Nurses experience stress, fear and anger while they are trying to reconcile their ideals/ goals about health care with its inadequacies and abuses (Jameton, 1984:5), while at the same time trying to stay true to their convictions (Lindh et al., 2010:552). Moral distress is experienced when nurses cannot adhere to these goals (Corley, 2002:637). Conflicting moral principles, stress-provoking and contradicting demands weaken the nurse’s sense of control, power and autonomy (Lützen et al., 2010:213). The current descriptions of moral distress inadequately define the concept, and this might lead to the inconsistent use of the term moral distress. Therefore, conceptual clarity is needed. Current available instruments measure antecedents and situations causing moral distress. Therefore, an instrument measuring the attributes of moral distress is urgently needed. Such an instrument might be used in a variety of clinical departments because it is not based on department-specific situations but on the attributes of moral distress. Moral distress has a great impact on the nurse, patient care and the organization. This research used Benson and Clark’s (1982) method of instrument development as a theoretical framework. It is the aim of this study to develop and validate an instrument to measure moral distress in the clinical health care context of the professional nurse. In order to attain this aim the following objectives were set: To conduct an integrative literature review to identify antecedents, consequences, attributes and empirical indicators of moral distress; to conduct interviews to explore professional nurses’ experience of moral distress; to develop an instrument to measure moral distress in professional nurses; to validate the instrument. A qualitative and quantitative research design with explorative, descriptive and contextual strategies was used. The research process was divided into phases. During Phase One, an integrative literature review was conducted and the population included all available national and international data on moral distress in nurses/ nursing and sampling included all-inclusive sampling. Data analysis was performed through descriptive synthesis.Phase Onealso included semi-structured interviews and the population included professional nurses working in hospitals and clinics in the North-West Province. The sampling method applied was purposive sampling. Tesch’s method was used as data analysis method. During Phase Two, a content validation was conducted and the population included experts in the field of moral distress and instrument validation, and purposive sampling was applied. Data collection was done through the instrument that was developedand data analysis was the content validity index. Phase Twoalso included a qualitative evaluation which was conducted and the population consisted of professional nurses working in hospitals and clinics in the North-West Province and purposive sampling was applied. Data was collected through the developed instrument and a focus group session. Data analysis was conducted through aconsensus discussion. During Phase Three, a pilot study was conducted and the population was professional nurses working ina hospital with different departments and clinics in the Free State Province. All-inclusive sampling was applied and the instrument that was developed was used as data collection. Data analysis included: Descriptive statistics, factor analysis (exploratory, confirmatory and Bartlett’s test of spherity), Cronbach’s alpha coefficient, correlations and ANOVA. According to the results from the face-, content-, exploratory and confirmatory, discriminant- as well as divergent validity, the instrument has been shown to be valid. The Cronbach’s alpha for the Moral Distress Instrument was deemed reliable. Finally, the research was evaluated and limitations were identified. Recommendations for nursing education, -practice, research and policy were formulated. / PhD (Nursing), North-West University, Potchefstroom Campus, 2014

Published literature has focused on understanding moral distress from a descriptive standpoint. Missing from the literature is an exploration of the role a nurse can play in his/her/own moral distress.A qualitative study with an interpretive design incorporated Clandinin and Connelly' narrative methodology. Results highlighted assumptions were made by participants in the absence of resources, which led them to" know the right action to take" from their own perspective.

