Empirical Ethics

Clinical Ethics
0(0) 1–16
Re-defining moral distress: A systematic ! The Author(s) 2019
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DOI: 10.1177/1477750919886088
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Christine Sanderson1 , Linda Sheahan2, Slavica Kochovska1,

Tim Luckett1, Deborah Parker3, Phyllis Butow4 and
Meera Agar1

Abstract
The concept of moral distress comes from nursing ethics, and was initially defined as ‘. . .when one knows the right thing
to do, but institutional constraints make it nearly impossible to pursue the right course of action’. There is a large body
of literature associated with moral distress, yet multiple definitions now exist, significantly limiting its usefulness. We
undertook a systematic review of the argument-based bioethics literature on this topic as the basis for a critical
appraisal, identifying 55 papers for analysis. We found that moral distress is most frequently framed around individual
experiences of distress in relation to local practices and constraints, and understood in terms of power relations and
workplace hierarchies. This understanding is directly derived from, and often still seen as specific to, nursing. Frequently
the perspective of the morally distressed individual is privileged. Understandings of moral distress have evolved towards
an ‘occupational health approach’, with the assumption that moral distress should be measured and prevented. Counter-
perspectives were identified, highlighting conceptual problems. Based on our review, we propose a redefinition of moral
distress: ‘Ethical unease or disquiet resulting from a situation where a clinician believes they have contributed to
avoidable patient or community harm through their involvement in an action, inaction or decision that conflicts with
their own values’. This definition is specific enough for research use, anchored in clinicians’ professional responsibilities
and concerns about harms to patients, framed relationally rather than hierarchically, and amenable to multiple perspec-
tives on any given morally distressing situation.

Keywords
Health care, professional ethics, professional relationships, philosophical aspects

Introduction
The term ‘moral distress’ was first put forward in 1984
by Andrew Jameton1 in reference to the work of
nurses, to describe the situation ‘. . .when one knows
the right thing to do, but institutional constraints
make it nearly impossible to pursue the right course
of action’. Since that time a substantial body of litera-
ture addressing this topic has developed, confirming
that these concerns have real and ongoing significance
in a range of clinical contexts.2–5
Moral distress as a problem of nurses?
As a nursing ethicist, Jameton1 made it clear in his
original discussion of moral distress that he wanted
to draw attention to a problem specific to nursing, in
which the distressing experience of having to do some-
thing that goes against one’s principles may be a direct
consequence of the constraints of the nurses’
1
Faculty of Health, ImPACCT, University of Technology Sydney, Sydney,
Australia
2
SE Sydney Local Health District Clinical Ethics Service, Sydney, Australia
3
Faculty of Health, Aged Care Nursing, University of Technology Sydney,
Sydney, Australia
4
Centre for Medical Psychology and Evidence-based Decision-Making,
University of Sydney, Sydney, Australia
Corresponding author:
Christine Sanderson, Faculty of Health, ImPACCT, University of
Technology Sydney, Level 3, 235 Jones St., Sydney, NSW 2007, Australia.
Email: Christine.Sanderson@student.uts.edu.au
2 Clinical Ethics 0(0)
professional role. His conceptualisation acknowledged
the power relations that have historically characterised
nursing. It focused on institutional constraints on
nurses as a barrier to their moral action, drawing atten-
tion to structural and power issues at play for nurses.
From its inception, the conceptualisation of moral dis-
tress was inextricable from Jameton’s understanding of
nurses’ professional role and its inherent conflicts, most
often with doctors as the directors of the patients’ care,
but also with hospital managers, funders, or with the
nursing hierarchy itself. The subsequent empirical work
of Wilkinson6 on nurses in critical care settings went on
to lay the basis for the development of the assessment
tools operationalising Jameton’s concept.7 The phe-
nomena Wilkinson identified in her study evolved
into the ‘root causes of moral distress’, many of
which now appear in iterations of the most commonly
used assessment tools, the Moral Distress Scale8 and
the revised Moral Distress Scale.9
Consistent with its origins in nursing ethics, the
moral distress literature is dominated by studies of
and by nurses.10–12 In their bibliometric analysis of
the quantitative moral distress literature, Lamiani
et al.2 found that 69% of the 239 studies identified
were focused on nurses. Within this literature there is
a divergence of opinion about whether moral distress is
a concept that is specific to nursing12,13 or whether it
can and should, in fact, be extended to other disci-
plines.5,14 However, given the way in which the defini-
tion originated and has been applied, the question of its
validity in other contexts and for other disciplines
needs to be raised. Indeed, a range of authors have
been concerned by the characterisation of moral dis-
tress as ‘a misuse of power’ in which nurses are
regarded as victims.15–17 Prentice et al.5 caution that
care should be taken because ‘. . .[i]nterventions based
on a singular or limited perspective have the potential
to decrease the impact of collaboration and exacerbate
the differences between healthcare providers’. The
implication is that the conceptualisation of moral dis-
tress and its application to professions other than nurs-
ing needs to be reconsidered in light of its origins,
structure, and context, and cannot simply be ‘translat-
ed’ to different situations.
Difficulties with the definition of moral distress
This discussion sits within a wider framework of defi-
nitional debate about moral distress. Despite the sig-
nificant body of work that has grown out of Jameton’s
initial characterisation, the definition of moral distress
continues to be far from settled, and consensus is lack-
ing about some of its core elements.16,18–20 McCarthy
and Gastmans21 summarised many of these debates in
their systematic review, undertaken from a nursing
standpoint, specifically addressing whether or not
moral distress can be regarded as a discrete entity,
whether or not constraint is an essential element of
the phenomenon, and whether moral agency should
be perceived as an individual or as a relational con-
struct. They analyse the debate regarding the scope of
the concept of moral distress, that is whether it should
be narrowly focused on a situation where the person
believes they know what to do, or whether other moral
and ethical concerns can be included under the umbrel-
la term of ‘moral distress’, such as moral uncertainty.
Within the moral distress literature, they identify a core
element as being the need for the clinician to make a
moral judgement, and they go on to summarise the
arguments that revolve around the problematic
