons for or barriers to successfully managing their patient’s pain that may potentially result in their own moral distress? mirror findings from the Nathaniel (2006) study. Nathaniel described “situational binds,” in which nurses’ core values came into conflict with decisions they feel forced to make. Nathaniel described three types of situational binds: (1) Core values conflict with professional or institutional norms, (2) power imbalances that lead to moral disagreement among decision makers, (3) deficiencies in the work environment that can cause harm to patients. Nurses’ responses in this study reflected all three of these situational binds as they talked of problems of communicating with physicians and power issues created by nurse/physician hierarchy issue. Comments like “The nurse always needs to be an advocate to get the right medications . . . [but] we shouldn’t have to fight like we do . . . ” suggest the need to seriously examine situational binds in effective pain management for hospitalized patients. Health care institutions can profit from adapting lessons of teamwork and safety from the aviation industry (Gordon, Mendenhall, & O’Connor, 2013). Interdisciplinary collaboration is needed for social and organizational transformation to eliminate situational binds that can harm patients and leave nurses with moral distress.
Conclusion Most bedside nurses must take care of patients with many different types of pain every day. The stories of nurses in this study whose efforts resulted in frustration and distress are compelling. As this study involved a secondary analysis of data from a primary study, it was not possible to explore with participants the stages of ease, resolution, and reflection that characterize the Moral Reckoning theory. Further qualitative research focused on nurses’ moral distress in caring for hospitalized patients with many difficult pain management needs could shed light on how nurses progress through the three stages. One finding in the primary study described here was that sometimes nurses “gave up” trying to implement pain management in a way that they
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felt was right (Siedlecki et al., 2014). Thus, it is important to find out more about how nurses resolve and reflect on moral distress with these patients. Research has consistently shown that nurses do not feel well educated for difficult decisions in pain management (Lewthwaite et al., 2011). Participants in this study clearly indicated a need for more education in pain management for both nurses and physicians. Participants also expressed situational binds and difficulty in communicating with physicians regarding their patients’ pain as being related to their distress. Interprofessional pain management education, where nurses and physicians learn together to understand and treat pain, may be a solution (Watt-Watson, Siddall, & Carr, 2012). Furthermore, important aspects of better communication for both nurses and physicians need to be emphasized in pain management courses to reduce frustration and a potential adversarial relationship that may result in nurses feeling that they must “fight” the physician for better pain care for their patient. Thinking together to find ways to effectively manage patients’ pain in the complex hospital environment may help to limit frustration and moral distress for nurses and physicians alike. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References Apfelbaum, J. L., Chen, C., Mehta, S. S., & Gan, T. J. (2003). Postoperative pain experience: Results from a national survey suggest postoperative pain continues to be undermanaged. Anesthesia & Analgesia, 97, 534-540. doi:10.1213/01. ANE.0000068822.10113.9E Blondal, K., & Halldorsdottir, S. (2008). The challenge of caring for patients in pain: From the nurse’s perspective. Journal of Clinical Nursing, 18, 2897-2906. doi:10.1111/j.1365-2702.2009.02794.x Coles, D. (2010). “Because we can.” Leadership responsibility and the moral distress dilemma. Nursing Management, 41(3), 26-30. doi:10.1097/01. NUMA.0000369495.69358.dc Corley, M. C. (2002). Nurse moral distress: A proposed theory and research agenda. Nursing Ethics, 9, 636-650. Retrieved from http://nej.sagepub.com/content/9/6/636 Dix, P., Sandhar, B., Murdoch, J., & MacIntyre, P. A. (2004). Pain on medical wards in a district general hospital. British Journal of Anaesthesia, 92, 235-237. doi:10.1093/bja/aeh052
