Colleen Varcoe

Registered Nurses’ Perceptions of Moral Distress and Ethical Climate

Moral distress is a phenomenon of increasing concern in nursing practice, education and research. Previous research has suggested that moral distress is associated with perceptions of ethical climate, which has implications for nursing practice and patient outcomes. In this study, a randomly selected sample of registered nurses was surveyed using Corley’s Moral Distress Scale and Olson’s Hospital Ethical Climate Survey (HECS). The registered nurses reported moderate levels of moral distress intensity. Moral distress intensity and frequency were found to be inversely correlated with perceptions of ethical climate. Each of the HECS factors (peers, patients, managers, hospitals and physicians) was found to be significantly correlated with moral distress. Based on these findings, we highlight insights for practice and future research that are needed to enhance the development of strategies aimed at improving the ethical climate of nurses’ workplaces for the benefit of both nurses and patients.

Framing the Issues: Moral Distress in Health Care

Moral distress in health care has been identified as a growing concern and a focus of research in nursing and health care for almost three decades. Researchers and theorists have argued that moral distress has both short and long-term consequences. Moral distress has implications for satisfaction, recruitment and retention of health care providers and implications for the delivery of safe and competent quality patient care. In over a decade of research on ethical practice, registered nurses and other health care practitioners have repeatedly identified moral distress as a concern and called for action. However, research and action on moral distress has been constrained by lack of conceptual clarity and theoretical confusion as to the meaning and underpinnings of moral distress. To further examine these issues and foster action on moral distress, three members of the University of Victoria/University of British Columbia (UVIC/UVIC) nursing ethics research team initiated the development and delivery of a multi-faceted and interdisciplinary symposium on Moral Distress with international experts, researchers, and practitioners. The goal of the symposium was to develop an agenda for action on moral distress in health care. We sought to develop a plan of action that would encompass recommendations for education, practice, research and policy. The papers in this special issue of HEC Forum arose from that symposium. In this first paper, we provide an introduction to moral distress; make explicit some of the challenges associated with theoretical and conceptual constructions of moral distress; and discuss the barriers to the development of research, education, and policy that could, if addressed, foster action on moral distress in health care practice. The following three papers were written by key international experts on moral distress, who explore in-depth the issues in three arenas: education, practice, research. In the fifth and last paper in the series, we highlight key insights from the symposium and the papers in the series, propose to redefine moral distress, and outline directions for an agenda for action on moral distress in health care.

Critical cultural perspectives and health care involving Aboriginal peoples

Despite a growing body of critical scholarship in nursing, the concept of culture continues to be applied in ways that diminish the significance of power relations and structural constraints on health and health care.In this paper, we take a critical look at how assumptions and ideas underpinning conceptualizations of culture and cultural sensitivity can influence nurses’ perceptions of Aboriginal peoples and Aboriginal health. Drawing on examples from our research, we examine how popularized assumptions about culture can shape nurses’ ideas about the context of Aboriginal health, and views of Aboriginal patients. These assumptions and perceptions require closer scrutiny because of their potential to influence nurses’ practice with Aboriginal patients. Our specific aims are to: (a) consider some of the limitations of cultural sensitivity in relation to health care involving Aboriginal peoples;(b) explore how ideas about culture have the potential to become problematic in nursing practice with Aboriginal peoples; and(c) explore the relevance of a ‘critical cultural approach’ in extending our understanding of culture in relation to Aboriginal peoples’ health. We discuss a critical cultural perspective as one way of broadening nurses’ understandings about the complexities of culture and the many facets of culture that require critical consideration. In relation to Aboriginal health, this will require nurses to develop greater critical awareness of culture as a relational process, and as necessarily influenced by issues of racism, colonialism, historical circumstances, and the current political climate in which we live.

Reinterpretations Across Studies: An Approach to Meta-Analysis

The authors undertook a qualitative meta-analysis of their own studies to examine the context of health care and health care relationships. They “translated” selected concepts and metaphors from each study through those of the other studies, yielding new interpretations. In this article, they present their methods, discuss possible applications of this approach, and examine some issues that remain unresolved in the area of qualitative meta-analysis. They offer this approach, which produced broader perspectives than the individual studies afforded, as a promising way of synthesizing qualitative findings, providing a foundation for praxis, and influencing practice toward health and social justice.

