A Grounded Theory of Moral Reckoning in Nursing

By Alvita K. Nathaniel, DSN, APRN, BC


Moral distress is a pervasive problem in nursing, contributing to nurses’
emotional and physical health problems, loss of nurses’ ethical integrity,
dissatisfaction with the work of nursing, and loss of nurses from the workforce.
The purpose of this research was twofold: 1) to further elucidate the
experiences and consequences of professional nurses’ moral distress and 2) to
formulate a logical, systematic, and explanatory theory of moral distress and its
consequences. METHOD: This Glaserian grounded theory study utilized
volunteer and purposive sampling to recruit 21 registered nurses. Analysis of the
data resulted in an original substantive theory of moral reckoning in nursing,
which reaches further than the concept of moral distress, identifying a critical
juncture in nurses’ lives and better explaining a process that affects nurses and
the health care that they deliver. Results: Moral reckoning in nursing consists of
a three-stage process. After a novice period, the nurse experiences a Stage of
Ease in which there is comfort in the workplace and congruence of internal and
external values. Unexpectedly, a situational bind occurs in which the nurse’s
core beliefs come into irreconcilable conflict with social norms. This forces the
nurse out of the Stage of Ease into the Stage of Resolution, in which the nurse
either gives up or makes a stand. The nurse then moves into the Stage of
Reflection in which beliefs, values, and actions are iteratively examined. The
nurse tries to make sense of experiences through remembering, telling the
story, examining conflicts, and living with the consequences. Implications: In
today’s complex health care system, nurses find themselves faced with morally
troubling situations which if not resolved can lead to serious consequences for
nurses, patients, and the health care system as a whole. This study sets the
stage for further investigation on the human consequences of moral distress.
Further, since moral reckoning impacts health, nurse leaders are challenged to
identify opportunities to facilitate successful moral reckoning in the workplace
through encouraging nurses to tell their stories, examine conflicts, and
participate as partners in moral decision making.


The investigator’s curiosity was initially piqued by stories about nurses’
experiences with moral distress in the workplace. Moral distress is the pain or
anguish affecting the mind, body, or relationships resulting from a patient care
situation in which the nurse is aware of a moral problem, acknowledges moral
responsibility, and makes a moral judgment about the correct action; yet, as a
result of real or perceived constraints, participates, either by act or omission, in
a manner perceived by the nurse to be morally wrong (Jameton, 1984;
Wilkinson, 1987-88; Nathaniel, 2003). According to extant literature, situations
involving moral distress may be the most difficult problems facing nurses,
resulting in unfavorable outcomes for both nurses and patients. Because of
moral distress, nurses experience physical and psychological problems,
sometimes for many years (Kelly, 1998; Wilkinson, 1987-88; Perkin, Young,
Freier, Allen & Orr, 1997; Fenton, 1988; Davies, et al., 1996; Krishnasamy, 1999;
Anderson, 1990). Reports of the number of nurses who experience moral
distress vary. Redman & Fry reported that at least one-third of nurses in their
study (n = 470) experienced moral distress (2000). Nearly fifty percent of nurses
in another study (n = 760) reported that they had acted against their
consciences in providing care to the terminally ill (Solomon, et al., 1993).
Between 43 and 50 percent of nurses leave their units or leave nursing
altogether after experiencing moral distress (Wilkinson, 1987-1988; Millette,

Extant literature also implies that moral distress affects the quality of nursing
care when nurses distance themselves from patients, become emotionally
unavailable, avoid going in patients’ rooms, leave the unit, or leave nursing
altogether (Viney, 1996; Davies et al., 1996; Krishnasamy, 1998; Fenton, 1988,
Wilkerson, 1987-88; Corley, 1995; Millett, 1994; Redman & Fry, 2000). Between
12 and 50 percent of nurses leave nursing or change their practice site as a
direct result of moral distress (Millette, 1994; Corley, 1995; Wilkinson, 1987-88).
Thus, moral distress may be a factor in the present nursing shortage–a selfperpetuating
downward spiral.