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Epstein, E. G., & Delgado, S. (2010). Understanding and addressing moral distress. OJIN: The Online Journal of Issues in Nursing, 15(3), Manuscript 1. doi:10.3912/ OJIN.Vol15No03Man01 Gallagher, A. (2010). Moral distress and moral courage in everyday nursing practice. OJIN: The Online Journal of Issues in Nursing, 16(2). doi:10.3912/OJIN. Vol16No02PPT03. Retrieved from http://gm6.nursingworld.org/MainMenu Categories/EthicsStandards/Courage-and-Distress/Moral-Distress-and-Couragein-Everyday-Practice.html Giordano, J., Engebretson, J. C., & Benedikter, R. (2009). Culture, subjectivity, and the ethics of patient-centered pain care. Cambridge Quarterly of Healthcare Ethics, 18, 47-56. doi:10.1017/S0963180108090087 Gordon, S., Mendenhall, P., & O’Connor, B. B. (2013). Beyond the checklist: What else health care can learn from aviation teamwork and safety. New York, NY: Cornell University Press. Graneheim, U. H., & Lundman, B. (2004). Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24, 105-112. doi:10.1016/j.nedt.2003.10.001 Hinds, P. S., Vogel, R. J., & Clarke-Steffen, L. (1997). The possibilities and pitfalls of doing a secondary analysis of a qualitative data set. Qualitative Health Research, 7, 408-424. doi:10.1177/104973239700700306 Jameton, A. (1993). Dilemmas of moral distress: Moral responsibility and nursing practice. Clinical Issues in Perinatal and Women’s Health Nursing, 4, 542-551. Lewthwaite, B. J., Jabusch, K., Wheeler, B. M., Schnell-Hoehn, K. N., Mills, J., Estrella-Holder, E., & Fedorowicz, A. (2011). Nurses’ knowledge and attitudes regarding pain management in hospitalized adults. Journal of Continuing Education in Nursing, 42, 251-257. doi:10.3928/00220124-20110103-03 Nathaniel, A. K. (2006). Moral reckoning in nursing. Western Journal of Nursing Research, 28, 419-438. doi:10.1177/0193945905284727 Pizzo, P. A., & Clark, N. M. (2012). Alleviating suffering 101: Pain relief in the United States. The New England Journal of Medicine, 36, 197-199. doi:10.1056/ NEJMp1109084 Polomano, R. C., Dunwoody, C. J., Krenzischek, D. A., & Rathmell, J. P. (2008). Perspective on pain management in the 21st century. Pain Management Nursing, 9(1), S3-S10. doi:10.1016/j.pmn.2007.11.002 Rice, E. M., Rady, M. Y., Hamrick, A., Verheijde, J. L., & Pendergast, D. K. (2008). Determinants of moral distress in medical and surgical nurses at an adult acute tertiary care hospital. Journal of Nursing Management, 16, 360-373. Rittenmeyer, L., & Huffman, D. (2009). How professional nurses working in hospital environments experience moral distress: A systematic review. JBI Library of Systematic Reviews, 7, 1233-1290. Schluter, J., Winch, S., Holzhauser, K., & Henderson, A. (2008). Nurses’ moral sensitivity and hospital ethical climate: A literature review. Nursing Ethics, 15, 304321. doi:10.1177/0969733007088357
Downloaded from cnr.sagepub.com at FLORIDA ATLANTIC UNIV on July 20, 2015
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Siedlecki, S. L., Modic, M. B., Bernhofer, E., Sorrell, J., Strumble, P., & Kato, I. (2014). Exploring how bedside nurses care for patients with chronic pain: A grounded theory study. Pain Management Nursing, 15, 565-573. Starks, H., & Trinidad, S. B. (2007). Choose your method: A comparison of phenomenology, discourse analysis, and grounded theory. Qualitative Health Research, 17, 1372-1380. doi:10.1177/1049732307307031 Wang, H. L., & Tsai, Y. F. (2010). Nurses’ knowledge and barriers regarding pain management in intensive care units. Journal of Clinical Nursing, 19, 3188-3196. Watt-Watson, J., Siddall, P. J., & Carr, E. (2012). Interprofessional pain education: The road to successful pain management outcomes. Pain Management, 2, 417-420. Wilkinson, J. M. (1988). Moral distress in nursing practice: Experience and effect. Nursing Forum, 23, 16-29.
Author Biographies Esther I. Bernhofer, PhD, RN-BC, is a Nurse Researcher at The Cleveland Clinic, Office of Research and Innovation, Nursing Institute. Jeanne M. Sorrell, PhD, RN, FAAN, is a Senior Nurse Scientist at The Cleveland Clinic, Office of Research and Innovation, Nursing Institute.
