RELATED LITERATURES

Nurses frequently make ethical decisions in the course of their work even though they
may not always be aware of doing so. They have different roles as a health care
provider, and it is inevitable to experience distress in the nature of their profession.
Moral distress is a major problem in nursing and it has generated a remarkable level of
interest among scholars in the field of nursing. (McCarthy,2008). The quality of nursing
practice is being threatened by the increasing frequency and complexity of ethical
challenges that nurses face in their daily routines. (Davis, 2012) Nurses may face
obstacle, resulting in conflict between their moral judgement regarding the most
appropriate

course

of

action

and

the

actual

treatment

given

to

patients.

(Austin,et.al,2005) this causes the nurses to doubt whether they are fulfilling their duty
as patient advocate and trusted care givers.
Moral distress is identified as a psychological disequilibrium resulting from not knowing
the ethical action to take but not taking it due to an inhibiting medical power structure or
institutional policy. (Jameton,1984,1993) it is also described as a sensory event: a
negative feeling state experienced when a person makes moral decision but does not
follow through by performing the moral behavior indicated by that decision.
(Corley,2002). A study was conducted among Iranian intensive care nurses and four
dimensions of moral distress were identified, namely: institutional barriers and
complaints, communication problems, futile actions, malpractice and medical/care
errors, and inappropriate responsibilities, resources and competencies. The study
showed that the dimensions of moral distress may vary in different settings.
(Shorideh,2012).

Moral distress can emanate from a variety of causes with variations also between
practitioners in the same clinical situation. A nurses world view such as expectations of
standards of care, (Austin, 2003) moral sensitivity (Lutzen,2010), and individual ethical
perspectives (Cutcliffe,2008) all contribute to the moral distress experience. Perceptions
of moral distress may develop from cumulative life experiences and prior experiences in
similar or identical situations. The notion that professional experience is a contributing
factor is intriguing, there has been some suggestion made that the length of experience
in nursing increased the exposure frequency to episodes of moral distress. (Rice,2008)
furthermore, nurses lacking experience in addressing ethically challenging situation may
be at higher risk of experiencing moral distress. (Meaney,2002). There has been
qualitative evidence that reveals that nurses experience moral distress when they fail to
act as advocates for patients based on their moral choices while dealing with
institutional constraints. (Rittenmeyer,2009) A study was conducted to determine the
prevalence and contributing factors of moral distress in medical and surgical nurses and
the results revealed that intensity of moral distress was uniformly high in situations
related to physician practice, nursing practice, institutional factors, futile care, deception
and euthanasia. (Rice,2008).
The Military is an organization well prepared and experienced in the rapid mobilization
and deployment of large volumes of personnel, equipment, and supplies. Military
operations other than war, however, present some unique challenges to the capabilities
of the military nurses because the focus is different. The limitations of the military or
these operations are related primarily to the failure or limited ability of the military nurse
to meet the needs of the affected populace within the deployment area. (Agazio,2010)

Moral Distress is particularly significant in the field of military nursing services. Nurses in
the military have the need to be responsive at a moments notice to take action in critical
settings and other related military crisis. They have the duty to accept deployment to
different places locally and internationally. Military forces of any country must be
assured that its nurses maintain a high readiness capability and that they can perform at
peak efficiency for long periods of time under certain conditions. Thus, any military force
is concerned about the moral well-being of military nurses and anything, including moral
distress, which can affect their ability to carry out their job effectively, Moral distress
occurs when a person has responsibility for a moral action, experiences an obstacle in
carrying out the desired action, and then experiences negative feeling states when the
action is not carried out. The experience of moral distress explicitly requires people to
have a responsibility for some action and to feel responsible for the outcomes of their
action. Two dimensions were identified with regards to military nursing moral distress
phenomenon, these are the psychological disequilibrium experienced when military
nurses encounter barrier to their desired moral behavior and the negative feeling such
as frustration, anger, anxiety, powerlessness, discomfort and hurt, that accompany the
experience of psychological disequilibrium. (Fry et al.1984, 2002).

SUMMARY OF RELATED LITERATURES

TITLE &
AUTHOR/S
Moral distress
experienced by
nurses: A
quantitative
literature review
Youngjae Oh &
Chris Gastmans

Gender and the

experience of moral
distress in critical
care nurses
Christopher B
OConnell

MAJOR
OBJECTIVES
The aim of the
review was to
examine the
quantitative
empirical
literature about
moral distress
experienced by
nurses. The
review included
the intensity and
frequency of
moral distress,
sociodemogrphi
c variables that
influence the
frequency and/or
intensity of
moral distress,
factors
influencing
moral distress
and
mechanisms of
nurses
The main aim is
to determine if
there is a
significant
gender
difference that
exists in the
moral distress
scores of critical
care.

VARIABLES

FINDINGS

METHOD

The variables
included are
sociodemographi
c variable,
sources,
psychological
responses and
coping strategies
concerning moral
distress.

The review
clarified the
notion that
nurses
experience a
rather low
frequency of
moral distress,
but a
moderately
intense level of
moral distress.
Although
morally
distressing
experiences
may not be
frequent, they
may have
significant
impact when
they do occur.

The study
conducted an
extensive
research in
different
established
databases to
acquire articles
on nurses moral
distress since
Jameton first
defined the
concept.

The dependent
variable in the
study was the
experiences of
critica care
nurses in critical
care setting. The
independent
variable was the
gender of the
nurses who

The results
revealed a
statistically
significant
gender
difference in
mean moral
distress scores
of participants.
Females
reportedly

Utilizing a
quantitative
descriptive
design,
participants were
recruited via an
internet nursing
community. No
material
incentives for
participation were

participated in the
study.

