The lived experience of moral distress: nurses who assisted with elective abortions.

The concept of moral distress has been studied mainly as an occupational issue and has not been developed for use in clinical practice. This study was designed to bridge prior studies of occupational moral distress with future clinical investigations of moral distress. Study aims were to discover the essence, properties, and full content domain of the concept of moral distress in order to develop a universal definition of the concept. A modified phenomenological study of nurses' experience of a particular moral issue was conducted. A maximum variation sampling strategy was used to recruit a final sample of registered nurses (N = 10). Interior aversion is the essential act of moral distress. Five properties of the lived experience of moral distress were identified: perception, pain, valuing, altered participation, and perspective. Three types of moral distress identified in this study were: shocked, muted, and suppressed (persistent). Type of moral distress was related to situational conditions, recognition of moral ends, quality of coping processes, and temporal breadth. Negative outcomes of moral distress, which probably exist, were undetectable with this study design. The definition has been composed in universal terms, but remains tentative, since the full content domain of moral distress was largely but not definitively identified. Keywords: moral distress; conscious reflexivity; abortion; Roy Adaptation Model This study examined the lived experience of moral distress (Hanna, 2002). Study aims were to discover the essence, properties, and full content domain of the concept of moral distress so that the concept could be redefined in universally applicable terms. Although several gains have been made toward developing a universal definition with this study, additional work is needed. Since the concept has been studied mostly as occupational moral distress, a work-related moral issue was selected, but a novel approach was used to conduct this study. The selected issue was nurses' willing or unwilling assistance with the conduct of legal, elective, surgically-induced abortions. Nurses who assisted against their own will were legally unable to refuse their assignments at the time. Nurses in Europe and other areas of the world still ask for the right to refuse, but this right has not been universally accorded (Cignacco, 2002; Jones, 1999). Annually, 26 million legal, induced abortions are provided worldwide (Wulf, 1999). Nurses from Australia, Great Britain, Korea, the Netherlands, South Africa, Switzerland, the United States of America, and New Zealand have described moral distress or negative experiences due to work with abortions in the English language literature (Anonymous, 2000; Char & McDermott, 1972; Cignacco, 2002; D'Arcangelo, 1975; Dooley, 1994; Dyson & While, 1999; Gmeiner & Van Wyck, 2000; Gmeiner, Van Wyck, Poggenpoel, & Myburgh, 2000; Huntington, 1996; Hurry, 1997; Hurwitz & Eadie, 1977; Jones, 1999; Marshall, Gould, & Roberts, 1994; Musgrave & Soudry, 2000; Olson, 1980; Poggenpoel, Myburgh, & Gmeiner, 1998; Rosen, Werley, Ager, & Shea, 1974; Um, 1999; Van der Arend & Remmers-van der Hurk, 1999; Zahourek, 1972; Zahourek, Freemesser, Kass, & Van Reit, 1972). The total number of nurses affected internationally is unknown. BACKGROUND A literature analysis was conducted to determine the current state of knowledge related to the concept of moral distress (Hanna, 2002, 2004). The analysis revealed an incomplete definition of moral distress that could not be used for clinical nursing encounters. Jameton (1984) defined moral distress as an employer/employee conflict, whereby the employee knew the right thing to do, but was prevented by the employer from carrying it out. Jameton's view equated the antecedent cause with the experience of moral distress. A mismatch between actual findings reported and the commonly accepted definition was noted by several authors (Bamford, 1995; Corley, 1995; Powell, 1998; Wilkinson, 1987-88). …