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Personal View
International Journal of
Pharmacy Practice
International Journal of Pharmacy Practice 2015, 23, pp. 361–366

The issue of moral distress in community pharmacy practice:

background and research agenda
Jayne L. Astbury, Cathal T. Gallagher and Richard C. O’Neill
Department of Pharmacy, University of Hertfordshire, Hatfield, UK

Keywords Abstract
community pharmacy; patient safety;
professional ethics; professional practice Objectives Moral distress arises from situations in which the individual identifies
the morally right action required, but feels unable to act accordingly due to organi-
Correspondence sational constraints within the work place. Research into this phenomenon has
Dr Cathal T. Gallagher, Department of
focused predominately on the experience of those in the nursing profession, due to
Pharmacy, University of Hertfordshire, Hatfield,
Herts, AL10 9AB, UK.
its perceived moral grounding and its traditionally subordinate role. As the concep-
E-mail: c.t.gallagher@herts.ac.uk tual boundaries of moral distress have developed, so too has the research interest in
the experiences of other professional groups. Here, we seek to determine if there is
Received August 28, 2014 scope to study moral distress in pharmacists.
Accepted December 12, 2014 Methods A review of the literature on moral distress in healthcare professions was
undertaken.
doi: 10.1111/ijpp.12174
Key findings Pharmacists working in the UK operate within a highly-regulated
occupational sphere, and are bound by strict legal frameworks and codes of profes-
sional conduct. This regulatory environment, when combined with the emerging
recognition that pharmacy is a value-based profession with a strong ethical ground-
ing, creates the potential for moral distress to occur due to the limitations placed on
acting in congruence with ethical judgements. Studies concerning moral distress in
nurses have identified significant negative consequences for both the practitioner
and for the quality of patient care.
Conclusions To date, the incidence of moral distress among UK-based community
pharmacists remains unexamined. Research must be undertaken to determine what
situations cause the highest instances of moral distress for community pharmacists,
and the extent to which these pharmacists experience moral distress in their working
lives.

What Is Moral Distress?

The term moral distress was first coined to describe some of
the ethical challenges and moral conflicts inherent in the pro-
vision of nursing care.[1] Jameton defined moral distress as
‘the distress felt when one knows the right thing to do,
but institutional constraints make it nearly impossible to
pursue the right course of action’. Wilkinson developed and
expanded upon Jameton’s definition to incorporate the
sensory experience of distress,[2] and redefined moral distress
as ‘the psychological disequilibrium and negative feeling state
experienced when a person makes a moral decision but does
not follow through by performing the moral behaviour indi-
cated by that decision’. Jameton later refined his theory of
moral distress to include a sense of having participated in a
moral wrong through action or inaction.[3] He also further
differentiated between aspects of initial and reactive distress:
initial distress occurs at the time the person is first prevented
from doing what he or she feels is right and is characterised by
feelings of acute anxiety and anger, while reactive distress
occurs later when the individual accepts that he or she has
acted in discordance with his or her beliefs. Reactive distress,
or moral residue, is characterised by chronic feelings of guilt,
low self-esteem and powerlessness.
These initial conceptualisations of moral distress
considered constraints on action to arise primarily from