Background: Moral distress is an increasing concern among nurses in their workplace. Previous research has suggested that moral distress is associated with ethical climate and job dissatisfaction. Economic restraints in the organization have led to loss of nurses from the workplace. Aim: To examine nurses experience of moral distress and their causes. Method: The study was a literature review. Twelve articles were used in the study. They had both qualitative and quantitative approaches. The articles were published between 2000-2011. Results: Three themes emerged from the articles: Powerlessness, meaninglessness and feeling unsafe. The main cause of these feelings was due to understaffing and working with nurses I consider unsafe. Another cause was to perform tasks that I consider meaningless for the patient and cause more harm than good. Conclusion: Moral distress is common among nurses in health care. It can be elicited from different kinds of situations encountered in the work environment. Keywords:  experience, job satisfaction, moral distress, nursing, occupational stress

Sjuksköterskor upplever stora krav och stor belastning i sitt dagliga arbete, dels från patienter, dels från kollegor och dels från sig själva vilket gör att de ofta känner sig otillräckliga. Den stora fysiska och psykiska belastningen leder till att sjuksköterskor känner oro över kvaliteten på vården vilket ger upphov till moralisk stress. Sjuksköterskor upplever moralisk stress i högre grad än andra professioner och är en betydande orsak till att sjuksköterskor avslutar sin anställning. I tidigare forskning har få studier moralisk stress som huvudsyfte. Därför syftar denna allmänna litteraturstudie till att undersöka närmare vad sjuksköterskan upplever i sin moraliska stress. Syftet var att beskriva sjuksköterskans upplevelser av moralisk stress. För att besvara syftet valdes 13 kvalitativa vetenskapliga artiklar ut. I resultatet framkom sex kategorier: Maktlöshet, Frustration, Vånda, Ilska, Självtvivel och Skuld. Maktlöshet har en betydande roll och många av de andra känslorna bottnar i maktlösheten. Maktlöshet beror framförallt på att sjuksköterskan inte känner sig delaktig i beslutsfattandet kring patienten. För att minska sjuksköterskans moraliska stress kan samverkan mellan professioner främjas. Vidare svensk forskning kan behövas för att identifiera om moralisk stress är en bidragande orsak till rådande sjuksköterskebrist. / Nurses are experiencing huge demands and big loads in their daily work, both from patients and from colleagues and from themselves so that they often feel inadequate. This great physical and psychological workload means that nurses are concerned about the quality of care which gives rise to the moral distress. Nurses are experiencing this moral distress at greater extent than other professions and is a major reason why nurses quit their jobs. In previous research, few studies have moral distress as their main purpose. Therefore this general literature review intends to look more closely at what the nurse is experiencing in his or her moral distress. The purpose was to describe the nurse's experiences of moral distress. For this purpose, 13 qualitative research articles were selected and the results revealed six categories: Powerlessness, Frustration, Agony, Anger, Self-doubt and Guilt. Powerlessness has a significant role and contributed to many of the other emotions listed. Powerlessness is mainly due to the nurse not feeling involved in decision-making regarding the patient. To reduce the nurse's moral distress collaboration between professions could be encouraged. Further Swedish research could be needed to identify whether moral distress is a contributing factor to the current nursing shortage.

Intensivvårdssjuksköterskor uttrycker upplevelser av moralisk stress i det dagliga arbetet och detta kan leda till utbrändhet eller behov av att byta yrke då de inte lyckas bemästra sin situation. Studiens syfte var att kartlägga moralisk stress hos intensivvårdssjuksköterskor med hjälp av Moral Distress Scale(MDS). Studien utfördes med en deskreptiv metod av tvärsnittsdesign där 45 sjusköterskor med intensivvårdsutbildning i västsverige tillfrågades att vid ett tillfälle besvara en enkät med en validerad svensköversatt MDS. Resultatet påvisade att det finns signifikant höga nivåer av moralisk stress hos intensivvårdssjuksköterskor yngre än 45 år(p=0,044) och även i gruppen med kandidat/-magisterexamen(p=0,003). De högsta nivåerna av moralisk stress kunde uppmätas när intensivvårdssjuksköterskorna ställdes inför situationer där de upplevde att ingen var beredd att fatta beslut om att avsluta livsuppehållande behandling. Bristande kompetens, "onödiga" behandlingar och resursbrist medförde också hög moralisk stress. För att motverka moralisk stress behövs enligt studier; debriefing, etiska vårdkonferenser och stöd från arbetsledningen. Denna studie kan bidra till att åskådliggöra moralisk stress och intesnifiera diskussionen samt skapa ett gemesnamt språk kring moralisk atress bland intensivvårdssjuksköterskor.

