Moving from conceptual ambiguity to knowledgeable action: using a critical realist approach to studying moral distress

Abstract

Moral distress is a phenomenon that has been receiving increasing attention in nursing and other health care disciplines. Moral distress is a concept that entered the nursing literature - and subsequently the health care ethics lexicon - in 1984 as a result of the work done by American philosopher and bioethicist Andrew Jameton. Over the past decade, research into moral distress has extended beyond the profession of nursing as other health care disciplines have come to question the impact of moral constraint on individual practitioners, professional practice, and patient outcomes. Along with increased interest in the phenomenon of moral distress have come increasing critiques - critiques that in their essence point to a serious lack of conceptual clarity in the definition, study, and application of the concept. Foundational to gaining conceptual clarity in moral distress in order to develop strategies to prevent and ameliorate the experience is a careful revisiting of the epistemological assumptions underpinning our knowledge and use of the concept of moral distress. It is our contention that the conceptual challenges reveal flaws in the original understanding of moral distress that are based on an epistemological stance that holds a linear conception of cause and effect coupled with a simplistic perspective of 'constraint' and 'agency'. We need a more nuanced approach to our study of moral distress such that our ontological and epistemological stances help us to better appreciate the complexity of moral agents acting in organizational contexts. We believe that critical realism offers such a nuanced approach.

Validation of an instrument to measure moral distress within the Australian residential and community care environments

“…Musto and Rodney (2016) also recognise this usage, but express concern over conceptual limitations. They suggest the original understandings of moral distress indicate a linear flow between cause and effect, which does not adequately consider the complexity for nurses (as moral agents) working within complex organisational contexts (Musto & Rodney, 2016). A need to understand these socio-political structures is seen as necessary in understanding the issue with clarity (Musto, Rodney, & Vanderheide, 2015).…”

“…Recently, McCarthy and Gastmans () identified most studies exploring moral distress as using Jameton's original definition. Musto and Rodney () also recognise this usage, but express concern over conceptual limitations. They suggest the original understandings of moral distress indicate a linear flow between cause and effect, which does not adequately consider the complexity for nurses (as moral agents) working within complex organisational contexts (Musto & Rodney, ).…”

Conscientious objection and moral distress: a relational ethics case study of MAiD in Canada

“…Other antecedent factors that a relationally oriented system could foster include: the ability to create meaning in life—including the meaning of morally distressing experiences, understanding and appreciating the diversity and contextual/cultural nature of values, the understanding that moral distress can lead to moral resilience and a perceived and/or actual reduction in moral stressors 20. Further research on moral resilience may help address the scant findings regarding constructive and sustainable solutions to moral distress 24…”

O sofrimento moral nas situações de final de vida em Unidades de Terapia Intensiva pediátrica: desenvolvimento do conceito

“…Muitos estudiosos concentraram-se também em trabalhos teóricos (Musto, Rodney, 2016;Lützen, Kvist, 2012;Rushton, Kaszniak, Halifax, 2013;Rushton, 2006), estudos de reflexão (Mendel, 2014;Wocial, 2002;Corley, Minick, 2002) e trabalhos de revisões (Cavinder, 2014;Huffman, Rittenmeyer, 2012;Burston, Tuckett, 2013;Kain, 2007;Hanna, 2004) sobre o sofrimento moral.…”