Moral distress and

Avoidance behavior
in nurses working in
critical care and
noncritical care
units
Mary Jo De villers
and Holli A DeVon

Ethical Issues Of
Air Force Nurse
Practitioners
In Clinical Practice
Carol Lynn
Gilchrist, BSN,
Capt, USAF, NC

The purpose of
this descriptive,
cross sectional
study was to
determine
similarities and
differences in
moral distress
and avoidance
behavior
between critical
care nurses and
non-critical care
nurses
Little has been
written about the
ethical issues
faced by nurse
practitioners.
This study
explored some
of the ethical
issues faced by
experienced
nurse
practitioners in
clinical practice.
The purpose of
this research is
to describe and
interpret the

The variable of
interest include
location of
employment,
length of work
experience, moral
distress,
avoidance
thoughts and
behavior, age,
gender, and
race/ethnicity.

The variables
included are
Educational level,
employment
status, years of
experience

statistically
significantly
higher moral
distress scores
than did males.
Overall, the
moral distress
scores for both
groups were
relatively low.
There was a
small positive
correlation
between moral
distress and
avoidance
behaviors for
both the
groups. Moral
distress is
present in both
critical care and
non-critical care
nurses.
Nonmaleficenc
e and
beneficence
were often
difficult to
separate as
frequently
they were
interwoven in
situations that
AFNPs
encountered.
The principle of
justice
was more
clearly stated in
terms of the

offered. Data
analysis was
conducted using
IBM1 SPSS ver.
21.

A cross-sectional
design was used
to compare the
relationship of
moral distress
and avoidance
behavior.

As a method,
phenomenology,
concerned
primarily with
description of the
experience, and
eliminating
presuppositions
from the
recounting of the
experience.
qualitative
method of
research was
also used to
interpret the
meaning of lived

ethical issues
AFNPs
encounter in
clinical practice.

Moral distress:
levels, coping and
preferred
interventions in
critical care and
transitional care
nurses
Melissa A. Wilson,
Diana M.
Goettemoeller,
Nancy A. Bevan, &
Jennifer M.
McCord.

Impact of ethical
climate on moral
distress revisited:
multidimensional
view
Gulem Atabay,
Burcu Guneri
Cangarli, &
Sebnem Penbek

To examine the
level of and
frequency of
moral distress in
staff nurses
working in two
types of units in
an acute care
hospital and to
gather
information for
future
intervention
addressing
moral distress.

To investigate
the relationship
between
different types of
ethical climate
as described in
Victor and
Cullens
framework and
moral distress
intensity among
nurses in

AFNPs feeling
limited in their
ability to
provide
equal treatment
for all patients
The variables
Overall, the
included are
nurses reported
Years as RN, age, lower levels
education level,
and frequency
certification, &
of moral
years in MS ICU. distress in
these units but
their openended
responses
appeared to
indicate moral
distress.
Nurses
identified
specific
resources that
they would find
helpful to
alleviate moral
distress.

The variables
included are Age,
gender, education
level, & years of
experience.

Positive
correlations
were identified
between certain
types of ethical
climate and
moral distress
intensity.

ethical
experiences
of AFNPs.

A descriptive
questionnaire
was used. Nurses
completed the 38
item moral
distress scale , a
coping
questionnaire and
indicated their
preferred
methods for
institutional
support in
managing
distressing
situation a
convenience
sample of staff
nurses was
approached to
complete the
moral distress
questionnaire.
This study is a
correlational
study between
ethical climate
and moral
distress. An
online survey was
administered to
collect data.
Questionnaire
includes moral
distress and

Turkish health
care settings.

Relationship
between Intensive
care unit nurses
moral distress with
burnout and
anticipated turnover
Foroozan
Atashzadeh
shoorideh, Tahereh
Ashktorab, Farideh
Yaghmaei & Hamid
Alavi Majd.

Determinants of

To determine
correlation
between moral
distress with
burnout and
anticipated
turnover in
intensive care
unit nurses.

The variables
included are Age,
Gender, Marriage
status, Education
level, Work
experience, &
work shift.

To determine the

The values of

ethical climate
scales in addition
to demographic
questions
Descriptivecorrelational
study.

The finding
showed ICU
nurses moral
distress and
anticipated
turnover was
high but
burnout was
moderate. The
results revealed
that there was a
positive
statistical
correlation
between ICU
nurses age,
their work
experience and
the fraction pof
nurses number
to number of
ICU beds with
their moral
distress and
burnout.
However, there
was no
correlation
between
gender,
marriage
status,
educational
degree and
work shift and
moral distress.
The intensity of A prospective

moral distress in
medical and
surgical nurses at
an adult acute
tertiary care
hospital
Elizabeth M. Rice
MSN, Mohamed Y.
Rady MD PhD,
Arreta Hamrick PAC, Joseph L.
Verheijde PhD
MBA, & Debra K.
Pendergast MSN

prevalence and
contributing
factors of moral
distress in
medical and
surgical nurses.

age, current
employment and
nursing
experience for the
entire study
cohort were
chosen to convert
continuous
variables into
categorical
variables. The
independent
variables include
nursing
experience and
type of patient
illness

moral distress
was uniformly
high to
situations
related to
physician
practice,
nursing
practice,
institutional
factors, futile
care, deception
and euthanasia.
Encounter
frequencies
with years of
nursing
experience and
caring for
oncology and
transplant
patients.

cross-sectional
survey using
moral distress
scale tool was
administered to
medical and
surgical nurses at
an adult acute
care hospital.