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CNRXXX10.1177/1054773814533124Clinical Nursing ResearchBernhofer and Sorrell
Article
Nurses Managing Patients’ Pain May Experience Moral Distress
Clinical Nursing Research 2015, Vol. 24(4) 401–414 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1054773814533124 cnr.sagepub.com
Esther I. Bernhofer, PhD, RN-BC1 and Jeanne M. Sorrell, PhD, RN, FAAN1
Abstract Bedside nurses care for patients with pain every day but the task is often challenging. A previous qualitative study that investigated nurses’ experiences as they treated patients with pain suggested that nurses may suffer from moral distress if they are unsuccessful in providing adequate pain relief. As 20 of the original 48 nurses interviewed described frustration and distress when constrained from doing the right thing to provide pain relief for their patients, the purpose of this secondary qualitative analysis was to answer new research questions on nurse moral distress related to managing pain. Findings indicated that difficulties in nurse/physician communication and lack of pain education were contributors to nurses’ frustrations and provided barriers to optimal pain management. Many participants indicated a need for interprofessional pain management education. Further investigation is needed to clarify the impact of moral distress on nurses managing hospitalized patients’ pain. Keywords pain, moral distress, nursing, qualitative study, secondary analysis
1The
Cleveland Clinic, OH, USA
Corresponding Author: Esther I. Bernhofer, Principal Investigator, Nurse Researcher, Office of Research and Innovation, Nursing Institute, The Cleveland Clinic, 9500 Euclid Avenue, T3-16, Cleveland, OH 44195, USA. Email: [email protected]
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Hospitalized patients often experience pain providing an ongoing challenge for nurses who care for them. Bedside nurses, many of whom have had little or no formal education in pain management (Polomano, Dunwoody, Krenzischek, & Rathmell, 2008), must do their best to help alleviate their patients’ suffering. Depending on their experience and resources, nurses may find providing optimal pain management for their patients to be a frustrating and sometimes insurmountable task (Siedlecki et al., 2014). Regardless of their condition or prognosis, some patients remain in unacceptable pain, whether it is acute post-operative pain, acute medical pain, chronic nonmalignant pain, or malignant pain. Despite the nurse’s best efforts, sometimes suffering is not resolved thus distressing the nurse as well as the patient. Moral distress may occur when nurses experience an inability to do what they believe to be the right thing. Moral distress in nurses is a phenomenon described by Jameton (1993) as “Feelings that are painful . . . disequilibrium that occurs when nurses find themselves in situations where they feel unable to do the right thing” (p. 542), and alleviating a patient’s pain and suffering is usually perceived as the right thing to do. Although moral distress has been studied in other nurse populations (Rice, Rady, Hamrick, Verheijde, & Pendergast, 2008; Rittenmeyer & Huffman, 2009), no studies could be found on moral distress in bedside nurses specifically related to the struggles of helping all patients with pain in the general hospital setting. This article describes a secondary analysis study that was implemented to investigate feelings of moral distress described by nurses who felt they were constrained in providing their hospitalized patients with optimal pain management regardless of the origins of their pain.
Background A primary focus of nursing has always been to help patients with their pain. Although great strides have been made in the science of pain management, patients often report that they experience moderate to severe pain that is not adequately controlled during their hospital stay (Apfelbaum, Chen, Mehta, & Gan, 2003; Dix, Sandhar, Murdoch, & MacIntyre, 2004). Most bedside nurses are well prepared to deal with the medical needs of their patients but they may find themselves less equipped to understand and treat complex pain issues (Blondal & Halldorsdottir, 2008; Lewthwaite et al., 2011). Even nurses who have some understanding of pain management may run into challenges when trying to meet patients’ pain needs in a complex hospital system (Giordano, Engebretson, & Benedikter, 2009; Wang & Tsai, 2010). When a patient continues to suffer despite the nurse’s best efforts, the nurse may feel as though he or she is unable to meet the ethical standard of
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providing the best pain relief possible for a patient. While moral distress may sometimes occur when an ethical dilemma is being considered, facing a dilemma is not always an essential element of moral distress. When the nurse knows and understands how to provide pain relief, yet is powerless to do so, a threat to the nurse’s own moral integrity is the cause of the distress (Epstein & Delgado, 2010). Moral distress is more than an uncomfortable, frustrating feeling; it can be wholly detrimental to the nurse who suffers from it. Frequent call-offs, illness, and burnout have been traced back to nurses experiencing moral distress (Coles, 2010). It may also be that nurses who must deal with many morally distressing episodes could experience lasting long-term personal and professional harm due to having to repeatedly act against one’s own moral values (Epstein & Delgado, 