nature of such moral judgements, and concerns about
privileging the views of a morally distressed person.
They also note the specifically professional character
of moral distress, and describe the debates within the
literature about how this intersects with clinicians’ per-
sonal values, and the sources and impacts of moral
distress in both a professional and a personal context.
The need to redefine moral distress
Given the many unresolved complexities relating to the
definition of moral distress,7,21 and its nursing-specific
origins and standpoint, which assume a high degree of
interprofessional conflict2,15 any study that aims to
explore moral distress as it occurs within and across
health care teams cannot take the conceptualisation
of moral distress for granted. Previous systematic
reviews have investigated different aspects of moral dis-
tress (e.g. in paediatric and neonatal intensive care,22–24
for nursing students,3,25 or in relation to burnout in
nurses26,27) and many have identified the need for fur-
ther clarification of the definition,5,21 but none have
directly addressed definitional concerns with a view to
broadening the conceptualisation beyond its funda-
mental orientation towards the nursing experience.
The topic of moral distress in end of life care is the
overarching concern of this project. This review is the
first part of a larger systematic review that will use
the meta-narrative review approach28 in order to
make sense of the complex and contested topic of
moral distress, examining causes of moral distress in
end of life care, and interventions that have been
undertaken in response to concerns about moral dis-
tress in end of life care. Meta-narrative review method-
ology allows the synthesis of the different paradigms
which have been significant in the study of moral dis-
tress, with the aim of achieving a clinically relevant
understanding of the topic for use in future empirical
work on moral distress in end of life decision-making.
Sanderson et al.
The aim of this first stage of the meta-narrative
review is to propose a definition of moral distress
informed by debates within the argument-based bioeth-
ics literature, to be understood from the perspective of,
and to be applicable to, the whole range of clinicians in
the health care team caring for patients at the end of
life. Systematic review methodology provides a robust
search process and transparent approach to data syn-
thesis, in order to delineate the main perspectives incor-
porated in definitions of moral distress. This summary
will underpin a critical analysis of the definitional liter-
ature. It adds to the existing literature by reframing the
discussion on moral distress beyond the nursing con-
text from which it has evolved, explicitly identifying
assumptions and conflicts associated with that context,
but without neglecting important learnings from the
nursing paradigm.
Methods
The protocol for the meta-narrative synthesis of
the literature on moral distress, of which this review
is the first part, has been registered with the online
database PROSPERO (International Prospective
Register of Systematic Reviews https://www.crd.york.
ac.uk/PROSPERO/ CRD42017070451). Methods are
reported according to the PRISMA (Preferred
Reporting Items for Systematic Reviews and
Meta-Analyses http://www.prisma-statement.org/)
guidelines.29
Search strategy
As the question for this part of the review relates to the
definition of moral distress, this term needed to appear
either as a keyword, or in the abstract or title. The
search therefore used ‘moral distress’ as the search
term, and piloting of the search strategy identified a
substantial and specific literature on moral distress, as
well as articles addressing a range of overlapping con-
cepts such as ‘burnout’, ‘ethical sensitivity’, and ‘moral
uncertainty’. Information sources searched were
Medline, CINAHL, Embase, PsycINFO, and Scopus,
in order to capture the clinically focused bioethics lit-
erature in peer-reviewed journals. Reference lists of
selected articles were scanned to identify any additional
articles that would fit the inclusion criteria and to con-
firm that the search was comprehensive. The search
period was from 1984 (the year of the original publica-
tion in which moral distress was defined1) to September
2017, the time of data analysis.
Inclusion criteria were that articles were in English,
published in a peer-reviewed journal, had moral dis-
tress as their main focus, addressed a clinical health
care context, and explored the definition of moral
3
distress. Articles in the category of argument-based
bioethics (i.e. with a primary focus on analysing ethical
arguments and concepts) were included in this analysis.
Articles describing the process of developing assess-
ment tools for measuring moral distress were also
included because, in operationalising a specific defini-
tion of moral distress, they illuminate the interpretation
of the concept in practice. Literature reviews, empirical
studies apart from those related to assessment tools for
moral distress, educational papers, first person narra-
tives, and case-studies were all excluded from the cur-
rent review.
Study selection and quality appraisal
Abstracts were separately screened for inclusion by two
reviewers (CS, SK). Disagreements were resolved by
discussion, with involvement by a third author (MA)
where required. Full-text articles were then retrieved
for further review.
There is no consensus on the best approach to
appraising quality of bioethics literature. However,
McCullough et al.30 have proposed a strategy for ana-
lysing the argument-based ethics literature which
adapts appraisal tools widely used in qualitative
research. However, McCullough’s tool is designed for
appraisal of a single article, requiring contextualisation
of the article within the associated literature and in
relation to a clinical context. We reviewed this
approach, and modified it using several fields from
the Joanna Briggs Institute Quality Appraisal Tool
for Text and Opinion,31 to generate a bioethics assess-
ment tool more suited to systematic reviews in which a
large number of papers need to be appraised, and
where the question of relevance to a specific clinical
situation is not paramount (Figure 1). Twenty papers
were independently appraised using the tool (CS, LS),
and the decisions were discussed, compared, and
agreed on. The remaining papers were appraised by
CS (Table 1).
Papers whose main focus was the development and
testing of an assessment tool were excluded from the
quality appraisal process, as they were not engaged in
ethical argument (n ¼ 16, 29%). Papers that used one
or more acceptable ethical appeals (as defined in the
quality appraisal tool and described by McCullough
et al.30) referred substantively to the literature, and
argued for their own account of moral distress, were
deemed to be of high quality (n ¼ 15, 27%). Papers that
addressed any, but not all, of these elements were
deemed to be of moderate quality (n ¼ 16, 29%).
Papers that did not meet these criteria were deemed
to be of lower quality (n ¼ 8, 15%). It should be
noted that quality scores were sometimes affected
when papers were part of a themed collection rather
4 Clinical Ethics 0(0)

