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jillian on Nov 29, 2004 in
Issue no.1, November 2004,
Volume 04 |
Comments Off on A Grounded Theory of Moral Reckoning in Nursing
By Alvita K. Nathaniel, DSN, APRN, BC Abstract 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. Significance 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,...