2010). Although little research has been done on the effect of nurse moral distress on patient outcomes, in an early writing, Wilkinson (1988) noted that patient care may be directly and negatively affected by nurses suffering from moral distress since nurses may avoid patients in an effort to deal with their own ethical turmoil. In 2002, Corley, writing about a proposed nursing theory on moral distress, noted that moral distress among nurses could lead to longer hospital stays and increased pain in patients. In the primary study on which this article is based, researchers used a grounded theory methodology to investigate how nurses made decisions when dealing with chronic and acute pain in their hospitalized patients (Siedlecki et al., 2014). Forty-eight nurses were individually interviewed. The research team met regularly to listen to the audio recordings of the interviews, carefully noting and comparing recurring themes; four core concepts emerged from the data analysis: (1) taking ownership of the problem, (2) nurse tenacity, (3) nurse frustration, and (4) moral distress. Figure 1 shows the model of the primary study, culminating in what was labeled moral distress for some nurses. The question for this study focused on what elements are described by nurses in the transition between frustration and moral distress. Although no nurse participant used the phrase “moral distress” during the interviews, fully 42% of respondents described distress at not being able to do what was right (Siedlecki et al., 2014), compelling the researchers to further explore this phenomenon.
Conceptual Framework The conceptual framework on which this secondary analysis is based is the nursing middle-range theory of Moral Reckoning (Nathaniel, 2006). This theory describes how nurses experience and work through times when their
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Figure 1. Model of how nurses make decisions when dealing with chronic and acute pain. Source. Reprinted from Siedlecki et al. (2014). Copyright 2014 by Elsevier. Reprinted with permission.
core moral beliefs are in direct conflict with external forces over which they have no control. Nathaniel proposed that institutional health care is a major trigger for moral conflict in nurses. Since a core concept from the primary study is moral distress among nurses who work in an institutional setting (the hospital) and must contend with many external forces, the researchers believe that the theory of Moral Reckoning provides a valuable framework for findings in this secondary analysis.
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Purpose of the Study The purpose of this secondary analysis study was to further investigate the experience of moral distress described by nurses interviewed in the primary study who felt they were constrained in providing their patients with optimal pain management.
Research Questions The research questions were as follows: (1) How do nurses describe their experience when unable to successfully manage their patient’s pain? and (2) What do nurses describe as the reasons for or barriers to successfully managing their patient’s pain that may potentially result in their own moral distress?
Study Design The study design is a qualitative secondary analysis of an original grounded theory study. A secondary analysis of qualitative data is used when new research questions emerge from the data. A subset of cases are extracted and analyzed to provide answers to the new research questions (Hinds, Vogel, & Clarke-Steffen, 1997).
Setting and Sample Forty-eight registered nurses from medical-surgical units and the emergency department in a large single tertiary care hospital in the Midwest participated in the primary study from which the data for this analysis are derived. These nurses were originally recruited through their nurse managers who were asked to recommend nurses who had previously discussed their experiences in caring for patients with acute and chronic pain (purposive sampling). The nurses were individually interviewed (Siedlecki et al., 2014). Original interview data from the same purposive sample of nurses were reviewed and no new data were obtained. Table 1 describes the sample.
Methods Institutional review board approval was obtained for the primary study prior to data collection and interviews. Informed consent was obtained from every nurse participant and included a statement that the recorded interviews would be digitally stored and reviewed for purposes of any analysis related to their experiences in the assessment and management of chronic and acute pain in the acute care setting.
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Table 1. Sample Characteristics of Nurse Participants in Primary Study (N = 48). Range Age (in years) Length of practice (in years)
23-59 1-37
n (%)
Gender Female Male Race Caucasian African American Specialty Medical/surgical Other Education Diploma Associate BSN MSN Did not respond
42 (87.5) 6 (12.5) 43 (89.6) 5 (10.4) 41 (85.4) 7 (14.6) 1 17 25 4 1
Source. Reprinted from Siedlecki et al. (2014). Copyright 2014 by Elsevier. Reprinted with permission.
The secondary analysis was conducted by members of the original research team of the primary study. The process included listening to all of the original 48 audio-recorded, digitally saved interviews and reviewing written notes (existing data) taken by the interviewers and researchers. Special attention was paid to themes of frustration, moral distress, and barriers to successful pain management.