Grounded theory is an inductive method in which theory emerges from the data.
It moves from the systematic collection of data in a substantive area to the
development of a multivariate conceptual theory. To allow continued discovery
and flexibility of exploration, as is appropriate to grounded theory research, this
study began with the following broad research question that narrowed and
redirected as the research progressed: What transpires in morally laden
situations in which nurses experience distress? With advice and guidance of Dr.
Barney Glaser, co-originator of the grounded theory method, the phenomenon
of moral distress among professional nurses was explored and a substantive
theory of moral reckoning emerged. The study was conducted in accordance
with the original method as described by Glaser and Strauss (1967) and
subsequently refined by Glaser (1978, 1996, 1998).

This study utilized a combination of nonprobability techniques of volunteer and
purposive sampling as described by Chinn (1986). The purpose of
nonprobability sampling is to describe, foster understanding, and elicit meaning.
Participants were initially selected because they could shed light on the
phenomenon under investigation. Subsequent sampling was related to the
findings that emerged in the course of the study, with the process continuing
until saturation was met. The investigator aspired to interview a broadly
representative cohort of nurses. Participants were recruited through various
means including an advertisement published a state nurses’ association
newsletter, distributed to nurse leaders for sharing with others, and posted at a
state nurses’ convention and regional nursing research conference. In the
advertisement, nurses were asked to either email or call (toll-free) the principle
investigator if he/she had ever been involved in a troubling patient care situation
that caused distress. Neither gender nor minority groups were excluded. The
target population included all registered nurses who had ever experienced
distress in relation to a moral/ethical problem in a patient care situation. All
those responding to the advertisement were interviewed until saturation of
categories was reached.

Participants were interviewed in an unstructured casual manner. This provided
an efficient, yet meaningful mix of interview, observation, and conceptualization.
Initial interviews were conducted in person or over the telephone. Face-to-face
interviews were conducted in quiet, private locations close to informants’ homes.
When face-to-face interviews were impracticable because of distance, interviews
were conducted by the telephone or through email. No interviews were
conducted in participants’ work settings. As recommended by Glaser (1998),
interviews were neither taped nor transcribed. Brief, unobtrusive
contemporaneous notes were taken to ensure that field notes were factually
correct. Field notes were written immediately following the interviews—usually
within one hour.

As is hallmark of the constant comparative method, analysis began with the first
episode of data gathering and occurred simultaneously with other steps of the
grounded theory process. Data were analyzed sentence by sentence and were
then coded. The coded data were organized into concepts and further into
categories, which were subsequently integrated into theory. Throughout the
process, emerging ideas about concepts and processes were recorded in the
form of conceptual memos. Theoretical sampling began when the investigator
found categories that required more refinement or areas that need more depth.
The core variable was identified when it emerged as the one to which all others
related. As categories became saturated and the relationships among them
became clear, the substantive Theory of Moral Reckoning in Nursing was found
to effectively synthesize, organize, and transcend what was previously known
about moral distress. During the final write-up, conceptual memos were
organized and field notes were revisited to illustrate the newly discovered theory.


The sample consisted of 21 registered nurses. Twenty were female and 17 were
married. Informants were highly educated and experienced: 2 with associate
degrees, 3 with bachelor degrees, 13 masters degrees, and 3 doctorates.
Nineteen participants were Caucasian, 1 was Hispanic, and 1 Native American.
Eighty percent had more than 10-year’s professional experience. Forty-three
percent reported that they had left a position because of a morally distressing

As the interviews were coded and compared, it became clear that moral
distress, the original focus of the investigation, was not emerging as a major
category. Specifically, the definition of moral distress in the literature is free from
process connotations, includes a requirement that the nurse must participate in
moral wrongdoing, and goes little further than to describe the psychological
implications. The definition of moral distress also implied an adversarial
relationship in which nurses are opposed by powerful wrongdoers. This
definition was not supported by the data in the present study, so it constituted
springboard for further investigation. As the data unfolded, new basic social
psychological process of Moral Reckoning was discovered to be the core
concept. Moral distress, as described in the extant literature, relates to three
facets of the highly organized theory of moral reckoning as follows: Moral
distress a) is triggered by a situational bind, b) overlaps a tiny portion of one
stage of a larger process, and c) overlaps a larger segment of a basic social
process. Figure 1 depicts the theory and its relationship to moral distress.

