Making Sense of Moral Distress Within Cultural Complexity

Abstract

The aim of this study was to explore nurses’ experiences working on a chronic ventilator-dependent unit with a predominance of elderly Orthodox Jewish patients at the end of life. Little is known about how cultural complexity creates differences between nurses’ and family’s expectations for patient care at the end of life. A qualitative study of 27 nurses was conducted using focus groups. Early interviews led to the expansion of the original question to include exploring nurses’ moral distress. Content analysis revealed 3 categories of themes, one of which is highlighted in this article. The main finding was an incongruence of perspectives, described as depth-of-field dissimilarity, in which the focus and depth of perspective depend on the person doing the looking. This study suggests that depth-of-field dissimilarity can be used to develop educational strategies, clinical interventions, and research to address moral distress and cultural complexity.

Understanding how patient’s personal value systems challenge nurses’ views when providing care

“…Similar to Bressler, Hanna, and Smith, [9] the nurses in this study experienced internal conflict related to caring for patients with contrary beliefs and practices. As noted in the theme moral code, these differences challenged the nurse's values adding to their internal conflict and their moral obligation to care.…”

“…Yap [10] makes a case for personal beliefs as influential in moral decision making and identified the need for an ethical framework in social-scientific education for students early on in their careers. Bressler, Hanna, and Smith's [9] study showed nurses did experience internal conflict when providing care that was contrary to their values; nurses in their study asked for more education on cultural and religious issues to improve their ethical practice.…”

“…[17] Studies involving end-of life have shown to evoke strong emotions from caregivers including subjective views that may conflict with the wishes of patients and their families. [9,18] In fact, imposition of personal views about what is perceived as correct care can override those of the patient. [18] A qualitative study with end-of-life elderly Jewish Orthodox patients explored conflicting values specific to cultural and religious differences that led to morally distressing experiences; nurses in the study experienced internal conflict when care was contrary to their beliefs.…”

“…[3,5,7,8] As nurses care for patients with diverse backgrounds, it is inevitable that there may be differences in values and that these conflicting beliefs could have a distressing nature. [9,10] The interpersonal aspect of the nurse and the patient places both parties in a relational situation where either could have differing practices. [11] Hanna [12] suggests that moral distress can be experienced when personal beliefs or practices are compromised.…”

“…[18] A qualitative study with end-of-life elderly Jewish Orthodox patients explored conflicting values specific to cultural and religious differences that led to morally distressing experiences; nurses in the study experienced internal conflict when care was contrary to their beliefs. [9] A mixed methods design addressing ethical reasoning skills (a framework used to assess the morality of a situation) in students in a biotechnology program in secondary education found that one's own beliefs and attitudes can be influential in moral situations and may even override what is deemed morally correct. [10] Personal conflict as a result of differences in value systems may be a moral challenge faced by nurses when caring for individuals with different values and beliefs than their own and is an area of limited study.…”