Over the last three decades, there has been a growing body of literature that has described moral distress as a prominent issue that negatively affects critical care nurses. However, little focus has been given to how nurses cope and continue on in their practice despite the hardship that moral distress can cause. This study sought to reveal nurses’ strategies of coping with moral distress to allow for a better understanding of this aspect of critical care nurses’ experiences. This study adopted a qualitative design that used Thorne’s (2008) approach to interpretative description. Face-to-face, semi-structured interviews were conducted with seven critical care nurses employed within two ICUs of a tertiary care academic hospital. Interviews were analyzed using Aronson’s (1995) approach to thematic analysis. The experience of coping with moral distress had an overarching theme of being “like grass in the wind.” Four major themes were identified: Going Against What I Think is Best, Moral Distress- It’s Just Inherent in Our Job, It Just Felt Awful, and Dealing with It.

The concept of compassion fatigue (CF) emerged in the early 1990s in North America to explain a phenomenon observed in nurses employed in emergency departments. A precursor to burnout, CF is a well-known phenomenon associated with emotional exhaustion, depersonalization, and an inability to work effectively. In nurses, CF has been shown to reduce productivity, increase staff turnover and sick days, and lead to patient dissatisfaction and risks to patient safety. The aim of this study was to determine if the use of a Watson Room designated as a 'quiet zone' with warm colors on the wall, massage chair, and soothing sounds in the workplace environment, reduced CF in clinical nurses at the bedside in acute care settings. The data came from a survey of nurses (n = 19) working in a level 1 trauma center in an acute care setting. This quantitative study was conducted over a two week period. A single-group of nurses completed both a pre and post professional quality of life (ProQol) survey, a 30 item self-measurement of positive and negative aspects of caring. The ProQol operationalizes in three subcategories: compassion satisfaction (10 items), burnout (10 items), and CF (10 items). The ProQOL survey results showed statistically significant differences in the mean scores in all three categories. Paired samples t tests indicate the Watson Room proved to be successful in increasing compassion satisfaction (p = .009), decreasing burnout (p = .002), and decreasing secondary trauma/CF respectively (p = .02). This study shows the importance of nurses taking care of themselves while taking care of others. Understanding CF and devising and implementing interventions to address the subject are important for nurses and patients.

In this thesis, I propose an argument against the possibility of moral dilemmas, which I construe as situations in which moral wrongdoing is inescapable. The first chapter addresses some terminological matters and attempts to sort out the main issues of contention between proponents and opponents of moral dilemmas. The second chapter lays out my argument, which I dub the "Argument from Action-Guidingness," against proponents of moral dilemmas. Negative moral judgments of the sort "X is wrong" typically carry with them the implication that X ought not to be done. If judgments of wrongness always have this action-guiding force, then moral dilemmas, which say that all courses of action available to the agent are morally wrong, threaten morality with incoherence. To avoid this problem, proponents of dilemmas will be forced to abandon the action-guiding implications of negative moral judgments when dilemmas arise. But this move is not without its own difficulties, which I elucidate. The final chapter identifies flaws in two prominent arguments in favor of dilemmas: the argument from moral distress and the argument from incommensurable values. The latter half of the chapter examines Sayre-McCord's "fairness argument" against dilemmas, and contrasts it with the argument from action-guidingness. / Master of Arts