Figure 1. Moral distress overlaps the process of Moral Reckoning
[please see PDF version for all diagrams]

Moral Reckoning, the core category, captures the culmination of the entire,
three-stage process. It connotes a process during which nurses critically and
emotionally reflect on motivations, choices, actions, and consequences of a
particularly troubling patient care situation. To reckon is defined as follows: “To
recount, relate, narrate, tell; to allege; to calculate, work out, decide the nature
or value of; to consider, judge, or estimate by, or as the result of calculation; to
consider, think, suppose, be of opinion; to speak or discourse of something; and
to render or give an account (of one’s conduct, etc)” (Simpson & Weiner, 1989,
Vol. XIII, p. 335-336). The three distinct stages of Moral Reckoning are the
Stages of Ease, the Stage of Resolution, and the Stage of Reflection. Each
stage is comprised of unique properties. Figure 2, illustrates the grounded
theory of moral reckoning with its stages and properties.

Figure 2. Stages and properties of Moral Reckoning [please see PDF version for all diagrams]

Stage of Ease

Integral to the Stage of Ease are the properties of (a) becoming, which signifies
an ongoing refinement of stable core beliefs and values of the individual, (b)
professionalizing, which relates to inculcation of the professional norms, (c)
institutionalizing, which signifies the process of internalizing institutional social
norms, and (d) working, the unique experience of the work of nursing. As is
noted in the following sections, conflict between and among the conditions
during a critical incident produce a situational bind.

Each person evolves a set of core beliefs and values through the process of
becoming. Core beliefs evolve over time through experience and from teaching
and modeling of parents, teachers, ministers, peers, and so forth. Moral integrity
indicates integration and consistency of core values over time (Beauchamp &
Childress, 2001). Evidence of participants’ core beliefs emerged from their
stories and included such indicators as their membership in a caring profession,
their sense of responsibility to relieve suffering, their commitment to uphold
professional and institutional norms, and the tumult that occurred when core
beliefs were challenged.

For nurses, professionalizing refers to inculcation of certain unique cultural
norms learned in nursing school and early practice. Conceptual ideals that
contribute to the nurse’s idea of what a good nurse should be or do are
considered professional norms. Nurses’ professional norms complement core
beliefs for the most part, so that the profession and professional norms become
internalized and uniquely important to the person. Nurses learn explicitly that
they have unique relationships with patients and that they are responsible to
keep promises implicit in the relationship. Perceived professional norms include
the following non-exclusive implicit rules: one must follow physicians’ orders,
complete assigned work with expert skill, and remain altruistic.

Through the process of institutionalizing, nurses are socialized within the
institutional setting to a different set of implicit and explicit norms. Institutional
norms are variably congruent with nurses’ core beliefs and professional norms.
For example, nurses learn to complete a job according to institutional standards
and respect lines of authority. Assuring that the business makes a profit,
following orders, handling crises without making waves, and covering are some
implicit institutional norms. Speaking about her disappointment within the health
care setting, one informant said, “Corporate is bigger than life itself.”