© 2015 Royal Pharmaceutical Society International Journal of Pharmacy Practice 2015, 23, pp. 361–366
362
institutional policy or the power dynamics inherent within
intra-professional hierarchies. Subsequent authors have
broadened the definition of moral distress to include situ-
ational binds arising from insufficient resources, legal
requirements, professional regulations and a sense of dis-
cordance between individual- and role-based morality, which
can occur when professional norms conflict with individual
moral values.[4,5] The concept of role morality accepts that
individuals must often adopt alternative moral codes in order
to meet the ethical requirements of their profession, and that
they may be required to act contrary to the core values to
which they are personally committed.[6] It is the betrayal of
individual beliefs and values and the subsequent fragmenta-
tion of self-integrity that are perceived to be at the core moral
of distress.[7–9] It is the individual’s perception of the situa-
tion, the values that they feel are at stake and the nature of any
situational constraints that influence the degree to which they
experience moral distress.[10]
Nathaniel proposed the following consolidated definition
of moral distress:
Moral distress is the pain affecting the mind, body or
relationships that results from a patient care situation,
in which the [practitioner] is aware of a moral
problem, acknowledges moral responsibility and
makes a moral judgement about the correct action, yet,
as a result of real or perceived constraints, participates,
either by act or omission, in a manner he or she per-
ceives to be morally wrong.[4]
This definition emphasises the process and contextual
nature of moral distress by recognising the related concepts
of moral awareness, moral responsibility and moral reason-
ing that combine to influence moral behaviour. Lutzen
and Ewalds-Kvist use the term moral agency to capture
the dynamic and integral relationship between these
concepts in relation to the experience of moral distress.[11]
Moral agency, in this sense, indicates a capability for
morally considered action and embodies an awareness
of the moral significance of one’s actions, a sense of
benevolent concern and accountability for the well-being
of others and a process of discernment regarding parti-
cular courses of action.[12] Enactment of moral agency
involves coherence between moral judgement and capacity
for implementation. When individuals are ultimately
prevented from exercising their moral agency and subse-
quently act in discordance with their moral judgements and
values, there is potential for moral distress to occur
(Figure 1).
The Effects of Moral Distress
Studies concerning moral distress in the nursing profession
have identified significant negative consequences for both the
© 2015 Royal Pharmaceutical Society
Moral distress in community pharmacy practice
practitioner and for the quality of patient care. The initial
feelings of anger and outrage that are experienced during the
event often develop into enduring feelings of guilt, hopeless-
ness, loss of confidence, decreased self-esteem, exhaustion
and burnout.[13] Physical symptoms of nausea, insomnia,
headaches and fatigue are also reported.[2] Coping mecha-
nisms include emotional and physical withdrawal, distancing
oneself from patient care and increasing passivity in the face
of clinical judgements felt to be contrary to the best interests
of the patient.[14,15] Moral distress has also been found to be
associated with leaving positions for alternative posts and,
ultimately, leaving the profession.[16–18]
Who Can Suffer from Moral Distress?
The initial emphasis on external constraints within Jameton
and Wilkinson’s theories of moral distress contributed to an
initially narrow research agenda that focused predominately
on the experience of nurses. This was in part due to the his-
torical perception of the profession as subordinate to other
disciplines within the medical hierarchy, and therefore the
most likely to experience distress as a result of the restrictions
imposed by others.[19] As the conceptual boundaries of moral
distress have developed, so too has the research interest in the
experiences of other professional groups. The findings have
shown that while moral distress was initially delineated
within nursing, the concept is relevant across other profes-
sional healthcare groups as each role carries its own code of
ethics, professional regulations, legal requirements, percep-
tion of clinical goals and relational position with allied
disciplines to be balanced against the individual practitio-
ner’s moral framework.[20] Subsequent studies have suggested
that moral distress is relevant to – and reported by – various
disciplines, including psychiatric nurses, psychiatrists,
podiatrists, psychologists, physiotherapists and respiratory
therapists.[21–26]
Is Moral Distress Potentially a
Problem for Pharmacists?
While it has historically received scant consideration in
bioethical discourse, there is an emerging recognition that
pharmacy is a value-based profession with a strong ethical
grounding.[27] In the past several decades, the pharmacy pro-
fession has sought to become more patient-focused and to
embrace an expanded role that shares responsibility for
optimal drug-therapy outcomes. Pharmacists play an active
and influential role in patient care and are required to make
clinical and ethical decisions regarding safe access to medi-
cines and treatment. As pharmacists expand their roles to
include pharmaceutical care, there are significantly more
opportunities for ethical and moral problems to arise. The
commercial nature of community pharmacy in particular
International Journal of Pharmacy Practice 2015, 23, pp. 361–366
Jayne L. Astbury et al.
Figure 1 The onset and development of moral distress.
can also present additional conflicts of interest that pharma-
cists must continue to address and resolve. Additionally, com-
munity pharmacists are generally more isolated from support
networks than their hospital-based colleagues.
Pharmacists working in the UK operate within a highly
regulated occupational sphere and are bound by strict legal
frameworks and codes of professional conduct. This regula-
tory environment creates the potential for moral distress to
occur due to the limitations it places on acting in congruence
with moral judgements. Many pharmacists have experienced
‘ethical dilemmas’ involving a conflict between an ethical
value and a legal or procedural issue.[28]
In instances where the statutory framework conflicts with
a pharmacist’s moral values, two diametrically opposed
causes of potential concern are created. The pharmacist may
choose to act within the legal or professional framework at