than written to stand alone. Quality appraisal was

undertaken to characterise the overall strength of the
included literature, and suggests that the rigour of the
included work is reasonable, as 80% of those appraised
were of either high or moderate quality. As the review
is the focus for a critical appraisal, it was deemed
appropriate to retain articles of lower quality in order
to describe the full range of the discussion in the
literature.

Data extraction and synthesis

Data extraction was undertaken using broad headings
(definitional domains) that were identified and refined
based on a reading of the papers as they were screened,
to reflect areas where there are divergent or contradic-
tory positions, and to encompass the main elements of
most definitions of moral distress. The domains that
were used were as follows:

a. the basis of ‘moral knowledge’ which allows a clini-

cian to decide ‘the right thing to do’
b. the nature of any constraints preventing moral
action
c. the experience of moral distress
d. the consequences of moral distress for clinicians,
patients, or organisations.

Text was extracted from the articles in relation

to each domain (CS), based on a reading of the
Figure 1. Quality appraisal tool for the argument based bio- full article, and extracts were then thematically
ethics literature. coded into subthemes. Text that included critiques of
the definition of moral distress was coded separately.

Table 1. Outcome of quality appraisal.

High quality (n¼15) Hardingham,32 Hanna,33 McCammon and Brody,14 Varcoe et al.,34 Jameton,35 Fiester,36
Fourie,20 Johnstone and Hutchinson,16 Fourie,12 April and April,37 Campbell et al.,19
Christen and Katsarov,38 Weber,39 Nyholm,40 and Landry41
Moderate quality (n¼16) Corley,42 Kopala and Burkhart,43 Cohen and Erickson,11 Austin et al.,44 Cox,45Epstein
and Delgado,46Epstein and Hamric,47Lützén and Kvist,48Lützén and Ewalds-Kvist,49
Bennett and Chamberlin,50Carnevale,10Carse,51Dudzinski,52Gorin,53Latham,54 and
Mares55
Lower quality (n¼8) Hamric,56 Corley and Minick,57 Erlen,58 Hamric,59 Barlem et al.,13 Barlem and
Ramos,60Burgart and Kruse,61 and Morley18
Unappraised assessment Corley62– MDS (Moral Distress Scale),Corley et al.8– MDS (Moral Distress Scale),
tools (n¼16) Eizenberg et al.63 – MDQ (Moral Distress Questionnaire),Pavlish et al.64–Ethics
Screening and Early Intervention Tool,Pavlish et al.65 – Screening tool for risk or ethical
conflicts,Schaefer et al.66 – MD (Moral Distress) Risk factors,Burston et al.67 – MDS-R
(Moral Distress Scale – Revised) Aged care,Sandeberg et al.68 MDS-R (Moral Distress
Scale – Revised) pediatric version (Swedish),Lazzarin et al.69 – MDS-PV (Moral Distress
Scale – paediatric version),Hamric et al.9 – MDS-R (Moral Distress Scale – Revised),
Wocial and Weaver70 – Moral Distress Thermometer,Kleinknecht-Dolf et al.71 – MDS
(Moral Distress Scale) German version,Penny et al.72 – MDS-R–OT[A] (Moral Distress
Scale – Revised – Occupational Therapy),Karagozoglu et al.73 – MDS-R (Moral Distress
Scale – Revised) Turkish version,Lamiani et al.74 – MDS-R (Moral Distress Scale –
Revised) Italian version. Sporrong et al.75
Sanderson et al.
One-tenth of the coded articles were checked (MA, PB)
and disagreements were resolved by discussion and
consensus.
Results
Of a total of 970 references screened, 55 met criteria for
inclusion (Figure 2). The majority (58%) of the papers
were from North America, whilst 22% were from
Europe or UK, and there was one paper each from
Israel, Turkey, Australia, and Brazil. Most of the
articles were published in bioethics journals (42%),
nursing journals (25%), or nursing ethics journals
(14%). Three articles were published in critical care
journals. Of the 55 included papers, 20 focused exclu-
sively on moral distress in nurses.
Table 2 provides representative examples of text for
each definitional domain, to clarify the type of issues
covered within each. Criticisms or adaptations of the
concept of moral distress are presented in Table 3.
Figure 2. PRISMA diagram.
5
Table 4 summarises the results for each included
paper. Summarising the most common view of moral
distress as identified in Table 4, the majority of writers
regard moral distress as an individual experience aris-
ing when an individual’s moral or ethical beliefs are
challenged, but they are confronted by local practices
or cultures that prevent them from performing the
morally appropriate action they have identified. These
situations are thought to arise most often because of
power relations and hierarchies within health care, and
the experience of moral distress is seen as causing phys-
ical and/or mental suffering to the person involved.
This summary suggests that Jameton’s original depic-
tion of the concept of moral distress has been extremely
influential within the argument-based bioethics
literature.
Yet, whilst this perspective is dominant, it has been
strongly challenged in multiple ways (Table 3),
although no consensus has been achieved amongst
the critics of the original Jameton definition.
6 Clinical Ethics 0(0)

Table 2. Domains and subthemes within definitions of moral distress.

Definitional domain Subtheme Representative examples

Basis of ‘moral Individual moral beliefs ‘. . .what he or she thinks is the right thing to do. . .’ – Lützén and Kvist48
knowledge’ Sense of responsibility ‘. . .perceiving oneself as involved in a situation. . .’ – Christen and Katsarov38
‘. . .negative feeling state brought on by a sense of responsibility and yet, also a
sense of powerlessness. . .’ – Landry41
‘. . .without further specification of the notion of “involvement,” the authors’
account of moral distress will generalize too far. The solution is to construe
the relevant notion of ‘involvement’ as moral responsibility. . .’ – Gorin53
Patient focus ‘. . .when witnessing and providing what they perceive to be overly aggressive
treatments. . .’ – Pavlish et al.64
‘. . . an immediate understanding that a specific situation is hurtful for a
patient. . .’ – Mares55
‘. . .inability to reduce pain and suffering. . . patient dehumanization. . .’ – Lützén
and Ewalds-Kvist49
‘. . . an immediate understanding of a patient’s vulnerable situation as well as an
awareness of the moral implications of decisions that are made on his or her
behalf. . .’ – Lützén and Kvist48
Professional ethics ‘When a practitioner is unable to follow the ethical values and professional
standards of his or her profession. . .’ – Penny et al.72
‘. . .one correctly perceives oneself as being involved in a morally undesirable
situation that compromises the basic ethical aims and values distinctive of the
role one performs as a health care worker. . .’ – Nyholm40
Nature of Individual ‘. . .self-defined inabilities to act, such as lack of knowledge. . .’ – Lützén and
constraints Ewalds-Kvist49
‘Self-doubt and a lack of knowledge are personal factors that could possibly
have an effect on moral distress . . .’ – Kleinknecht-Dolf et al.71
Institutional ‘. . .the institution or co-workers make it difficult or impossible for the nurse to
practice/culture act on that judgment. . .’ – Fourie12
‘. . .constrained by morally irrelevant considerations such as institutional regu-
lations or care team hierarchies. . .’ – April and April37
‘External pressures in the perioperative environment. . .’ – Cox45
Structural (beyond ‘. . .broader external influences [regulatory care standards/third-party expect-
the institution) ations]. . .’ – Burston et al.67
‘. . .inability to enact standards in their practice in spite of attempts to do so as a
consequence of the context including both institutional and broader socio-
political contexts. . .’ – Varcoe et al.34
‘. . .care and treatment services which have complex and flexible structure can
be affected by political and economic processes . . .’ – Karagozoglu et al.73
Experience of Mental/physical ‘. . .anguish, sleeplessness, nausea, migraine headaches, gastrointestinal upset,
moral distress tearfulness, a sense of isolation, or of knowing very early the immorality of a
situation that others haven’t grasped . . .’ – Hanna33
‘pain and psychological disequilibrium of moral distress have been found to be
manifested as anger, frustration, guilt, loss of self-worth, depression and
nightmares, as well as by physical symptoms. . .’ – Corley42
Social/relational ‘. . .although I was an active member of the care team to be involved, I felt I was
relegated to being a quiet bystander, a technician expected to provide the
skills, but not the critical reflection, which I still feel makes us physicians. . .’ –
Carse51
‘unresolved feelings and obligations . . .’ – Bennett and Chamberlin50
Moral/ethical ‘. . ..these intense reactions are more easily understood as a result of repeated
threats to moral integrity. . .’ – Epstein and Hamric47
‘. . .moral injury. . .’ – McCammon and Brody14
‘When this perceived conflict obtains, and is not merely apparent, the expec-
tation that gives rise to moral distress undermines one’s integrity, one’s sense
of oneself as an individual. . .’ – Weber39
(continued)
Sanderson et al. 7

Table 2. Continued.
Definitional domain Subtheme Representative examples

Consequences of For the clinician ‘This integrity-violating feature of moral distress is intrinsically harmful for the
moral distress one who experiences it, on either a comparative or a non-comparative
account of harm. . .’ – Weber39
‘The repetitive nature of the situations and the perceived powerlessness that
accompanies each situation may be caused by a wearing down of moral
integrity. . .’ – Epstein and Hamric47
For the patient ‘. . .may affect nurses’ ability to care for patients. . .’ – Cohen and Erickson11
‘. . .loss of the ability to give good patient care. . .’ – Austin et al.44
‘. . .affects the quality and/or safety of the care provided. . . . A considerable
number of nurses exhibit evasive behaviour and experience a decrease in
their involvement with patients and families. . .’ – Schaefer et al.66
For the organisation ‘. . .may lead to worker dissatisfaction, for example, and difficulties in staff
retention. . .’ – Fourie12
‘professional manifestations such as job dissatisfaction, burnout, and abandon-
ment of the profession. . .’ – Carnevale10
‘It seems the primary reason moral distress is problematic in the health care
setting is that it can lead to a reduction in the quality and quantity of care, as
well as to increased costs via providers’ dissatisfaction with their work and
subsequent attrition. . .’ – Gorin53
‘Medicine cannot afford for educated and motivated nurses to become so
distressed that they leave nursing. . ..’ – Cox45

Table 3. Representative examples highlighting key areas of definitional debate.