Working is another condition of the first stage of Moral Reckoning. The unique
work of nursing is varied, challenging, and rewarding and requires technical skill
and attendance to many facets of patients’ lives. Nurses work at “arm’s length”
(Penticuff, 1997) from patients as they attend to the most personal and private
of needs. In the process, they learn tremendous amounts about patients’ hopes,
fears, and desires. They get to know patients who stay on their units for
extended periods or return many times. Nurses hear what patients say and
understand the meaning. They intimately know about suffering patients—from
touch, sight, smell, and sound. Patients’ interests, very clearly, become nurses’
interests. Their descriptions of the work of nursing include vivid sensual
descriptions and heart-wrenching stories. Doing the work of nursing includes the
properties of knowing patients, witnessing suffering, accepting responsibility to
care, desiring to do the work well, and knowing what to do. Held in fragile
balance, the conditions of becoming, professionalizing, institutionalizing, and the
work of nursing comprise the Stage of Ease. Nurses are motivated by core
beliefs and values to uphold congruent professional and institutional norms
during this stage. Having technical skills and feeling satisfied to practice within
the boundaries of self, profession, and institution, nurses are comfortable, they
know what is expected of them and experience a sense of flow and
at-homeness. One informant said, “Early in my career I was employed in the
hospital setting and very conscientious about my work. I was very in-tune to the
patients and their care, wanting to make sure that everything was done that was
supposed to be done and that I completed all my work before the next shift
came on. I loved the challenge of the medically difficult patient. I always did well
in the emergencies—CPR, GI bleeds, chest pains, etc. After those first few
months of new nurse jitters, I felt at ease and comfortable at my station….” The
Stage of Ease is depicted in figure 3.

Figure 3 During the Stage of Ease, moral problems in the presence of
compatible core values and professional and/or institutional norms lead to
satisfactory solutions.  [please see PDF version for all diagrams]

The Stage of Ease continues as long as the nurse experiences fulfillment with
the work of nursing and comfort with the integration of core beliefs and
professional and institutional norms. For some, a morally troubling event will
challenge the integration of core beliefs with professional and institutional
norms. Nurses find themselves in Situational Binds that herald a critical juncture
in their professional lives.

Situational Binds

A situational bind interrupts the Stage of Ease. Situational binds involve an
intricate interweaving of many factors including professional relationships,
divergent values, workplace demands, and other implications with moral
overtones. Situational binds vary in their complexity, context, and particulars but
are similar in terms of their immediate and long-term effects. Nurses’ turmoil
may meet or exceed the traditional definitions of moral distress. Situational binds
compel nurses to make difficult decisions and culminate in critical junctures in
their lives. As depicted in figure 4, nurses feel constricted by binds involving
conflicts with ethical/moral overtones that occur between core values, and
professional or institutional norms or between nurses and others. When this
happens, inner dialogue guides the nurse toward critical decisions in which he
or she must choose one value or belief over another. Situational binds
encountered by nurses in this study included intricate combinations of demands
and conflicts with both moral and practical implications. Specific types of
situational binds include conflicts between a) core values and professional or
institutional norms, b) participants with imbalance of power, and c) nurses’
values and workplace deficiencies: all of which lead to consequences for nurses
and patients. Situational binds and their resolution constitute critical junctures as
nurses moves toward the processes of resolution and reflection—the remaining
stages of moral reckoning.

Figure 4. During the Stage of Ease, moral problems in the presence of
compatible core values and professional and/or institutional norms lead to
satisfactory solutions.   [please see PDF version for all diagrams]

Professional or institutional norms may challenge core beliefs. This is evidenced
when informants reveal core beliefs as they talked about the struggle to come to
terms with conflicts involving professional or institutional norms. For example,
one nurse is still troubled because she believes she tortured a patient when she
followed orders. The patient was a young woman for whom the physician had
ordered “nothing by mouth.” Through the day, the woman begged for something
to drink. Following orders, the nurse refused to give the woman fluids. The
young woman died the next day and the nurse still struggles with the “harm” she
feels she caused the woman. In this case, the nurse was in a bind because the
actions prescribed by the profession and institution (maintaining NPO status)
conflicted with the nurse’s commitment to relieving suffering, which seemed to
her to be the morally correct action.

Situational binds are often the result of asymmetrical power relationships during
morally troubling patient care situations. Many times, nurses believe they are
excluded from the ethical decision-making process. They feel strongly that they
have a duty to respect patients’ wishes and to affect appropriate outcomes and
they are frustrated when their attempts fail. For example, several informants
voiced a sense of powerlessness in situations in which physicians and family
members seemed to make important life decisions that were in conflict with
autonomous patients’ wishes. Specific decisions included performing surgery,
inserting feeding tubes, and performing resuscitation. The nurses were strongly
committed to patients’ rights to make autonomous decisions, yet they were not
able to successfully advocate for the patients’ choices. Even though they tried to
intervene, they felt great distress when patients suffered.

