moral reckoning in nursing. a grounded theory study

10.1177/0193945905284727Western Journal of Nursing ResearchNathaniel / Moral Reckoning in Nursing

Moral Reckoningin NursingAlvita K. NathanielWest Virginia University, Charleston

Analysis of qualitative data resulted in an original substantive grounded theoryof moral reckoning in nursing, a three-stage process. After a novice period, thenurse experiences a stage of ease in which there is comfort in the workplaceand congruence of internal and external values. Unexpectedly, a situationalbind occurs in which the nurse’s core beliefs come into irreconcilable conflictwith external forces. This compels the nurse into the stage of resolution, inwhich he or she either gives up or makes a stand. The nurse then moves into thestage of reflection in which he or she lives with the consequences and iter-atively examines beliefs, values, and actions. The nurse tries to make sense ofexperiences through remembering, telling the story, and examining conflicts.This study sets the stage for further investigation of moral distress. The theoryof moral reckoning challenges nurses to tell their stories, examine conflicts,and participate as partners in moral decision making.

Keywords: moral distress; ethics; grounded theory; moral dilemma; decisionmaking

Every day nurses are challenged to deal with morally troubling patientcare situations. Morally laden questions about right and wrong, harm

and benefit, rights and responsibilities are inherent in modern health care.Because they work at arm’s length from patients, nurses are caught in thevortex of serious moral problems. When nurses’ moral values conflict withthe realities of the workplace, they experience distress, which may linger formany years after the event. Even though scant research exists on this impor-tant subject, the concept of moral distress is used often to describe the painnurses feel during these troubling times. Moral distress is a contributing fac-tor to loss of nurses’ integrity and dissatisfaction with their work. It also con-tributes to problems with nurse-patient relationships and thus affects thequality, quantity, and cost of nursing care (Erlen, 2001; Hamric, 2000;Jameton, 1984; Nathaniel, 2004; Wilkinson, 1987-88). The current nursing

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Western Journal ofNursing Research

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Author’s Note: The author wishes to acknowledge Dr. Barney Glaser, who served as a mentorfor this study.

shortage affects the delivery of health care services and leads to questionsabout the future of the profession. Moral distress is a major contributor tonurses leaving their work setting and even the profession. Moral distress,however, is a narrow concept that fails to explain the long-term, ongoing pro-cess that nurses experience. The purpose of this article is to present a newlydeveloped grounded theory of moral reckoning in nursing that evolved dur-ing research examining nurses’ experiences with morally troubling patientcare situations. This new theory explains more clearly and thoroughlynurses’struggles. Moral reckoning is similar to the familiar concept of moraldistress but moves further, identifying a critical juncture in nurses’ lives andbetter explaining a process with predictable properties and stages. Thegrounded theory of moral reckoning in nursing is the first to identify a pro-cess that includes the stages of ease, resolution, and reflection and to pointout workplace deficiencies as a serious moral problem in nursing. Nursessuffer and their lives are forever changed as a direct result of morally trou-bling patient care situations. Telling their stories emerged as integral to theprocess of reflecting and as a powerful data-gathering strategy. The theory ofmoral reckoning also points to a deficiency in nurses’ knowledge about for-mal nursing ethics and a need to develop a common moral language amonghealth care professionals.

Moral Distress and Nursing Care

Development of the theory of moral reckoning in nursing began with areview of the extant literature on moral distress, a significant problem innursing. Although reports of the number of nurses who experience moral dis-tress vary, there is evidence that moral distress is common and may be a con-tributing factor to the critical shortage of nurses in the workforce. Nearly50% of nurses in Rushton and Scanlon’s (1995) study reported that they hadacted against their conscience, and Redman and Fry (2000) report that atleast one third of nurses in their study experienced moral distress. The imme-diate and ultimate consequences of moral distress include nurses blamingothers; excusing their own actions; self-criticizing; self-blaming; experienc-ing anger, sarcasm, guilt, remorse, frustration, sadness, withdrawal, avoid-ance behavior, powerlessness, burnout, betrayal of values, sense of insecurity,low self-worth; internalizing anguish; and, possibly, developing aggressivebehavior patterns (Davies et al., 1996; Fenton, 1988; Kelly, 1998; Krish-nasamy, 1999; Rushton & Scanlon, 1995; Wilkinson, 1987-88). Physicalcomplaints reported by nurses who experience moral distress include weep-ing, palpitations, headaches, diarrhea, and sleep problems (Anderson, 1990;Fenton, 1988; Wilkinson, 1987-88).

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The extant literature also indicates that moral distress affects the quality ofnursing care. Nurses experiencing moral distress have reported the followingbehavior toward patients: distancing themselves from patients, becomingemotionally unavailable, avoiding going in patients’ rooms, and leaving theunit or nursing altogether (Corley, 1995; Davies et al., 1996; Fenton, 1988;Krishnasamy, 1998; Millette, 1994; Redman & Fry, 2000; Viney, 1996;Wilkinson, 1987-88). In all, 50% of Millette’s (1994) informants, 12% ofCorley’s (1995) informants, and 45% of Wilkinson’s (1987-88) informantsleft nursing or changed their practice site as a direct result of moral distress.Thus, moral distress may be a factor in the present nursing shortage—a self-perpetuating downward spiral.