1. Problems in conceptualising moral distress
‘What kind of phenomenon is moral distress then? Is it a psychological response to an ethical
phenomenon? Or is it the phenomenon that prompts the response (like moral dilemma)?
Another way of asking this is, is it meant to be an outcome or the possible cause of that
outcome? Although Jameton does not make this clear, his discussion of moral distress implies
that it is both. it seems that Jameton’s understanding of moral distress is that it is a compound
phenomenon, which includes both the response and a specific cause. . .’ – Fourie20
‘.. it commits the fallacy of “begging the question”, that is, it “takes for granted, in statement and
argument, precisely what is in dispute” . . . in this instance: the rightness of nurses’ moral judg-
ments; the powerlessness of nurses to take remedial action. . .’ – Johnstone and Hutchinson16
‘Logically, the higher the level of abstraction of a concept, such as in the contemporary discourse on
moral distress, the more difficult it is to find a common ground or a consensus definition of the
understanding or interpretation of the concept . . . [the] focus could be shifted to multidiscipli-
nary conceptual models guiding empirical research relevant to health care practice. . .’ – Lützén
and Kvist48
2. Multiple/inconsistent definitions
‘Research and scholarly works addressing ethical dilemmas and moral distress frequently use the
terms without defining them. . .’ – Kopala and Burkhart43
‘. . . what is actually being measured by empirical studies does not necessarily conform to the
narrow definition of moral distress. . . . this is indicative of a problem with the definition of moral
distress rather than that these studies are not measuring the “correct” phenomenon. . .’ –
Fourie20
‘The phenomenon itself is seen and defined differently, various theoretical models arise; even the
terminology is not settled. . .’ – Mares55
‘Perhaps the abundance of studies have problematized Jameton’s early definition of moral distress
and further complicated the possibility of studying it as 30 years later there is still no central
agreement on its key definitional features. . .’ – Landry41

(continued)
8 Clinical Ethics 0(0)
Table 3. Continued
3. Status of the ‘moral knowledge’ involved in moral distress
Concerns about prioritising
the moral views of the
distressed clinician
Concerns about
oversimplification
of context
4. Nature of the moral/ethical challenges to clinician
Inclusion of moral conflict,
uncertainty, or moral
dilemma within the
definition of moral
distress
Threat to the
clinician’s core
values
‘[Jameton’s] definition implies first that the agent experiencing the distress has some sort of
privileged knowledge about what is morally right . . . and second that the agent’s concerns—
because they are moral as opposed to merely self-interested or hierarchical or financial—ought
to carry the day. . .’ – April and April37
‘. . . it risks what shall be termed here “moral imposition”, whereby nurses impose their views onto
others in ways that are unwelcome and morally risky. An example of this can be found in
multicultural healthcare contexts where nurses act as self-appointed defenders of patient
autonomy and impose the principle of autonomy and other values in culturally inappropriate and
morally harmful ways . . .’ – Johnstone and Hutchinson16
‘[Campbell et al’s] broader definition of moral distress equips us to frame these ethically charged
situations in a much better way: as cases of moral disagreement among sincere and well-inten-
tioned stakeholders . . .’ – April and April37
‘. . .. it is not simply that other people are arbitrarily or unfairly standing in the nurse’s way but that
they genuinely disagree with the nurse on a moral basis. . .’ – Fourie20
‘On our broader definition, moral distress can arise in situations where a person perceives herself
to be involved in a morally undesirable situation. This allows for the possibility that an individual
does not know what the morally right thing to do is (moral uncertainty), that the individual did
the morally best thing though things turned out badly (bad moral luck), that there may not be a
morally right thing to do (moral dilemma), or that one’s own action is not the issue (distress by
association). . .’ – Campbell et al.19
‘As an umbrella category that contains the other two, moral distress could accompany moral
uncertainty or moral dilemma. . .’ – Hanna33
‘I claim that moral distress should be understood as a specific psychological response to morally
challenging situations such as those of moral constraint or moral conflict, or both. . .’ – Fourie20
‘. . .the [Campbell] definition does not refer to the context of health care work in particular. It
instead simply talks about situations regarded as morally undesirable in more general terms. . ..
[it] could be incorporated into any area of life where people might have negative self-directed
feelings due to seeing themselves as being involved in morally undesirable situations. This could
be in a private/personal context, or in the context of one’s profession, where this might be any
profession . . .[which is] too watered down to capture the type of phenomena typically discussed
under the heading of “moral distress” in the nursing literature and more recently in health care
ethics more generally. . .’ – Nyholm40
‘. . . the expression stress-related moral problem is used. By using the term problem, we do not by
definition break up the concepts conflict, dilemma or issue because, according to our knowledge,
there is to date no evidence that a moral conflict causes “a different type” of moral distress than a
moral dilemma does. . .’ – Lützén and Kvist48
‘. . .[some] situations are psychologically stressful, but one’s core values are not necessarily violated
and often one can act on one’s ethical obligations. This is not moral distress. . .’ – Epstein and
Hamric47
‘The traditional definition of moral distress is quite restrictive and offers no vocabulary for our
observations. Clinicians know something is wrong and that it might be of a moral nature.
However, they don’t know the “right” thing to do, and the institution isn’t preventing them from
acting. In our practice, most ethics consults do not have “right” answers, but they almost uni-
versally have people struggling with moral unease. . ..[yet] the traditional definition of moral
distress implies that one’s moral integrity must be in extremis in order to deserve protection. . .’
– Burgart and Kruse61
‘I wonder, though, whether as a result of our interest in morality we may attribute to moral distress
an importance that it does not really deserve, and whether we may as a consequence lose sight of
the underlying problem . . .. There is no reason to think that an overbearing coworker or regular
exposure to the suffering and death of patients cannot wear a person down more quickly than
moral distress, especially if the latter is what authors call ‘mild moral distress. . .’ – Gorin53
‘. . . the integrity-violating aspects of moral distress indicate a need to distinguish between moral
distress and these other kinds of moral conflict. Neither moral dilemmas nor moral uncertainty
involve expectations that one act in a manner that conflicts with one’s own values, or threaten to
alienate one from their own actions. . .’ – Weber39
‘. . .the normative debate about what one must do when one is placed in moral distress is actually
fairly narrow if one defines moral distress as involving definite compromise of one’s core moral
convictions. . ..’ – Latham54
(continued)
Sanderson et al. 9