Data Analysis In this secondary analysis, researchers focused on the concept of moral distress and commonalities between participants’ descriptions of their experiences related to this concept. An important aspect of assuring credibility in analysis of qualitative data is the value of shared dialogue between researchers in the data analysis process (Graneheim & Lundman, 2004). For this study, researchers listened to each audio-recording while writing memos that reflected their ideas and insights that evolved as they interacted with the data (Starks & Trinidad, 2007).
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Memos also served as an audit trail to document emerging impressions of meaning in the data and the interrelationships between these ideas. At the end of each data analysis session, researchers discussed the emerging core concepts to arrive at consensus in the sorting and labeling of the data. Graneheim and Lundman note that there is no single correct meaning in qualitative data. Trustworthiness relies on establishing arguments for the most probable interpretations and is enhanced by presentation of findings in a way that allows readers to look for alternative interpretations, which is the intent of the following section.
Findings Unable to Manage Patients’ Pain The most common words that nurses used to describe their experience when unable to help manage a patient’s pain were “frustrating” or “frustrated.” Frustration is often based on perceiving a lack of power or control, a classic element of moral distress (Wilkinson, 1988). Nurses’ comments suggested that moral distress may be related to the frustrating feelings of being powerless that build and continue over time. Twenty respondents described their frustration with being unable to help their patients with their pain: For example, “It’s hard for me with pain patients because I feel like we are never going to make it better” and “no one is paying attention to our requests [for help in controlling the patient’s pain].” Distress is evident in the following quote: “ . . . we couldn’t do much about it [patient’s chronic pain]. It was sad and he expired.” Two nurses stated, “I couldn’t do anymore” and “I tried and tried.” Notably distressed voice intonation, sighs, and pauses were heard on the audio recordings of the nurses interviewed. Written memos from the interviewer describing dejected-looking body language also suggested a sense of moral distress in a nurse who stated, . . . nothing I was doing was relieving his [the patient’s] pain . . . I contacted the doctor . . . again I called . . . he told me he [the physician] can’t do anything now. At the end of the day, they did increase his [patient’s] pain medicine but it still wasn’t adequate . . . there was no resolution and I just don’t know how to deal with this . . .
Barriers to Managing a Patient’s Pain Nurses described experiences that centered on difficulty communicating with or obtaining the necessary orders from the physician, nurse/physician hierarchy issues, and a lack of pain management education.
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A few nurses stated that throughout their efforts to help a patient with pain, the doctor “didn’t call,” “doesn’t understand,” or “isn’t educated.” A common problem (barrier) was expressed by one nurse who stated, “reaching the doc and how they respond is an issue,” and, “The nurse always needs to be an advocate to get the right medications . . . [but] we shouldn’t have to fight like we do . . . ” Noting that moral distress arises when one knows the right thing to do, but it is nearly impossible to pursue the right course of action (Gallagher, 2010), one nurse described her distress due to nurse/physician hierarchy this way: I just truly felt we weren’t treating this patient appropriately and I was not sure where else to go . . . this patient was basically in medical purgatory. [The doctor] refused to see him . . . I am so upset . . . we did a very poor job of giving him the medical support he needed . . . this was not fair to the patient or [the nurse caring for him].
Lack of physician collaboration led one nurse to express: You just can’t let [a patient] suffer like that! It’s inhumane! The man was dying and I made 10 calls to residents and staff . . . His wife was crying, “Just make him comfortable!” It’s so wrong and there’s nothing else we [nurses] could do.
And I had a patient with pulmonary hypertension . . . I called . . . I called again . . . his pain medication still wasn’t adequate . . . he was still waiting the next day . . . I don’t know . . . Some nurses are a lot more verbal and being more assertive with the doctor and some are not comfortable at all.
A lack of pain management education was expressed as a barrier that may lead to moral distress: “We need more education, “the doctor’s aren’t educated on it,” and “I think education of doctors is a huge thing.” When pain management education is lacking, common myths and biases toward patients with pain may remain and contribute to frustration and distress: . . . doctors are more hesitant to order the amount of the medications they need. They’re like, they shouldn’t have that much pain from the surgery . . . I’ve had doctors tell me that they’re just drug-seeking . . . A lot of times the doctors have a hard time with it, you know, they’ll only prescribe so much . . . they’re afraid to prescribe as much as the patient was
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taking. That’s the biggest barrier . . . it can be a big problem . . . even if the patient’s been on it at home, they think the patient is seeking drugs. I called the Ombudsman . . . my intent was to say that I did not feel this physician was treating this patient very appropriately or fair . . . the patient was very upset.