This paper provides an analysis of Bradshaw and Colleagues' model of military healthcare professionals' moral distress experiences. Using novel interview data collected from Canadian Forces healthcare professionals, the steps of the model are validated or potential refinements are suggested. / Military healthcare professionals (HCPs) may experience moral distress during international deployment. Moral distress is experienced when a HCP faces a moral dilemma, e.g., knows the morally correct course of action but is blocked from taking it, or where all available courses of action require something of moral significance be given up. While the literature indicates that moral distress often negatively impacts the mental health of the individual and the effectiveness of the organization, limited research has examined moral distress amongst military HCP. Many similar stressors and psychological health problems are present for both civilian and military HCP; however, the unique context of deployment necessitates further examination. This thesis explores the military HCP experience with moral distress by using Bradshaw and colleague’s model of progression from the encounter with a moral dilemma to the impact on individuals and organizations. Through the analysis of novel interviews collected by the Ethics in Military Medicine Research Group (EMMRG), Bradshaw and colleague’s model of military moral distress is compared to participant’s experiences and qualitatively analysed, with the results outlining where the model is supported and where refinement is recommended. These challenges were then supported by a literature review from the disciplines of virtue and feminist ethics, moral psychology, bioethics, and civilian HCP moral distress research. Two novel and significant revisions to the model are suggested: representing and integrating the cumulative experience of moral distress, and re-conceptualizing the resolution process based on the consideration of contextual controllability on moral responsibility. / Thesis / Master of Science (MS) / This thesis examines the experience of moral distress in military healthcare professionals (HCPs) while working abroad, where a HCP faces a moral dilemma, e.g., knows the morally correct course of action but is blocked from taking it or it requires something of moral significance be given up. This thesis analyses the most recent model of military HCP moral distress (Bradshaw, et al., 2010) by comparing it to the experiences described by participants in the Ethics in Military Medicine Research Group (EMMRG) study. The results outline support for the model as well as novel suggestions for revision, which are supported by literature from a variety of disciplines. Two adjustments to Bradshaw and colleague’s model are suggested: clearer representation of the cumulative nature of moral distress as well as a reconceptualization of the resolution process to consider the influence of the immediate and extended environment on moral responsibility.

Bakgrund: Etisk stress upplevs av sjuksköterskorna när deras handlingar är moralisk rätta men de blir hindrade av att utföra dessa på grund av reella eller upplevda hinder. När etiska problem uppstår har sjuksköterskorna ICN´s etiska kod att stödja sig på. Sjuksköterskor som var involverade i patientnära vård var mer troliga att uppleva etisk stress. Den etiska stressen kan leda till att sjuksköterskorna lämnar sin profession. Syftet: Syftet med studien var att beskriva sjuksköterskornas upplevelse av etisk stress i omvårdnadsarbetet. Metod: Studien är en kvalitativ litteraturöversikt med induktiv ansats. Studien baseras på 12 artiklar som studerat etisk stress.  Dataanalysen skedde i fem steg enligt Friberg’s modell för analys av litteraturöversikt. Resultat: Två huvudkategorier identifierades i litteraturöversikten. Dessa var: Att vara begränsad i att ge rätt vård samt Att ta den lätta vägen istället för den rätta vägen. Slutsats: Reflektionen som ett redskap är undervärderat och bör tillämpas för att lindra etisk stress och/eller öka patientsäkerheten.  Etisk stress kan komma att öka då sjuksköterskeprofessionen står inför en stor personalbrist. / Background: Moral distress is experienced by the nurses when they know the right thing to do but are constrained by real or experienced obstacles. When ethical problems arise the nurses can rely on find support in ICN's ethical code. Bedside nurses where more likely to experience moral distress. Moral distress can result in nurses leaving the profession altogether. Aim: The aim of the study was to describe nurses’ experiences of moral distress in nursing care. Method: The study is a qualitative study with an inductive approach. It was a literature review conducted on 12 studies on moral distress. Data analysis was done in five steps according to Friberg model (2012a) for analysis of literature reviews. Result: Two main themes where identified in this literature review. These where "to be limited in conducting good care" and "taking the easy way instead of the right way". Conclusion: Reflection as a tool is undervalued and ought to be used to relieve moral distress and/or improve patient safety. Ethical stress may increase because the nursing profession is facing a major shortage of staff.