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Moral Distress in Nursing: A Hindrance to Nurses’ Performance


The concept of moral distress has been broadly researched in various contexts in the healthcare sector. The dynamics facing healthcare organizations resulted to the emergence of complex issues relating to moral distress. On the other hand, the emergence of cutting edge health care innovations have led to numerous developments in the healthcare system, creating a provision for prolonging life in conditions with poor prognosis and improving patients’ quality of life in specialized care units. Various scholars have researched the concept of moral distress in regard to its manifestation in the healthcare fields.

In nursing, this concept has been explored in specialized units such as critical care nursing, neuroscience, and surgical nursing. The vast dynamics of this concept have been a challenge in explicitly defining the concept. The attributes of moral distress remain vague. However, its consequences and antecedents are constantly discovered. This paper endeavors to examine the meaning of moral distress, evaluate its application in the healthcare system and showcase how it is related to moral reckoning (a midrange theory).

Definitions of Moral Distress by various Authors

Moral distress has been defined by many scholars based on empirical findings deduced from hypothetical frameworks linking moral distress to healthcare quality issues. According to Jameton (1984, p. 2), moral distress is a situation whereby “one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action”. However, Repenshek (2009) notes in spite of the continued use of this definition, its critical analysis remains limited. On the other hand, Wilkinson’s desire to develop a deeper understanding of this concept prompted him to conduct studies on nurses based on the hypothesis that patient care is negatively impacted by moral distress (Wilkinson, 1984).

Wilkinson’s study illustrated monumental findings regarding moral distress. The findings indicated that the concept was frequently observed in various circumstances. Most importantly, in issues such as inability to alleviate pain and suffering of patients, the life prolongation of dying patients, and dehumanization of patients (Wilkinson, 1984). Additionally, the findings from Wilkinson’s study indicated that a number of factors contribute to moral distress. “Emotion driven factors like anger, guilt frustration, powerlessness and conflicting loyalties” are good examples of these factors (Wilkinson, 1987, p.15).

Moreover, Elpern et al. (2005) argue that moral distress among nurses is associated with negative feelings such as frustration and anger, changes in perception of self image, health-related practices, and spirituality. Additionally, the scholars established a significant relationship between the duration of working in the nursing field and moral distress (Elpern et al., 2005).

Manifestation of Moral Distress in the healthcare system

According to Wilkinson (1987), the attributes of this concept include frustration and anger, especially during the process of resuscitating a patient and instances of withholding truth from a patient. The contribution of powerlessness to moral distress stems from the organizational hierarchy in hospitals. Powerlessness among nurses has been found to generate negative feelings; a feature that limits nurses’ capability to address patients’ suffering and pain. This attribute has also been established by Erlen (2001) and Calvin et al. (2007).

Conflicting loyalties are also attributable to moral distress. They occur when a patient’s course of action is established but cannot be undertaken as a result of conflicts with other stakeholders. The role of the nurse as an advocate equals to nurses being in the middle of conflicting values of other groups such as families and physicians (Wilkinson, 1987). Similar findings were reported in the study by Elpern et al. (2005) who found a correlation between moral distress and negative feelings that evoked anger and frustration. Feelings of powerlessness, hopelessness, and lack of a support system among others were found to be associated with moral distress (Elpern et al., 2005).

Related concepts to moral distress include moral dilemma and moral sensitivity. Wilkinson (1987) defined moral distress as the situation in which the right course is established or known but owing to impeding factors, cannot be pursued. Moral dilemma, on the other hand, refers to a situation where the nurse is obliged to pursue courses of action, but, neither of the courses is preferred to the other one (Hamric & Delgado, 2009). On the other hand, moral sensitivity refers to the ability to assess moral implications based on moral dilemmas in relation to vulnerable patients (Corley, 2002).

Antecedents of moral distress according to Wilkinson (1987) refer to the ability of nurses to make a moral decision, but inability to act on it, therefore, causing moral distress. It commonly happens when competing values precede the nurse’s values, therefore, defining the next step to be taken. The step taken taken, however, evokes feelings that cause nurses to feel, instead of alleviating pain, they cause undue pain. In cases of possible futile care and administrational constraints in ensuring quality healthcare delivery, the situation ends to be clearly apparent (Wilkinson, 1987). Elpern et al. (2005) report similar findings from the study indicating the dilemma nurses face when they feel that they are causing the patient undue suffering.

Moral distress negatively affects nurses’ self-image and their physical well-being. In addition, spirituality, job satisfaction, and personal relationships of nurses succumb o the negative influence of moral distress. Physical symptoms linked to moral distress include fatigue, insomnia, palpitations among others. Additionally, nurses have reported changes in health related and religious practices (Wilkinson, 1987). Similarly, Elpern et al. (2005) reported that moral distress impacted negatively on job satisfaction and retention. A respondent commented on the issue of job satisfaction saying “I often equate my job with keeping the dead people alive… of late I have been finding it difficult to work to work” (Elpern,Covert, & Kleinpell, 2005, p. 525).

Moral distress also impacted negatively on nurses’ attitude towards the patients. A respondent commented “It feels as I have created a defense mechanism of just blocking a patient’s death or inevitable death out of my mind” (Elpern, Covert, & Kleinpell, 2005, p. 526). The findings further established a correlation between moral distress and physical symptoms such as insomnia, changes in health-related decisions, religious practices, and loss of self worth.