What about those who were interviewed in the primary study and did not describe frustration or potential moral distress? Their comments appeared to indicate a lack of understanding of the importance of pain care for a patient. For example, the response of one nurse illustrates how pain care can receive low-level priority: If a patient can’t speak with you, we just kind of ignore the chronic pain. We work in the here and now . . . brush it under the rug . . . we’ll fix that some other time . . . it’s not as pressing a matter as if you’re here for cardiac issues. (Siedlecki et al., 2014)
Another nurse indicated a lack of knowledge regarding pain treatment and biases against patients with chronic pain issues: We need to make sure that the patients are really honest. [And,] The hugest barrier is the drug-seeking behaviors and manipulation of the patients. It tends to make them less trustworthy if they are drug seeking at every moment . . .
Discussion Moral distress is not a phenomenon solely relegated to nurses who care for critically ill patients or those at the end of their lives with a certain type of pain such as malignant pain; the phenomenon of moral distress may also extend to medical-surgical bedside nurses who are unable to successfully care for their patients with many types of suffering. Responses from nurses in this study suggest that frustration with their inability to provide appropriate pain care for a patient, no matter the source of the pain, may turn into personal suffering over the patient’s suffering, leading to feelings of moral distress. Nurses who knew what to do but encountered barriers seemed to suffer the most, suggesting that those with more knowledge about pain management were more inclined to move from frustration to moral distress as they knew what could potentially help the patient, yet felt powerless to act on what they knew. In fact, nurses who reported any type of extra education in pain management more often described this frustration/moral distress phenomenon: Of the 20 (42%) participants of the primary study who described words or
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frustration/moral distress, 13 (65%) had extra pain management education somewhere in their nursing career (Siedlecki et al., 2014). In similar findings, a literature review by Schluter, Winch, Holzhauser, and Henderson (2008) identified a significant relationship between educational level/experience and moral distress, suggesting that nurses with more education and experience have higher levels of moral distress. Although effective pain care for inpatients requires that nurses become more educated in pain management strategies (Blondal & Halldorsdottir, 2008; Wang & Tsai, 2010), it may be that educating nurses in the mechanisms, theories, and optimum methodologies of pain management without educating their physician colleagues may not be enough to help patients and may lead to unintended stressors, rather than optimal pain care for patients. Unfortunately, just like nurses, many physicians have had minimal instruction in pain management resulting in their own frustrations and less than optimal pain care for their patients (Pizzo & Clark, 2012).
Study Limitations There were two noteworthy limitations to this study. First, although there were a large number of participants in the primary qualitative study, nurses from only one hospital were interviewed. Therefore, it is not known if the experience of nurses who care for patients with chronic and acute pain is similar in other hospital settings. Also, as the study design was a secondary analysis and the only data available were what was included in the primary study, investigators could not ask specifically about “moral distress” or its components. The research questions were answerable only through analysis of recorded responses obtained from the interviewees in the primary study. Therefore, saturation of the concepts/ themes was unable to be determined as moral distress questions were not explicitly asked in the primary study interviews. Any follow-up qualitative studies should include interview questions specific to the experience of moral distress to achieve the goal of saturation of themes.
