Re‐examining the relationship between moral distress and moral agency in nursing

Abstract

In recent years, the phenomenon of moral distress has been critically examined—and for a good reason. There have been a number of different definitions suggested, some that claimed to be consistent with the original definition but in fact referred to different epistemological states. In this paper, we re‐examine moral distress by exploring its relationship with moral agency. We critically examine three conceptions of moral agency and argue that two of these conceptions risk placing nurses' values at the center of moral action when it ought to be the patient's values that shape nurses' obligations. We propose that the conception of moral agency advanced by Aimee Milliken which re‐centers patient values, should be more broadly accepted within nursing. We utilize a case example to demonstrate a situation in which the values of a patient's parents (surrogates) justifiably constrained nurses' moral agency, creating moral distress. Through an examination of constraints on nurse agency in this case, we illustrate the problematic nature of ‘narrow' moral distress and the value of re‐considering moral distress. Finally, we provide an action‐oriented proposal identifying mediating steps that we argue have utility for nurses (and other healthcare professionals) to mediate between experiences of narrow moral distress and the exercise of moral agency.

Sub-categories of moral distress among nurses: A descriptive longitudinal study

“…22 There are three significant critiques of current moral distress scales: that they fail to generate participant responses representative of the clinical and ethical situation 25,26 ; perpetuate the assumption morally distressed individuals have correctly assessed the ethically supportable pathway 12 ; and scale items do not prompt the ethical reflection required to address moral distress. 25,26 In addition, these scales focus on constraint-based moral distress only. The approach used in this study to capture five sub-categories of moral distress may enhance diagnostic capability and lead to more specific testing of interventions.…”

“…22 Some scholars may question, therefore, whether a new moral distress measure is needed when the Moral Distress Scale-Revised is valid, reliable and has been used internationally, 20,23,24 and the newer MMD-HP shows promising validity and reliability. 22 There are three significant critiques of current moral distress scales: that they fail to generate participant responses representative of the clinical and ethical situation 25,26 ; perpetuate the assumption morally distressed individuals have correctly assessed the ethically supportable pathway 12 ; and scale items do not prompt the ethical reflection required to address moral distress. 25,26 In addition, these scales focus on constraint-based moral distress only.…”

Moral Distress as Moral Heuristic Missing the Mark

“…A decade ago, a colleague and I proposed a link between moral distress and epistemic injustice as an insidious influence on nurses’ moral agency in their work environments (Reed & Rishel, 2015). Similarly, scholars today are turning toward explicating the “constraints” embedded in the definition of moral distress (for example, Morley & Sankary, 2024). In doing so, they suggest that a nurse’s feeling or intuition of moral distress is a “call to action”—a call to step back and broaden one’s perspective, reflect on one’s feelings, interrogate the situation, and engage with others about their values.…”