Modelling the effects of intimate partner violence and access to resources on women's health in the early years after leaving an abusive partner ☆

Although the negative health effects of intimate partner violence (IPV) are well documented, little is known about the mechanisms or determinants of health outcomes for women who had left their abusive partners. Using data collected from a community sample of 309 Canadian women who left an abusive partner, we examined whether womens personal, social and economic resources mediate the relationships between the severity of past IPV and current health using structural equation modelling. A good fit was found between the model and data for hypothesized models of mental and physical health. In the mental health model, both the direct and total indirect effects of IPV were significant. In the physical health model, the direct effect of IPV on physical health was about four times as large as the total indirect effects. In both models, more severe past IPV was associated with lower health and womens personal, social, and economic resources, when combined, mediated the relationship between IPV and health. These findings demonstrate that the health outcomes of IPV for women who have left an abusive partner must be understood in context of womens resources.

Nurses’ perceptions of and responses to morally distressing situations:

Research on moral distress has paid limited attention to nurses’ responses and actions. In a survey of nurses’ perceptions of moral distress and ethical climate, 292 nurses answered three open-ended questions about situations that they considered morally distressing. Participants identified a range of situations as morally distressing, including witnessing unnecessary suffering, being forced to provide care that compromised values, and negative judgments about patients. They linked these situations to contextual constraints such as workload and described responses, including feeling incompetent and distancing themselves from patients. Participants described considerable effort to effect change, calling into question the utility of defining moral distress as an “inability to act due to institutional constraints” or a “failure to pursue a right course of action.” Various understandings of moral distress operated, and action was integral to their responses. The findings suggest further conceptual work on moral distress and effort to support system-level change.

Health Care Relationships in Context: An Analysis of Three Ethnographies

A qualitative meta-analysis of three ethnographic studies conducted by the original investigators of those studies yielded new understandings of the dynamics of health care relationships in context. Through this analysis, the authors show that moral judgments and decision making in health care are highly relational and contextual. The use of power to compel health care providers and patients to comply with organizational practices is shown as fundamental to organizational functioning, and nurses participate in activities that often perpetuate conditions that contribute to their own moral distress. Furthermore, resistant actions often operate to sustain the practice patterns and ideologies being resisted. The authors call for an understanding of moral distress as relational and for collective strategies to counter practices that thwart ethical practice.

Moral Distress: Tensions as Springboards for Action

In the previous four papers in this series, individual versus structural or contextual factors have informed various understandings of moral distress. In this final paper, we summarize some of the key tensions raised in previous papers and use these tensions as springboards to identify directions for action among practitioners, educators, researchers, policymakers and others. In particular, we recognize the need to more explicitly politicize the concept of moral distress in order to understand how such distress arises from competing values within power dynamics across multiple interrelated contexts from interpersonal to international. We propose that the same socio-political values that tend to individualize and blame people for poor health without regard for social conditions in which health inequities proliferate, hold responsible, individualize and even blame health care providers for the problem of moral distress. Grounded in a critical theoretical perspective of context, definitions of moral distress are re-examined and refined. Finally, recommendations for action that emerge from a re-conceptualized understanding of moral distress are provided.

Cultural adaptation and translation of measures: An integrated method

Differences in the conceptualization and operationalization of health-related concepts may exist across cultures. Such differences underscore the importance of examining conceptual equivalence when adapting and translating instruments. In this article, we describe an integrated method for exploring conceptual equivalence within the process of adapting and translating measures. The integrated method involves five phases including selection of instruments for cultural adaptation and translation; assessment of conceptual equivalence, leading to the generation of a set of items deemed to be culturally and linguistically appropriate to assess the concept of interest in the target community; forward translation; back translation (optional); and pre-testing of the set of items. Strengths and limitations of the proposed integrated method are discussed.

Knowledge Translation in Everyday Nursing: From Evidence-based to Inquiry-based Practice

The interconnection of theory, evidence, and practice is most often conceptualized as an epistemological enterprise. In this article, we shift the discussion from one that is solely concerned with epistemology to one that considers the significance of ontology and the way in which epistemology and ontology are intricately intertwined in every nursing action. Drawing on deconstructive hermeneutics, we contend that to understand and affect the interconnection of theory, evidence, and practice, an ontological inquiry at the action level is required. Using a nursing practice example, we illustrate the complexities of knowledge translation and how effective integration of knowledge into practice involves an embodied process of ontological inquiry and action. This inquiry process draws on theory and evidence to enlarge and imagine possibilities for action in particular moments, situations, and contexts and rests in a way-of-being in which the interconnection of theory, evidence, and practice is embodied.