Application Findings from this secondary analysis of data provide a foundation for considering several applications to nursing practice. Participants’ responses to the first research question, How do nurses describe their experience when unable to successfully manage their patient’s pain? reflected their appreciation for the opportunity to describe how their inability to manage their patient’s pain affected them. Nathaniel (2006) noted the importance of
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“telling the story,” as emotions triggered by troubling patient situations linger for years. She emphasized that the process of remembering and reflecting is iterative and that moral reckoning can continue indefinitely as the nurse tries to make sense of the experience. One wonders how nurses like those in this study will make sense of feelings that “I tried and tried” but “I couldn’t do anymore.” Implementing changes in the institutional environment to encourage shared dialogue and reflection about troubling aspects of pain management could help nurses come to terms with their feelings and explore options to improve pain management and diminish moral distress. Responses to the second research question, What do nurses describe as the reasons for or barriers to successfully managing their patient’s pain that may potentially result in their own moral distress? mirror findings from the Nathaniel (2006) study. Nathaniel described “situational binds,” in which nurses’ core values came into conflict with decisions they feel forced to make. Nathaniel described three types of situational binds: (1) Core values conflict with professional or institutional norms, (2) power imbalances that lead to moral disagreement among decision makers, (3) deficiencies in the work environment that can cause harm to patients. Nurses’ responses in this study reflected all three of these situational binds as they talked of problems of communicating with physicians and power issues created by nurse/physician hierarchy issue. Comments like “The nurse always needs to be an advocate to get the right medications . . . [but] we shouldn’t have to fight like we do . . . ” suggest the need to seriously examine situational binds in effective pain management for hospitalized patients. Health care institutions can profit from adapting lessons of teamwork and safety from the aviation industry (Gordon, Mendenhall, & O’Connor, 2013). Interdisciplinary collaboration is needed for social and organizational transformation to eliminate situational binds that can harm patients and leave nurses with moral distress.
Conclusion Most bedside nurses must take care of patients with many different types of pain every day. The stories of nurses in this study whose efforts resulted in frustration and distress are compelling. As this study involved a secondary analysis of data from a primary study, it was not possible to explore with participants the stages of ease, resolution, and reflection that characterize the Moral Reckoning theory. Further qualitative research focused on nurses’ moral distress in caring for hospitalized patients with many difficult pain management needs could shed light on how nurses progress through the three stages. One finding in the primary study described here was that sometimes nurses “gave up” trying to implement pain management in a way that they
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felt was right (Siedlecki et al., 2014). Thus, it is important to find out more about how nurses resolve and reflect on moral distress with these patients. Research has consistently shown that nurses do not feel well educated for difficult decisions in pain management (Lewthwaite et al., 2011). Participants in this study clearly indicated a need for more education in pain management for both nurses and physicians. Participants also expressed situational binds and difficulty in communicating with physicians regarding their patients’ pain as being related to their distress. Interprofessional pain management education, where nurses and physicians learn together to understand and treat pain, may be a solution (Watt-Watson, Siddall, & Carr, 2012). Furthermore, important aspects of better communication for both nurses and physicians need to be emphasized in pain management courses to reduce frustration and a potential adversarial relationship that may result in nurses feeling that they must “fight” the physician for better pain care for their patient. Thinking together to find ways to effectively manage patients’ pain in the complex hospital environment may help to limit frustration and moral distress for nurses and physicians alike. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References Apfelbaum, J. L., Chen, C., Mehta, S. S., & Gan, T. J. (2003). Postoperative pain experience: Results from a national survey suggest postoperative pain continues to be undermanaged. Anesthesia & Analgesia, 97, 534-540. doi:10.1213/01. ANE.0000068822.10113.9E Blondal, K., & Halldorsdottir, S. (2008). The challenge of caring for patients in pain: From the nurse’s perspective. Journal of Clinical Nursing, 18, 2897-2906. doi:10.1111/j.1365-2702.2009.02794.x Coles, D. (2010). “Because we can.” Leadership responsibility and the moral distress dilemma. Nursing Management, 41(3), 26-30. doi:10.1097/01. NUMA.0000369495.69358.dc Corley, M. C. (2002). Nurse moral distress: A proposed theory and research agenda. Nursing Ethics, 9, 636-650. Retrieved from http://nej.sagepub.com/content/9/6/636 Dix, P., Sandhar, B., Murdoch, J., & MacIntyre, P. A. (2004). Pain on medical wards in a district general hospital. British Journal of Anaesthesia, 92, 235-237. doi:10.1093/bja/aeh052
