When health practitioners' moral choices and actions are thwarted by constraints, they may respond with feelings of moral distress. In a Canadian hermeneutic phenomenological study, physicians, nurses, psychologists and non-professional aides were asked to identify care situations that they found morally distressing, and to elaborate on how moral concerns regarding the care of patients were raised and resolved. In this paper, we describe the experience of moral distress related by nurses working in mental healthcare settings who believed that lack of resources (such as time and staff) leads to dispiritedness, lack of respect, and absence of recognition (for both patients and staff) which severely diminished their ability to provide quality care. The metaphors of flashlight and hammer are used to elaborate nurses' possible responses to intolerable situations.

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Once a term used primarily by moral philosophers, "moral distress" is increasingly used by health professionals to name experiences of frustration and failure in fulfilling moral obligations inherent to their fiduciary relationship with the public. Although such challenges have always been present, as has discord regarding the right thing to do in particular situations, there is a radical change in the degree and intensity of moral distress being expressed. Has the plight of professionals in healthcare practice changed? "Plight" encompasses not only the act of pledging, but that of predicament and peril. The author claims that health professionals are increasingly put in peril by healthcare reform that undermines their efficacy and jeopardizes ethical engagement with those in their care. The re-engineering of healthcare to give precedence to corporate and commercial values and strategies of commodification, service rationing, streamlining, and measuring of "efficiency," is literally demoralizing health professionals. Healthcare practice needs to be grounded in a capacity for compassion and empathy, as is evident in standards of practice and codes of ethics, and in the understanding of what it means to be a professional. Such grounding allows for humane response to the availability of unprecedented advances in biotechnological treatments, for genuine dialogue and the raising of difficult, necessary ethical questions, and for the mutual support of health professionals themselves. If healthcare environments are not understood as moral communities but rather as simulated marketplaces, then health professionals' moral agency is diminished and their vulnerability to moral distress is exacerbated. Research in moral distress and relational ethics is used to support this claim.

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The moral distress of psychologists working in psychiatric and mental health care settings was explored in an interdisciplinary, hermeneutic phenomenological study situated at the University of Alberta, Canada. Moral distress is the state experienced when moral choices and actions are thwarted by constraints. Psychologists described specific incidents in which they felt their integrity had been compromised by such factors as institutional and interinstitutional demands, team conflicts, and interdisciplinary disputes. They described dealing with the resulting moral distress by such means as silence, taking a stance, acting secretively, sustaining themselves through work with clients, seeking support from colleagues, and exiting. Recognizing moral distress can lead to a significant shift in the way we perceive moral choices and understand the moral context of practice.

Empirical phenomenology and hermeneutic phenomenology, the 2 most common approaches to phenomenological research in psychology, are described, and their similarities and differences examined. A specific method associated with each form of phenomenological inquiry was used to analyze an interview transcript of a woman's experience of work-family role conflict. A considerable degree of similarity was found in the resulting descriptions. It is argued that such convergence in analyses is due to the human capacities of reflection and intuition and the presence of intersubjective meanings. The similarity in the analyses is also encouraging about researchers' ability to reveal meaning despite the use of different methods and the difficulties associated with interpreting meaning.

A summary of the existing literature related to moral distress (MD) and the paediatric intensive care unit (PICU) reveals a high-tech, high-pressure environment in which effective teamwork can be compromised by MD arising from different situations related to: consent for treatment, futile care, end-of-life decision making, formal decision-making structures, training and experience by discipline, individual values and attitudes, and power and authority issues. Attempts to resolve MD in PICUs have included the use of administrative tools such as shift worksheets, the implementation of continuing education, and encouragement to report. The literature does not yet show these approaches to be effective in the resolution of MD. The need to acknowledge MD among PICU teams is discussed and an argument made that, to facilitate understanding among team members, practice stories need to be shared.

In this Canadian study, a participatory action research approach was used to examine the relationships between families of residents of traditional continuing care facilities and the health care team. The objectives were to (a) explore the formation and maintenance of family-staff relationships, with attention paid to the relational elements of engagement and mutual respect; (b) explore family and staff perspectives of environmental supports and constraints; and (c) identify practical ways to support and enhance these relationships. Results indicate that the resource-constrained context of continuing care has directly impacted family and staff relationships. The nature of these relationships are discussed using the themes of "Everybody Knows Your Name," "Loss and Laundry," "It's the Little Things That Count," and "The Chasm of Us Versus Them." Families' and staff's ideas of behaviors that support or undermine relationships are identified, as are concrete suggestions for improving family- staff relationships in traditional continuing care settings in Canada.