Moral distress is a complex concept that has been widely researched in a bid to capture a clear definition. Various aspects of this definition have been established however, other aspects remain ambiguous, and there is a substantial need to evaluate further this concept. Moral distress contributes to a psychological and emotional that that limits people (nurses included) from taking the right course of action (Repenshek, 2009)).

Moral distress occurs when moral sensitivity has been demonstrated by a nurse identifying the source of the moral distress. In a study by Aft (2011), nurses identified the issue of inadequate nursing staffing as a situation causing moral distress. One respondent stated that she often encounters challenges emanating from understaffing. The nurse lamented that nothing was done to address the issue even after requesting the supervisor to send for additional nurses. According to her, understaffing compromises the care given to the patients.

Furthermore, moral distress is perceived to evoke negative feelings of frustration and guilt, especially in instances of futility care. This occurs when a patient who has a poor prognosis undergoes treatments, procedures, and tests constantly; this causes nurses to feel frustrated and guilty. A respondent described the following incident “Frequent episodes where the patient was coded over and over again because no one addressed the patient’s situation in a realistic way so that family. This was terribly frustrating because I could tell that the patient was gone but could not go out and talk to family myself about what was realistic” (Aft, 2011, p.1).

In the study conducted by Elpern et al. (2005), respondents described feelings of powerlessness, lack of support, and hopelessness. A respondent stated “It is extremely challenging to be in a situation whereby the nurse knows it is hopeless, but all available measures are implemented to prolong a patient’s life, and the nurse is powerless to do otherwise” (Erplen, Covert, & Kleinpell, 2005, p. 528).

Effects of Moral Distress

Moral distress has led to notable consequences on nurses. Negative impact on nurses’ physical well being has been recorded. According to a nurse respondent (Aft, 2011, p. 2) “It’s hard to sleep sometimes, wondering when will a patient die due to inadequate treatment because of the nurses’ inexperience or short staffing. I would feel physically sick to my stomach and request to change assignments for the next shift if possible. Sometimes I would even cry privately.” Negative impact on job satisfaction and retention has been linked to moral distress. For instance, a nurse respondent reported that he once wrote a 2-page letter to his supervisor requesting for a reshuffle to the acute care unit (Aft, 2011).

Moral distress also impacts negatively on self-image. For instance, according to Elpern et al. (2005), a respondent stated “My personality has changed to cynical, suspicious, unhelpful, and lacking enthusiasm, unwilling to help others” (Elpern, Covert, & Kleinpell, 2005, p. 29). In reference to spirituality, a respondent stated “If anything, my religious beliefs have gotten cynical” (Elpern, Covert, & Kleinpell, 2005, p. 530). In relation to health-related decisions, one of the respondents was quoted “I do not wish to give my liver for donation due to the way liver transplant is done here” (Elpern, Covert, & Kleinpell, 2005, p. 531). Another respondent said “Due to my experiences I have had discussions with my family members regarding their wishes as well as mine” (Elpern, Covert, & Kleinpell, 2005, p. 532).

Moral Distress and Moral Reckoning (Middle Range Theory)

Middle range theory can be defined as a group of related ideas which are diverted to a limited direction of the reality of nursing (Leihr & Smith, 2008, p. 15). These theories are composed of concepts and suggested relationships among these concepts that can be depicted in a model. An example of such a model is the moral reckoning theory. Moral reckoning theory refers to a situation whereby nurses’ beliefs and external forces engage in irreconcilable conflicts (Leihr & Smith, 2008, p. 20).

Moral reckoning propels nurses into a stage of resolution and reflection. Eventually, the theory enables nurses to handle conflicts and make morally acceptable decisions. Amazingly, moral reckoning theory and moral distress share common principles. Moral distress imposes institutional constraints that prevent individuals from making morally upright decisions. These constraints may reflect the external forces that are manifested in moral reckoning. Thus, moral distress is a manifestation of moral reckoning. The two concepts subject nurses’ morality to areal test. While moral distress exerts constraint on decision making, moral reckoning offers a chance for reevaluation of the constraint. Therefore, nurses need to be conversant with the two concepts in order to become sound decision makers and morally upright professionals.


Moral distress remains to be a widely researched phenomenon owing to its complex and multifaceted nature. The disequilibrium caused by knowing the right action to take but with the inability to act accordingly as a result of several factors, provokes emotional as well as psychological unrest causing moral distress. Moral sensitivity occurs in almost every field of nursing, especially in specialized units where conditions with poor prognosis are common. Research has been recently carried out in different areas such as surgical nursing (Aft, 2011), neuroscience (Russell, 2012), and critical care nursing (Elpern et al., 2005).

The findings have striking similarities on the negative consequences of moral distress and other similarities. This concept still needs to be further studied. The most crucial part entails the provision of practical and sustainable solutions to this issue that challenge a significant percentage of the nursing field. Moral distress, therefore, remains a complex concept that is significant not only to nurses but also to health workers and other stakeholders in the healthcare system.


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Wilkinson, J. (1987). Moral distress in nursing practice: Experience and effect. Nursing Forum, 23 (1), 16-29.

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