Power imbalance is also evident when physicians do not believe what nurses tell
them. This is a frequent theme. Because nurses feel a strong sense of
responsibility to patients and take seriously the implicit promise to relieve their
suffering, they are frustrated when they attempt to communicate patients’ wishes
or status to physicians who will not listen. Informants talked about instances
when physicians refused to come in to see patients, refused to order emergency
medication, or disbelieved the nurses’ assessment of patients’ deteriorating
conditions. One nurse talked about her distress when a series of consultants
ignored her concerns about a patient’s deteriorating condition following a
gunshot wound to the neck. The patient died from a simple wound because
physicians ignored the nurse’s appeals.

Sometimes nurses perceive themselves to be in binds when there is no frank
moral wrongdoing, but rather divergent core beliefs. When decision makers have
legitimate beliefs that are different from the nurse, the nurse might believe that
moral wrongdoing is occurring. For example, several informants denounced
physicians who they believed coerced families or patients to make decisions
consistent with the physicians’ personal beliefs, but conflicting with the nurses’
beliefs. In these cases, even though an objective bystander would not identify
moral wrongdoing, the nurses felt a great deal of distress. Paradoxically, the two
types of cases in which this was most dramatic included instituting life
sustaining measures and allowing patients to die.

On occasion, nurses experience distress when deficiencies in the workplace
lead to patient harm.Workplace deficiencies place nurses in situational binds
because they challenge nurses’ core values. Specific deficiencies identified in
this study included chronic staff shortage, unreasonable institutional
expectations, and equipment failure. For example, nurses can be overwhelmed
by overly heavy patient care assignments. This constitutes a situational bind
when a nurse is truly committed to providing care that meets professional and
institutional standards, yet must care for more patients than he or she believes
is safe. This leads to distress when the nurse cannot meet all of his or her own
and others’ expectations and lingering guilt about real or potential harm to
patients. One nurse tearfully recalled a morning when a visitor had a cardiac
arrest on her unit. The nurse was responsible for “working the code” while no
one cared for her assigned patients.Years later, she continues to be troubled
about the potential harm to patients who essentially had no nurse that day and
by the violation of her own values.

There are consequences that occur as the result of situational binds. During the
situational bind and for some time afterwards, nurses experience profound
emotions and reactive behaviors directed toward themselves or others.
Participants said they were “very torn,” “bothered horribly,” and “incredibly sad.”
They talked about feelings of guilt, anger, powerlessness, conflict, depression,
outrage, betrayal, and devastation. They also experienced physical
manifestations such as near syncope, crying, sleeplessness, and vomiting.
Reactive behaviors included fleeing the unit, going into a rage, drinking alcohol,
and sacrificing self.

Nursing care subsequent to situational binds is affected in a number of ways.
Following morally troubling situations, nursing care may be negatively affected,
unchanged, or improved. Different than extant reports of moral distress, very few
informants in this study reported that their nursing care was negatively affected.
One nurse was able to perform only routine tasks at the desk and called for a
replacement within a couple of hours. Another said even though she had always
loved her work, after a troubling incident she resigned because she believed her
care would be affected. In contrast, most nurses reported that their nursing care
improved as a direct result of a situational bind. Some reported that they were
compelled to make up for what they considered to be harm resulting from
others’ moral wrongdoing by giving more compassionate care—even to the point
of sacrificing themselves. One nurse talked about feeling compassion for the
patient and trying to treat him with dignity. Others said that their care improved
in the long term because they were better prepared to deal with situational
binds. In any case, painful feelings and realizations about harm to patients
propels nurses toward the Stage of Resolution.

Stage of Resolution

Situational binds constitute crises of intolerable internal conflict and produce
critical junctures in nurses’ lives. In order to maintain moral integrity, something
must be done immediately to rectify the situation. The move to set things right
signifies the beginning of the Stage of Resolution. For most, this stage alters
professional trajectory. There are two foundational choices in the Stage of
Resolution: making a stand and giving up. These choices are not mutually
exclusive. In fact, many nurses give up initially, regroup, and make a stand.
Others make an unsuccessful stand and give up at a later time.