Table 3. Continued
5. Characteristics of moral distress
The experience ‘We think that emotion or attitudes are essential to capturing the “distress” part of moral dis-
of distress tress. . .’ – Campbell et al.19
‘. . .a negative state of psychological disequilibrium, experienced on making a moral decision . . .
negative stress symptoms. . .’ – Eizenberg et al.63
‘Other discussions of moral distress make the mistake of characterizing this phenomenon too
narrowly . . . By characterizing moral distress in terms of specific kinds of emotional responses,
which lead to specific psychological and physical effects, we restrict the range of responses that
one might have to morally distressing situations. . .’ – Weber39
‘. . .. by assuming that knowledge of right action always preceded an event, moral distress was
defined by a single quality of antecedent knowledge (the quality of certainty), rather than by its
core word “distress.” The label of moral distress, however, connotes an experience of anguish or
suffering. The adjective moral indicates the type of anguish it is. . .’ – Hanna33
Ethical/moral aspects ‘. . .blurring and broadening of the original concept may achieve some or all of the following:
of distress minimize the experience of moral distress to something of mere emotional content, incorrectly
place moral distress in a primarily psychological category rather than in an ethical one. . .’ –
Epstein and Hamric47
‘Much of what has been written about moral distress, however, involves little more than an
appropriation of “ordinary” psychological and emotional reactions (e.g. frustration, anger, anx-
iety, dissatisfaction) that nurses may justifiably feel when encountering difficult ethical issues,
disagreements and conflicts in the workplace.
Whether these reactions necessarily constitute “moral” distress, however, is debatable. . .’ –
Johnstone and Hutchinson16
‘More attention is paid to the circumstances resulting in moral distress than to moral distress
itself. . .’ – Mares55
‘. . .shift the focus from negative psychological reactions to a focus on exploring the ethical com-
ponent, for example by examining what ethical principles are at stake and how moral demands
are perceived and interpreted. . .’ – Lützén and Kvist48
6. Professional context of distress
‘. . .nurses are particularly vulnerable to experiencing moral distress because of the ‘in -between
moral binds’ that are inherent in the profession . . . significant responsibilities toward the patients
and families assigned to them, yet have very limited authority to control the conditions and
standards within which they practice. . .’ – Carnevale10
‘Moral distress is not an affliction peculiar to nurses or to health care workers in general. . .’ – April
and April37
‘. . .the model presented here was constructed largely from nursing research data. One question is
whether other disciplines experience the crescendo effect [of moral distress] in a way that is
similar to what nurses experience. . .’ – Epstein and Hamric47
‘The assumption there is often that moral distress arises from the hierarchy inherent in medical
teams (doctor-nurse) and, more often than one would expect in this day and age, to gender
stereotypes (male–female). Such analyses conceal the similarities between the role of medical
student or resident and that of the nurse, in that both may feel similarly powerless to affect
patient care decisions even in the face of a felt moral imperative. . .’ – McCammon and Brody14
‘. . .moral distress is not confined to nursing but is an experience common to many professionals,
workers, and citizens broadly. . .’ – Jameton35
‘While moral constraint [as a cause of moral distress] may be particularly relevant for nurses, it
seems clear that other hospital staff, including physicians, could also be vulnerable to the expe-
rience of moral constraint, particularly perhaps due to economic and resource constraints that
they may feel hampers their treatment of patients. . .’ – Fourie20
‘Constraint distress [is] a concern of justice because it is related to the (potentially) unfair distri-
bution of moral distress. The moral concern is that members of a group who are already dis-
advantaged (here nurses in terms of their decision-making powers) are being further
disadvantaged. This group risks an extra burden—the experience of moral distress—on top of
the disadvantage they already have. . .’ – Fourie12
‘. . . it doesn’t follow that moral distress is unique to health care. . . In principle, any profession
where one’s ability to do as morality requires is restricted could lead to moral distress. . .’ –
Weber39
Table 4. Distribution of subthemes within the definitional literature on moral distress.
10

Basis of ‘moral knowledge’ Nature of constraints Experience of moral distress Consequences of moral distress

Institutional
Domain Individual Professional Patient practice/ Mental/ Social/ Moral/ For the For the For the
Subtheme beliefs ethics Responsibility focus Individual culture Structural physical relational ethical clinician patient organisation

N (%) of articles 45 (82%) 17 (31%) 13 (24%) 16 (29%) 16 (29%) 41 (74%) 16 (29%) 40 (73%) 9 (16%) 24 (44%) 29 (53%) 23 (42%) 31 (56%)
referencing
subtheme
Hamric56 1 1 1 1 1 1
Corley42 1 1 1 1 1 1 1 1 1
Corley and Minick57 1 1 1
Hanna33 1 1 1 1 1 1 1
Hardingham32 1 1 1 1 1
Kopala and Burkhart43 1 1 1 1 1
Cohen and Erickson11 1 1 1 1
Erlen58 1
Austin et al.44 1 1 1 1 1 1 1 1 1 1
Cox45 1 1 1 1 1 1 1 1 1
Epstein and Hamric47 1 1 1 1 1 1 1
Epstein and Delgado46 1 1 1 1 1 1
Hamric59 1 1 1 1 1
Lützén and Kvist48 1 1 1 1 1 1 1
McCammon and Brody14 1 1 1 1
Varcoe et al.34 1 1 1 1 1 1 1 1 1
Barlem et al.13 1 1 1 1 1 1 1 1 1 1
Bennett and Chamberlin50 1 1 1 1
Carnevale10 1 1 1 1 1 1 1
Carse51 1 1 1 1 1
Jameton35 1
Lützén and Ewalds-Kvist49 1 1 1 1 1 1
Barlem and Ramos60 1 1 1 1 1 1 1 1
Fiester36 1 1 1 1
Fourie20 1 1 1 1
Johnstone and Hutchinson16 1 1 1 1 1 1 1 1 1
Weber39 1 1 1 1 1 1 1 1
April and April37 1 1 1
Burgart and Kruse61 1 1
Campbell et al.19 1 1 1
Christen and Katsarov38 1 1 1 1 1 1
Dudzinski52 1 1 1 1 1 1 1 1
(continued)
Clinical Ethics 0(0)
 Sanderson et al.

Table 4. Continued.
Basis of ‘moral knowledge’ Nature of constraints Experience of moral distress Consequences of moral distress

Institutional
Domain Individual Professional Patient practice/ Mental/ Social/ Moral/ For the For the For the
Subtheme beliefs ethics Responsibility focus Individual culture Structural physical relational ethical clinician patient organisation