the expense of their patient’s needs, leading to the sensation
of moral distress. Of equal concern is the finding that phar-
© 2015 Royal Pharmaceutical Society
363
macists may knowingly practise outside of regulatory and
legal requirements: this may be as a means of avoiding situa-
tions in which they would have otherwise experienced
moral distress[19] or because they believe that the conflict
between regulation and patient care is philosophically
wrong.[29] In the latter case, distress may still result, but it is
not moral distress, as the pharmacist is acting in a manner
consistent with their own personal values. Nonetheless, this
has been extensively examined in the context of the moral
development of pharmacists through education.[30–33] These
practitioners have typically reached a level of moral devel-
opment at which they reflect on such moralistic thoughts as
‘Would my actions in this case bring more total good for
society?’ However, although they are highly critical of the
conventional social order, they offer nothing positive in its
place.[29,34–38] Clearly, this approach presents risks for patients
who may receive care interventions that do not comply
with the legal and professional safeguards and for the
International Journal of Pharmacy Practice 2015, 23, pp. 361–366
364
pharmacists themselves as they gamble with their continued
registration.
Within the last decade, several extensive qualitative studies
have examined pharmacist’s values in the context of the
ethical problems and their resolution.[39–41] These studies all
recognise the potential for moral distress as we have derived
above, albeit without referring to this phenomenon by name.
Deans noted that among pharmacists, ethics had two mean-
ings: regulation and subjective relative morality. It was noted
that ‘acting morally may sometimes require pharmacists to
act contrary to the law and guidelines’ (pp.60–61).[40] Simi-
larly, Cooper noted that ‘regulations . . . led to conflicts
between benefiting the patient and complying with legal
requirements’ (p.72).[39]
A number of studies have considered the prevalence of
moral distress in Swedish pharmacists: however, to date, no
similar studies have been done in the UK. Given that Swedish
pharmacists operate within a unique healthcare system, it is
unclear to what extent the findings of these studies can be
generalised to UK pharmacists.
Swedish Study
Kälvemark et al. initially explored levels of moral distress
experienced across a range of hospital-based healthcare disci-
plines, including pharmacy, in a qualitative study that gath-
ered data from a series of semi-structured focus groups.[19]
Content analysis highlighted themes relating to resources,
rules versus praxis, conflicts of interest and lack of supporting
structures. Ethical dilemmas were seen to arise primarily
from the conflicting interests of the patient and the interests
of the organisation. Participants also spoke of the stress that
they experienced as a result of violating professional rules in
order to act in line with their personal beliefs regarding what
was right.
The qualitative data gathered from this study were then
used to inform the development of a questionnaire to
measure moral distress in a sample of 59 pharmacy staff
working in three pharmacy practices.[42] Respondents rated
prioritising between patients, time constraints, implications
of the public system of subsidising medications and dispens-
ing prescriptions of questionable appropriateness as causing
the highest levels of distress. A global statement regarding
acting against one’s conscience also yielded high scores, with
younger pharmacists expressing significantly higher levels of
distress than their older colleagues in this regard.
Kälvemark Sporrong et al. went on to develop a further
questionnaire that could be used to quantify moral distress
across various healthcare settings and disciplines including
pharmacy.[43] Responses were received from 200 clinicians
and 59 pharmacists. As with the previous study, time con-
straints and implications for quality of patient care were
© 2015 Royal Pharmaceutical Society
Moral distress in community pharmacy practice
reported as causing the highest levels of distress. Older par-
ticipants across the two groups reported less distress than
their younger colleagues.
Proposed Research Agenda
The instruments developed in these studies were derived
from focus group data gathered from Swedish pharmacists
and healthcare professionals. As Sweden operates a different
model of healthcare provision than the UK, the development
of an instrument focusing on the experiences of pharmacists
practising in the UK is needed before the extent to which they
experience moral distress in their working lives can be fully
explored.
Pharmacy is a profession with a history of strong statutory
regulation and an authoritarian approach to professional
suitability.[44] Situations can arise where supplying a medica-
tion in the best interests of a patient could breach legal regu-
lations.[45] Fear that an action with strong moral grounding
could later be deemed as an illegal act with dire professional
consequences has been shown to generate distress.[46] Balanc-
ing moral obligations towards patients in pain against legal
concordance has been cited as a cause of distress in many
pharmacists.[45,46]
An enhanced understanding of the extent to which phar-
macists experience moral distress in their working lives,
together with an exploration of its antecedent triggers, would
enable the development of guidance, supportive resources,
targeted interventions and strategies to reduce such inci-
dences and reduce the risk to patient safety and pharmacists’
well-being associated with moral distress.
Very little research regarding moral distress has been
undertaken in pharmacy; thus, prominent research gaps have
arisen for the development of a robust tool to measure and
quantify moral distress experienced in the profession. There
is currently no validated tool to quantify moral distress in
UK-based community pharmacists. Research must be under-
taken to determine: what situations cause the highest
instances of moral distress for community pharmacists; the
extent to which these pharmacists experience moral distress
in their working lives; and if demographic variables (age, sex,
religious beliefs) or work experience variables (employment
status, time in profession, level of job satisfaction) predict the
level of moral distress experienced.
Declarations
Conflict of interest
The Author(s) declare(s) that they have no conflicts of inter-
est to disclose.
International Journal of Pharmacy Practice 2015, 23, pp. 361–366
Jayne L. Astbury et al.
Funding
Funding for this work was provided by Pharmacy Research
UK (PRUK).
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