Some nurses resolve their distress by making a stand. All forms of making a
stand include professional risk. Nurses make a stand when they initiate
negotiations, refuse to follow physicians’ orders, break the rules, whistle blow,
and so forth. Making a stand is rarely successful in the short term, but may
occasionally improve the overall situation in the long term. For example,
informants made a stand when they refused to help with resuscitation of
patients who had voiced their objection, to sign coerced surgical consent, and to
administer potentially fatal doses of medication. Sadly, in every case, another
nurse was willing to intervene and follow the questionable order.

In contrast, nurses may also resolve a situational bind by giving up. In general,
nurses give up because they recognize the futility of making an overt stand.
They are simply not willing to sacrifice themselves to no avail. They may also
give up to protect themselves or to seek a way or find a place where they can
live their ground projects with better integration of core beliefs, professional
norms, and institutional norms. Specifically, giving up includes participating in an
activity considered to be morally wrong, leaving the unit or resigning, or leaving
the profession altogether. For example, a number of informants talked about
feeling as if they have given up when, against their conscience, they
administered medication in doses that they knew were likely to be lethal. This
occurred almost exclusively when patients were dying. Nurses subsumed their
core beliefs to institutional norms, which strongly favored following physicians’
orders. They administered the medications with regret and resigned from their
positions soon afterwards. Nurses do not pass through the Stage of Resolution
unscathed, yet they do move forward—into the Stage of Reflection.

Stage of Reflection

The Stage of Reflection may last a lifetime during which nurses reflect and
reckon their actions. In most cases, the incidents nurses recall occurred early in
their careers. During the Stage of Reflection nurses raise questions about prior
judgments, particular acts, and the essential self. The interrelated properties of
the Stage of Reflection include remembering, telling the story, examining
conflicts, and living with consequences.

One of the more intriguing properties of the Stage of Reflection is remembering.
After situational binds nurses retain vivid mental pictures. These memories
evoke emotions many years later. One nurse said, “I don’t let go of it.” Nurses
experience sensual memories of the incident—memories of the sights, sounds,
and smells. After 15 or 20 years, informants talked about patients’ faces, exact
locations of the patients’ beds, and sometimes a patient’s position in bed. Unlike
their memories of other patients, nurses remember particulars about patients
involved in morally troubling situations such as their names, ages, and
diagnoses. For example, one nurse recalled that the patient was wrapping
Christmas presents at home when she was injured. As she talked about his
incident she called forth emotions as well as memories.

Nurses experience evoked emotion many years after the situational bind.
Emotions that are evoked as nurses remember morally troubling situations
include feelings of guilt and self-blame, lingering sadness, anger, and anxiety.
Unlike descriptions of moral distress, nurses feel guilt and self-blame even when
they did not actually participate in moral wrongdoing. They experience guilt
related to the patient’s outcome, rather than their own participation in a troubling
event. Even when they report a series of events in which they are above
reproach, informants continue to blame themselves for the harm that occurred
to patients. Lingering effects include anxiety attacks, crying episodes,
depression, and prolonged psychiatric care.

Nurses also continue to express anger toward those they believe were
responsible for causing harm to patients. Physicians, other nurses, and
institution administrators are targets of anger and blame. Anger harbored over
many years leads to fracturing of professional relationships. For example, talking
about a physician who did not respond during an emergency, one nurse said, “I
still have no use for him.”

Remembering is an iterative process with nurses continuing moral reckoning
over time—telling the story as they try to make sense of it. Informants in the
present study desired to tell their stories, volunteering to participate in hour-long
interviews and later voicing gratitude for the chance to tell their stories. Telling
their stories evoked emotions even though troubling patient situations may have
occurred 15 to 20 years previously. Regardless of the interval between the
incident and the telling of it—many wept as they talked about the incidents.

Remembering and telling their stories, nurses begin examining conflicts in the
situations. They struggle as they examine conflicts between personal values and
professional ideals. They examine their values and ask themselves questions
about what actually happened, who was to blame, and how they can avoid
similar situations in the future. Thus, they move toward full-dimensional,
reflective awareness of experiences, thoughts, feelings, emotions, and values.