Fourie12 1 1 1 1 1
Gorin53 1 1 1 1 1
Latham54 1 1
Mares55 1 1 1 1 1 1 1 1 1 1 1 1
Morley18 1 1 1 1 1
Nyholm40 1 1 1 1 1
Landry41 1 1 1 1 1
Corley62 1 1 1 1 1 1 1 1
Corley et al.8 1 1 1 1 1 1
Sporrong et al.75 1 1 1 1
Eizenberg et al.63 1 1 1 1 1 1 1
Hamric et al.9 1 1 1 1
Lazzarin et al.69 1 1 1 1 1 1 1 1
Wocial and Weaver70 1 1 1 1 1 1
Pavlish et al.64 1 1 1 1
Kleinknecht-Dolf et al.71 1 1 1 1 1 1
Pavlish et al.65 1 1 1 1 1 1
Penny et al.72 1 1 1 1 1
Schaefer et al.66 1 1 1 1 1 1 1
Burston et al.67 1 1 1 1 1 1 1
Karagozoglu et al.73 1 1 1 1 1 1 1 1 1
Lamiani et al.74 1 1 1
Sandeberg Af et al.68 1 1 1 1 1 1
11
12
Problems raised by a number of authors16,33,43,55 focus
particularly on the circularity and self-referential
nature of the concept, which incorporates both the
cause and the effect of moral distress, or the inconsis-
tency with which the concept is used in the literature.
Concerns are raised that the status of ‘moral knowl-
edge’ leading to moral distress should not be taken for
granted, Jameton’s simple statement about knowing
‘the right thing to do’ notwithstanding.16,20,37,54 The
narrowest definitions limit moral distress to situations
where a person is sure of what needs to be done but is
unable to do it because they are constrained by direct,
external factors.12 Broader definitions seek to include a
wider range of types of distress that can be thought of
as responding to broadly moral concerns and also a
widened range of constraints.19,20,40,41 Definitions also
vary with regard to the severity of distress required for
the person to qualify as morally distressed. One group
of authors argue that moral distress needs to entail a
significant threat to one’s integrity39,46 whilst others
argue that any degree of moral unease caused by mor-
ally challenging problems of clinicians should be
included within the definition.19,40 The specificity of
the conceptualisation of moral distress to nursing has
continued to be argued for, and many of the included
definitions exclusively refer to nurses.10,11,46
Discussion
The current systematic review explores the discussion
of the definition of moral distress in the argument-
based bioethics literature. We propose that a conceptu-
alisation which addresses the concerns identified and
can capture all clinicians’ experiences of moral distress,
including those of nurses, is needed. This will differ in
important ways from the predominant view of moral
distress in this literature, as it is shown in Table 4.
Considering the results of the systematic review, a
number of key issues can be highlighted.
Moral knowledge
The status of the moral knowledge required for distress
to occur has been questioned by a number of papers in
this review.16,20,37,54 A person who is morally distressed
because (s)he ‘knows the right thing to do’ – although
this is the predominant basis of moral knowledge
according to this systematic review (Table 4) – may
not always have a morally or ethically justifiable
point of view, nor do they necessarily have a complete
clinical understanding of a situation. Privileging a lim-
ited viewpoint may not lead to better patient care. The
terminology of ‘knowing the right thing to do’ has a
polarising effect, generating a right/wrong dichotomy
as the underlying principle driving moral distress,
Clinical Ethics 0(0)
especially when anchored in ‘knowing’ rather than in
‘believing’. As noted in the ‘Introduction’ section,
themes of interprofessional disagreement and conflict
have been key elements in the evolution of ideas about
moral distress, and the risk is that the usefulness of the
concept may be lost within these conflicts. We support
a different approach as described by April and April,37
which is to think of moral distress being caused by
‘cases of moral disagreement among sincere and well-
intentioned stakeholders’. Without denying the
fundamental problem of their conflicting views, or the
intensity with which any particular individual’s view
may be held, this allows for the inclusion of a multi-
plicity of perspectives all of which have their potential
value, and so can encompass the clinical and ethical
uncertainties inherent in complex health care decisions.
Moving away from the right/wrong dichotomy towards
a concern with patient harm may refocus the definition
so as to allow for consideration of a range of clinician
perspectives, none of which are automatically privi-
leged. In so doing, it places moral distress on more
defensible terrain.
Constraints
The focus on external constraints in relation to moral
distress can be seen as an outcome of its evolution from
nursing, since the nursing role has traditionally been
conceived of as constrained in its professional function,
predominantly in relation to doctors, rather than being
autonomous.12 However, any implication that con-
straints in relation to decision-making exist only for
members of the nursing discipline is not consistent
with the daily reality of health care. Processes of
shared decision-making between patients and clini-
cians, the necessity to provide care within administra-
tive and clinical protocols, and the many different
inputs into care processes in multidisciplinary health
care teams mean that power in decision-making may
be diffused through multiple inter-related hierarchies,
and that ultimately all clinicians are constrained in dif-
ferent ways. Yet the burden of moral distress that is
associated with ethically troubling situations may be
experienced differently by different clinicians according
to their roles. For instance, whilst the nursing role may
be specifically associated with moral and emotional
labour because of its location at the bedside and the
high intensity of the interactions with patients, doctors
carry a different burden of decision-making and
responsibility which may be manifested differently,
but nonetheless be a potential source of moral distress.
Such a perspective is consistent with the views of recent
writers who propose that moral distress is in essence
relational and intrinsic to health care settings, rather
than a property of a distressed individual alone.
Sanderson et al.
These authors have linked moral distress to the ethical
climate of organisations, and to the variety and dynam-
ics of practising health care teams.20,39,43,46
Why does moral distress matter?
The proposition that moral distress is itself harmful to
the person who experiences it, as well as to the system
in which they work, is one of the most frequently iden-
tified reasons for studying the problem, as indicated in
the findings of this systematic review. Much has been
written about the experience of moral distress and its
consequences, and the catalogue of physical and psy-
chological symptoms associated with it is extensive.
However, a focus on the experience of distress has led
to a quasi-diagnostic approach by some writers. Indeed
the name of the phenomenon suggests that distress is its
most significant feature; had it been called ‘moral pow-
erlessness’, for instance, the approach to describing and
understanding it might have been somewhat different.
This has resulted in an occupational health approach to
identifying and managing moral distress, based on the
assumption that since moral distress is harmful it
should be either prevented or controlled.
It is clear from this systematic review that the
emphasis of many writers is on the experience and
the intensity of distress, rather than the problem caus-
ing the distress, that is issues related to patient harm.
Despite the fact that patient care is the raison d’être of
health professionals’ practice, and moral distress is
experienced in that context, harm to the patient is not
central to the definition. We agree with Lützén and