Downloaded from cnr.sagepub.com at FLORIDA ATLANTIC UNIV on July 20, 2015
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Epstein, E. G., & Delgado, S. (2010). Understanding and addressing moral distress. OJIN: The Online Journal of Issues in Nursing, 15(3), Manuscript 1. doi:10.3912/ OJIN.Vol15No03Man01 Gallagher, A. (2010). Moral distress and moral courage in everyday nursing practice. OJIN: The Online Journal of Issues in Nursing, 16(2). doi:10.3912/OJIN. Vol16No02PPT03. Retrieved from http://gm6.nursingworld.org/MainMenu Categories/EthicsStandards/Courage-and-Distress/Moral-Distress-and-Couragein-Everyday-Practice.html Giordano, J., Engebretson, J. C., & Benedikter, R. (2009). Culture, subjectivity, and the ethics of patient-centered pain care. Cambridge Quarterly of Healthcare Ethics, 18, 47-56. doi:10.1017/S0963180108090087 Gordon, S., Mendenhall, P., & O’Connor, B. B. (2013). Beyond the checklist: What else health care can learn from aviation teamwork and safety. New York, NY: Cornell University Press. Graneheim, U. H., & Lundman, B. (2004). Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24, 105-112. doi:10.1016/j.nedt.2003.10.001 Hinds, P. S., Vogel, R. J., & Clarke-Steffen, L. (1997). The possibilities and pitfalls of doing a secondary analysis of a qualitative data set. Qualitative Health Research, 7, 408-424. doi:10.1177/104973239700700306 Jameton, A. (1993). Dilemmas of moral distress: Moral responsibility and nursing practice. Clinical Issues in Perinatal and Women’s Health Nursing, 4, 542-551. Lewthwaite, B. J., Jabusch, K., Wheeler, B. M., Schnell-Hoehn, K. N., Mills, J., Estrella-Holder, E., & Fedorowicz, A. (2011). Nurses’ knowledge and attitudes regarding pain management in hospitalized adults. Journal of Continuing Education in Nursing, 42, 251-257. doi:10.3928/00220124-20110103-03 Nathaniel, A. K. (2006). Moral reckoning in nursing. Western Journal of Nursing Research, 28, 419-438. doi:10.1177/0193945905284727 Pizzo, P. A., & Clark, N. M. (2012). Alleviating suffering 101: Pain relief in the United States. The New England Journal of Medicine, 36, 197-199. doi:10.1056/ NEJMp1109084 Polomano, R. C., Dunwoody, C. J., Krenzischek, D. A., & Rathmell, J. P. (2008). Perspective on pain management in the 21st century. Pain Management Nursing, 9(1), S3-S10. doi:10.1016/j.pmn.2007.11.002 Rice, E. M., Rady, M. Y., Hamrick, A., Verheijde, J. L., & Pendergast, D. K. (2008). Determinants of moral distress in medical and surgical nurses at an adult acute tertiary care hospital. Journal of Nursing Management, 16, 360-373. Rittenmeyer, L., & Huffman, D. (2009). How professional nurses working in hospital environments experience moral distress: A systematic review. JBI Library of Systematic Reviews, 7, 1233-1290. Schluter, J., Winch, S., Holzhauser, K., & Henderson, A. (2008). Nurses’ moral sensitivity and hospital ethical climate: A literature review. Nursing Ethics, 15, 304321. doi:10.1177/0969733007088357
Downloaded from cnr.sagepub.com at FLORIDA ATLANTIC UNIV on July 20, 2015
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Siedlecki, S. L., Modic, M. B., Bernhofer, E., Sorrell, J., Strumble, P., & Kato, I. (2014). Exploring how bedside nurses care for patients with chronic pain: A grounded theory study. Pain Management Nursing, 15, 565-573. Starks, H., & Trinidad, S. B. (2007). Choose your method: A comparison of phenomenology, discourse analysis, and grounded theory. Qualitative Health Research, 17, 1372-1380. doi:10.1177/1049732307307031 Wang, H. L., & Tsai, Y. F. (2010). Nurses’ knowledge and barriers regarding pain management in intensive care units. Journal of Clinical Nursing, 19, 3188-3196. Watt-Watson, J., Siddall, P. J., & Carr, E. (2012). Interprofessional pain education: The road to successful pain management outcomes. Pain Management, 2, 417-420. Wilkinson, J. M. (1988). Moral distress in nursing practice: Experience and effect. Nursing Forum, 23, 16-29.
Author Biographies Esther I. Bernhofer, PhD, RN-BC, is a Nurse Researcher at The Cleveland Clinic, Office of Research and Innovation, Nursing Institute. Jeanne M. Sorrell, PhD, RN, FAAN, is a Senior Nurse Scientist at The Cleveland Clinic, Office of Research and Innovation, Nursing Institute.
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