As nurses think about their roles in what they consider past moral wrongdoing,
some make practical decisions. They set limits or rules concerning future
actions. They identify a point beyond which they will not go and some vow to
take risks to help patients in the future.

Nurses experience living with the consequences for a prolonged period. Since
they are no longer comfortable in the original workplace, nurses move from one
institution to another or from one specialty area to another. They are likely to
seek further education, often intending to correct the type of moral wrongs they
experienced in the past. Many informants in this study attended graduate school
subsequent to their morally troubling event. Few of them remain at the bedside,
even though most talked about enjoying the work they were doing during the
Stage of Ease.


The current study identifies a very powerful, yet heretofore unidentified basic
social process. The theory is powerful because it has fit and relevance, and it
works. Congruent with Glaser (1998), concepts and categories of Moral
Reckoning emerged from stories told by nurses (fit); emergent concepts relate
to true issues of the nurses interviewed (relevance); the stages account for most
of the variation of nurses’ behavior (work); and, the theory can be constantly
modified to fit and work with relevance. Thus, this theory, which is rigorously
grounded in data is easily understandable and imbues trust. Moral Reckoning is
a new and original theory that establishes unique connections—making familiar
ideas relevant, while giving integrative scope and a new perspective. Because
the theory is very broad and overarching, it provides opportunities for future
research that can move in many directions.

The theory calls for programs of research that will further explore and more fully
develop its categories and concepts and begin to identify causes and make
comparisons and predictions. Vigorous theoretical sampling is needed to 1)
allow a more thorough and useful understanding of the stages of Ease,
Resolution, and Reflection and different ways that nurses might progress
through them, 2) provide a better understanding of core values as they intersect
with professional and institutional norms, and 3) modify the theory to include
different types of nurses.

In addition, nursing ethics research is needed to shed light on what nurses
understand about nursing ethics, the depth of this understanding, how their
understanding of nursing ethics factors into every day decision making, and
what kinds of learning leads to empowered, patient-centered, ethical decision
making. Further qualitative and quantitative research is also needed to
determine the characteristics of nurses who experience moral distress and
moral reckoning versus those who do not and the quality of patient care
provided by each group. Correlational research is needed to identify nurses who
leave and those who stay, particularly in relation to whether or not they
experience moral distress and moral reckoning. In the face of the nursing
shortage, this has implications for nurse recruiting and retention. If, as the
present study suggests, caring and sensitive nurses leave the bedside, it is
important for research to identify strategies to retain them.

Research on moral reckoning should not be limited to the profession of nursing.
The Grounded Theory of Moral Reckoning in Nursing easily lends itself to
development of a formal grounded theory of moral reckoning—one that is
generalizable to other substantive areas. Investigators have an opportunity to
use the theory with other professions and to modify it for a wide variety of
populations. It is an evocative theory, which has the power to widely inform
practitioners and leaders about the realities of the struggle between personal
moral convictions and collective decision making.

This new theory encompasses moral distress, but reaches further—identifying a
critical juncture in nurses’ lives and better explaining a process that includes
motivation and conflict, resolution, and subsequent reflection. Based on the life
experiences of nurses, the Grounded Theory of Moral Reckoning in Nursing is a
powerful new theory that has fit, work, and reliability, and is easily modifiable. It
transcends, organizes, and synthesizes the extant literature on moral distress,
and explains stages of a newly identified basic social process, which is also
relevant to many other substantive areas. It also offers important implications for
nursing practice, education, and administration and, in the face of a nursing
shortage of crisis proportions, presents urgent and unique opportunities for
further investigation.


Alvita K. Nathaniel, DSN, APRN, BC
Coordinator of Family Nurse Practitioner Track
Assistant Professor
West Virginia University, School of Nursing
3110 MacCorkle Avenue, SE
Charleston, West Virginia 25304


Phone: (304) 347-1224
Fax: (304) 347-1346
E-mail: anathaniel@hsc.wvu.edu


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