Kvist’s48 proposal that the ‘focus could be shifted to
multidisciplinary conceptual models guiding empirical
research relevant to health care practice’, and this
ought to firmly anchor the definition within clinicians’
concerns about patients, instead of in their experiences
of being distressed. Rather than attempting to
decide how severe distress needs to be in order to be
counted as significant, we would instead argue that a
threshold of ethical unease or disquiet is appropriate,
as this may be a signal of potentially serious problems,
depending on the context and the individuals involved.
Additionally, a definition of moral distress needs to be
explicitly linked to the full range of responsibilities of a
clinician, whether that be to patients, their families and
caregivers, or to the community more broadly.
Definition of moral distress – A proposal
In response to issues raised in this systematic review
and analysed in the discussion above, we propose an
alternative definition of moral distress for health care
providers. ‘Moral distress: Ethical unease or disquiet
resulting from a situation where a clinician believes
13
they are contributing to avoidable patient or commu-
nity harm through their involvement in an action, inac-
tion or decision that conflicts with their own values’.
This proposed definition acknowledges the experi-
ence of moral distress to be that of an individual, but
avoids a simple right versus wrong dichotomy, and is
anchored in clinician concerns about patient harm and
a sense of responsibility for that harm. Broadening the
concept to include ‘community harm’ recognises the
responsibilities of health care professionals whose role
goes beyond looking after individual patients, and may
allow consideration of a range of different interests,
such as the patients’ caregivers, families, and/or the
broader community. It locates the problem as resulting
from the person’s involvement in the decision-making
processes of a team or organisation, and so implies a
relational construct. This allows for a focus on team
dynamics and the context of decision-making,
acknowledging that differences of perspective, which
include inter-disciplinary perspectives, may potentially
lead to moral distress. We would argue that this is more
important than pre-specifying the range or intensity of
individuals’ responses to these situations, or the types
of constraint which may lead to a morally distressing
situation.
We suggest that the scope of this definition is precise
enough to be useful in defining research questions
about moral distress, whether in relation to end of
life decision-making or in other areas of health care.
We propose that this definition itself should be validat-
ed with a range of clinicians, in order to understand
whether it provides a useful tool for them to character-
ise ethically troubling clinical experiences that they
may face.
Limitations
In synthesising the substantial literature addressing the
definition of moral distress, pragmatic inclusion and
exclusion criteria were adopted. For instance, articles
related to the development or initial validation of
assessment tools were included. Non-English language
papers were excluded due to lack of resources to trans-
late these. Whilst there is some risk of failing to identify
significant research as a result of excluding papers in
languages other than English, there is no evidence that
systematic bias results from such a limitation,76 and the
included literature is very diverse. The limitation to
argument-based ethics is intended to capture the most
rigorously developed work on this topic, although it is
acknowledged that within the moral distress literature
as a whole definitional issues are frequently raised.
Finally, as our adaptation of the quality appraisal
tool of McCullough et al.30 has not yet been validated,
we have approached the quality appraisal aspect of this
14
review with caution. Nonetheless, based on our experi-
ence of using it, this adapted tool appears to have util-
ity in the systematic review context.
Conclusion
Moral distress is a concept that speaks powerfully to
clinicians about a range of problems frequently
encountered in their practice, where they may feel
they have not provided the care that a patient needs,
but rather have contributed in some way to harm.
However, clarity is essential in defining the concept of
moral distress as a basis for research, and for a con-
ceptualisation that can encompass the range of experi-
ence of different clinicians. The systematic review
methodology provides a robust framework for a criti-
cal appraisal of the bioethics literature on moral dis-
tress. Based on this review, we have proposed a
redefinition of moral distress that we intend to use in
studying the occurrence and effects of moral distress in
health care teams as they provide end of life care.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The authors disclosed receipt of the following financial sup-
port for the research, authorship, and/or publication of this
article: Sanderson gratefully acknowledges the receipt of a
NSW Health PhD scholarship to support this project.
ORCID iD
Christine Sanderson https://orcid.org/0000-0001-5423-
5778
References
1. Jameton A. Nursing Practice: The Ethical Issues.
Englewood Cliffs, NJ: Prentice Hall, 1984.
2. Lamiani G, Borghi L and Argentero P. When healthcare
professionals cannot do the right thing: a systematic
review of moral distress and its correlates. J Health
Psychol 2017; 22: 51–67.
3. Sasso L, Bagnasco A, Bianchi M, et al. Moral distress in
undergraduate nursing students: a systematic review.
Nurs Ethics 2016; 23: 523–534.
4. Oh Y and Gastmans C. Moral distress experienced by
nurses: a quantitative literature review. Nurs Ethics
2015; 22: 15–31.
5. Prentice T, Janvier A, Gillam L, et al. Moral distress
within neonatal and paediatric intensive care units: a sys-
tematic review. Arch Dis Child 2016; 101: 701–708.
6. Wilkinson J. Moral distress in nursing practice: experi-
ence and effect. Nurs Forum 1988; 23: 16–29.
Clinical Ethics 0(0)
7. Morley G, Ives J, Bradbury-Jones C, et al. What is ‘moral
distress’? A narrative synthesis of the literature. Nurs
Ethics 2019; 26: 646–662.
8. Corley MC, Elswick RK, Gorman M, et al. Development
and evaluation of a moral distress scale. J Adv Nurs 2001;
33: 250–256.
9. Hamric AB, Borchers CT and Epstein EG. Development
and testing of an instrument to measure moral distress in
healthcare professionals. AJOB Prim Res 2012; 3: 1–9.
10. Carnevale FA. Confronting moral distress in nursing:
recognizing nurses as moral agents. Rev Bras Enferm
2013; 66: 33–38.
11. Cohen JS and Erickson JM. Ethical dilemmas and moral
distress in oncology nursing practice. Clin J Oncol Nurs
2006; 10: 775–780.
12. Fourie C. The ethical significance of moral distress:
inequality and nurses’ constraint-distress. Am J Bioeth
2016; 16: 23–25.
13. Barlem EL, Lunardi VL, Lunardi GL, et al. Moral dis-
tress in nursing personnel. Rev Lat Am Enfermagem 2013;
21: 79–87.
14. McCammon SD and Brody H. How virtue ethics informs
medical professionalism. HEC Forum 2012; 24: 257–272.
15. Prentice TM, Gillam L, Davis PG, et al. The use and
misuse of moral distress in neonatology. Semin Fetal
Neonatal Med 2018; 23: 39–43.
16. Johnstone MJ and Hutchinson A. ‘Moral distress’ – time
to abandon a flawed nursing construct? Nurs Ethics 2015;
22: 5–14.
17. McCarthy J and Deady R. Moral distress reconsidered.
Nurs Ethics 2008; 15: 254–262.
18. Morley G. Perspective: the moral distress debate. J Res
Nurs 2016; 21: 570–575.
19. Campbell SM, Ulrich CM and Grady C. A
broader understanding of moral distress. Am J Bioeth
2016; 16: 2–9.
20. Fourie C. Moral distress and moral conflict in clinical
