What We Know About Moral Distress.

: This article provides an overview of moral distress, including the existing research on the concept, and a discussion of ways to evolve our understanding of moral distress in order to meet current and future practice challenges.

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

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.

Toward interventions to address moral distress: navigating structure and agency.

BACKGROUND: The concept of moral distress has been the subject of nursing research for the past 30 years. Recently, there has been a call to move from developing an understanding of the concept to developing interventions to help ameliorate the experience. At the same time, the use of the term moral distress has been critiqued for a lack of clarity about the concepts that underpin the experience. DISCUSSION: Some researchers suggest that a closer examination of how socio-political structures influence healthcare delivery will move moral distress from being seen as located in the individual to an experience that is also located in broader healthcare structures. Informed by new thinking in relational ethics, we draw on research findings from neuroscience and attachment literature to examine the reciprocal relationship between structures and agents and frame the experience of moral distress. CONCLUSION: We posit moral distress as a form of relational trauma and subsequently point to the need to better understand how nurses as moral agents are influenced by-and influence-the complex socio-political structures they inhabit. In so doing, we identify this reciprocity as a framework for interventions.

Parents as caregivers for children with schizophrenia: moral dilemmas and moral agency.

Because the ability of people with schizophrenia to achieve anticipated success and independence is compromised, many of their parents assume responsibility for protecting, nurturing, and directing care for their offspring. The emotional, social, and financial challenges of caregiving, extended beyond the usual child-rearing duration, are complicated by the societal designation of their children as adults. Decisions about caregiving involve many practical and moral dilemmas. In this article, we examine several dilemmas encountered by parents who try to fulfill their perceived responsibility to care for adult children with schizophrenia. After exploring the related concept of moral agency, we close with some reflections on the assumptions surrounding psychiatric care and parental responsibility.