ethics. Bioethics 2015; 29: 91–97.
21. McCarthy J and Gastmans C. Moral distress: a review of
the argument-based nursing ethics literature. Nurs Ethics
2015; 22: 131–152.
22. Cavinder C. The relationship between providing neonatal
palliative care and nurses’ moral distress: an integrative
review. Adv Neonatal Care 2014; 14: 322–328.
23. Kain V. Moral distress and providing care to dying
babies in neonatal nursing. Int J Palliat Nurs 2007; 13:
243–248.
24. Austin W, Kelecevic J, Goble, et al. An overview of
moral distress and the paediatric intensive care team.
Nurs Ethics 2009; 16: 57–68.
25. Bickhoff L, Sinclair P and Levett-Jones T. Moral courage
in undergraduate nursing students: a literature review.
Collegian 2017; 24: 71–83.
26. Dalmolin G, Lunardi V, Lunardi G, et al. Moral distress
and burnout syndrome: are there relationships between
these phenomena in nursing workers? Rev Lat Am
Enfermagem 2014; 22: 35–42.
27. Epp K. Burnout in critical care nurses: a literature
review. Dynamics 2012; 23: 25–31.
Sanderson et al.
28. Greenhalgh T and Wong G. Training Materials for Meta-
narrative Reviews (Version 1). London: Global Health
Innovation and Policy Unit, 2013.
29. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting
items for systematic reviews and meta-analyses: the
PRISMA statement. PloS Med 2009; 6: e1000097.
30. McCullough LB, Coverdale JH and Chervenak FA.
Argument-based medical ethics: a formal tool for criti-
cally appraising the normative medical ethics literature.
Am J Obstet Gynecol 2004; 191: 1097–1102.
31. Joanna Briggs Institute. Checklist for text and opinion,
http://joannabriggs.org/research/critical-appraisal-tools.
html (2018, accessed 20 May 2018).
32. Hardingham LB. Integrity and moral residue: nurses as
participants in a moral community. Nurs Philos 2004; 5:
127–134.
33. Hanna DR. Moral distress: the state of the science. Res
Theory Nurs Pract 2004; 18: 73–93.
34. Varcoe C, Pauly B, Webster G, et al. Moral distress:
tensions as springboards for action. HEC Forum 2012;
24: 51–62.
35. Jameton A. A reflection on moral distress in nursing
together with a current application of the concept.
J Bioeth Inq 2013; 10: 297–308.
36. Fiester A. Neglected ends: clinical ethics consultation and
the prospects for closure. Am J Bioeth 2015; 15: 29–36.
37. April CW and April MD. Understanding moral distress
through the lens of social reflective equilibrium. Am J
Bioeth 2016; 16: 25–27.
38. Christen M and Katsarov J. Moral sensitivity as a pre-
condition of moral distress. Am J Bioeth 2016; 16: 19–21.
39. Weber E. Moral distress, workplace health, and intrinsic
harm. Bioethics 2016; 30: 244–250.
40. Nyholm S. The normative and evaluative status of moral
distress in health care contexts. Am J Bioeth 2016; 16:
17–19.
41. Landry C. Not knowing the “right thing to do”: moral
distress and tolerating uncertainty in medicine. Clin
Ethics 2017; 12: 37–44.
42. Corley MC. Nurse moral distress: a proposed theory and
research agenda. Nurs Ethics 2002; 9: 636–650.
43. Kopala B and Burkhart L. Ethical dilemma and moral
distress: proposed new NANDA diagnoses. Int J Nurs
Terminol Classif 2005; 16: 3–13.
44. Austin W, Lemermeyer G, Goldberg L, et al. Moral dis-
tress in healthcare practice: the situation of nurses. Alta
RN 2008; 64: 4–5.
45. Cox KM. Moral distress: strategies for maintaining
moral integrity. Perioper Nurs Clin 2008; 3: 197–203.
46. Epstein EG and Delgado S. Understanding and address-
ing moral distress. Online J Issues Nurs 2010; 15.
47. Epstein EG and Hamric AB. Moral distress, moral resi-
due, and the crescendo effect. J Clin Ethics 2009; 20:
330–342.
48. Lützén K and Kvist BE. Moral distress: a comparative
analysis of theoretical understandings and inter-related
concepts. HEC Forum 2012; 24: 13–25.
49. Lützén K and Ewalds-Kvist B. Moral distress and its
interconnection with moral sensitivity and moral
15
resilience: viewed from the Philosophy of Viktor E.
Frankl. J Bioeth Inq 2013; 10: 317–324.
50. Bennett A and Chamberlin S. Resisting moral residue.
Pastoral Psychol 2013; 62: 151–162.
51. Carse A. Moral distress and moral disempowerment.
Narrat Inq Bioeth 2013; 3: 147–151.
52. Dudzinski DM. Navigating moral distress using the
moral distress map. J Med Ethics 2016; 42: 321–324.
53. Gorin M. The role of responsibility in moral distress. Am
J Bioeth 2016; 16: 10–11.
54. Latham SR. Moral distress and cooperation with wrong-
doing. Am J Bioeth 2016; 16: 31–32.
55. Mares J. Moral distress: terminology, theories and
models. Kontakt 2016; 18: e137–e144.
56. Hamric AB. Moral distress in everyday ethics. Nurs
Outlook 2000; 48: 199–201.
57. Corley MC and Minick P. Moral distress or moral com-
fort. Bioethics Forum 2002; 18: 7–14.
58. Erlen JA. Moral reckoning in nursing. West J Nurs Res
2006; 28: 442–443.
59. Hamric AB. Empirical research on moral distress: issues,
challenges, and opportunities. HEC Forum 2012; 24: 39–49.
60. Barlem EL and Ramos FR. Constructing a theoretical
model of moral distress. Nurs Ethics 2014; 22: 608–615.
61. Burgart AM and Kruse KE. Moral distress in clinical
ethics: expanding the concept. Am J Bioeth 2016; 16: 1.
62. Corley MC. Moral distress of critical care nurses. Am J
Crit Care 1995; 4: 280–285.
63. Eizenberg MM, Desivilya HS and Hirschfeld MJ. Moral
distress questionnaire for clinical nurses: instrument
development. J Adv Nurs 2009; 65: 885–892.
64. Pavlish CL, Henriksen Hellyer J, Brown-Saltzman K,
et al. Barriers to innovation. Nurses’ risk appraisal in
using a new ethics screening and early intervention tool.
ANS Adv Nurs Sci 2013; 36: 304–319.
65. Pavlish CL, Hellyer JH, Brown-Saltzman K, et al.
Screening situations for risk of ethical conflicts: a pilot
study. Am J Crit Care 2015; 24: 248–256.
66. Schaefer R, Zoboli EL and Vieira M. Identification of risk
factors for moral distress in nurses: basis for the develop-
ment of a new assessment tool. Nurs Inq 2016; 23: 346–357.
67. Burston A, Eley R, Parker D, et al. Validation of an
instrument to measure moral distress within the
Australian residential and community care environments.
Int J Older People Nurs 2017; 12: 2.
68. Sandeberg Af M, Wenemark M and Bartholdson C, et al.
To change or not to change – translating and culturally
adapting the paediatric version of the Moral Distress
Scale-Revised (MDS-R). BMC Med Ethics 2017; 18: 1.
69. Lazzarin M, Biondi A and Di Mauro S. Moral distress in
nurses in oncology and haematology units. Nurs Ethics
2012; 19: 183–195.
70. Wocial LD and Weaver MT. Development and psycho-
metric testing of a new tool for detecting moral distress:
the Moral Distress Thermometer. J Adv Nurs 2013; 69:
167–174.
71. Kleinknecht-Dolf M, Frei IA, Spichiger E, et al. Moral
distress in nurses at an acute care hospital in Switzerland:
results of a pilot study. Nurs Ethics 2015; 22: 77–90.
16
72. Penny NH, Ewing TL, Hamid RC, et al. An investigation
of moral distress experienced by occupational therapists.
Occup Ther Health Care 2014; 28: 382–393.
73. Karagozoglu S, Yildirim G, Ozden D, et al. Moral dis-
tress in Turkish intensive care nurses. Nurs Ethics 2017;
24: 209–224.
74. Lamiani G, Setti I, Barlascini L, et al. Measuring moral
distress among critical care clinicians: validation and psy-
chometric properties of the Italian moral distress scale-
revised. Crit Care Med 2017; 45: 430–437.
Clinical Ethics 0(0)
75. Sporrong SK, Hoglund AT and Arnetz B. Measuring
moral distress in pharmacy and clinical practice. Nurs
Ethics 2006; 13: 416–427.
76. Morrison A, Polisena J, Husereau D, et al. The effect
of English-language restriction on systematic review-
based meta-analyses: a systematic review of empirical
studies. Int J Technol Assess Health Care 2012; 28:
138–144.