Purpose

The purpose of this research was twofold: (a) to further elucidate theexperiences and consequences of professional nurses’ moral distress and (b)to formulate a logical, systematic, and explanatory theory of moral distressand its consequences. This study began with the following broad researchquestion: What transpires in morally laden situations in which nurses experi-ence distress? To allow continued discovery and flexibility of exploration, asis appropriate to grounded theory research, the initial research question wasnarrowed and redirected as the research progressed.

Definition

The following is a synthesized definition of moral distress as described inprevious literature: Moral distress is pain affecting the mind, the body, orrelationships that results from a patient care situation in which the nurse isaware of a moral problem, acknowledges moral responsibility, and makes amoral judgment about the correct action, yet, as a result of real or perceivedconstraints, participates, either by act or omission, in a manner he or she per-ceives to be morally wrong (Jameton, 1984; Nathaniel, 2004; Wilkinson,1987-88).

Design

This research utilized qualitative interview data to develop a substantivegrounded theory that was developed in strict accordance with the classicmethod as described by Glaser and Strauss (1967) and subsequently byGlaser (1978, 1996, 1998).

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Sample

The sample consisted of 21 registered nurses, of which 20 were femaleand 17 were married. Informants were highly educated and experienced: 2had associate degrees, 3 had bachelor’s degrees, 13 had master’s degrees, and3 had doctorates. Also, 19 participants were Caucasian, 1 was Hispanic, and1 was Native American. In addition, 80% had more than 10 years of profes-sional experience, and 43% had left a position because of a morally distress-ing situation.

To ensure the protection of human participants, the proposal for this re-search was examined and approved by the institutional review board for theprotection of human research participants. Informed consent was obtained.Interviews were conducted in private, nonwork settings that afforded privacyto the nurses as they told their stories. The only potential risk identified waspsychological distress that might occur during or following the interview.

Participants were recruited through various means including an advertise-ment that was published in a newsletter for nurses, distributed to nurse lead-ers for sharing with others, and posted at a nurses’ convention. In the adver-tisement, nurses were asked to either e-mail or call (toll free) the principleinvestigator if he or she had ever been involved in a troubling patient care sit-uation that caused distress. Participants were not excluded based on genderor minority status. The target population included all registered nurses whohad ever experienced distress in relation to a moral or ethical problem in apatient care situation. All those responding to the advertisement were inter-viewed until saturation of categories and their properties was reached.

Method

Grounded theory is an inductive method that moves from the systematiccollection of data in a substantive area to the development of a multivariateconceptual theory. For this study, interviews were unstructured and casual.An interview method that Glaser (1998) suggests offers an efficient yetmeaningful mix of interview, observation, and conceptualization. Interviewswere recorded in the form of field notes written immediately after each inter-view. Because of the sensitive nature of the information and the likelihoodthat participants would be less likely to share dangerous information, theinterviews were not recorded on tape. During interviews, the investigatormade brief, contemporaneous notes to ensure that subsequent field noteswere factually correct. Field notes were written immediately following theinterviews. The constant comparative method was used to gather and com-


pare data and to conceptualize, analyze, organize, and write the resultanttheory.

Analysis of Data

Analysis was simultaneous with other steps of the grounded theory pro-cess. It began with the first episode of data gathering. Using constant com-parison, data were analyzed sentence by sentence as they were coded. Alldata were organized into concepts and further into categories that were thenintegrated into theory. The investigator then went back to the data to illustratethe resultant theory. The focus of analysis was on organizing concepts thatemerged from the data. Glaser (1978) calls this a process of double-backsteps. The investigator collected research data and immediately began opencoding. This led to theoretical sampling and generation of memos. As thisprocess proceeded, core social psychological processes began to emerge,furnishing the foundation for subsequent selective theoretical sampling, cod-ing, and memoing around the identified core category of moral reckoning innursing.

Conceptual memos were written as ideas about categories and processesemerged. Theoretical sampling began when the investigator found categoriesthat required more refinement or areas that needed more depth. As the inter-views were coded and compared, moral distress, the original focus of theinvestigation, failed to emerge as a major category. The core variable, moralreckoning, was identified when it emerged as the one to which all others wererelated. Analysis of the data revealed that moral distress occurred in nurseswho were in the midst of the moral reckoning process. As seen in Figure 1,moral reckoning is much broader, both in temporal and psychosocial spheres,and more explanatory and predictive than is the extant concept of moral dis-tress. As categories became saturated and the relationships among thembecame clear, the substantive grounded theory of moral reckoning in nursingemerged. Thus, the new theory effectively synthesizes, organizes, and tran-scends what was previously known.

As with each of the widely divergent qualitative methods, groundedtheory has its own rules concerning evidence, inference, and verification(Sandelowski, 1986). Glaser (1978) devised terms to describe methods thatare unique to classic grounded theory to ensure rigor. These terms, fit, work,relevance, and modifiability, correspond loosely with Lincoln and Guba’s(1985) trustworthiness criteria of credibility, transferability, dependability,and confirmability. For the present study, rigor was ensured by fit in that thecategories fit the data. No data were forced or selected to fit preconceived or


preexistent categories, nor were any discarded in an attempt to keep an extanttheory intact. Thus, the resultant theory is truthful and dependable. Workmeans that the theory is able to explain what happened, predict what willhappen, and interpret what is happening in the substantive areas. This wasachieved by getting the facts as perceived by the participants. After the the-ory was written, feedback from participants and other nurses confirmed thetheory. Relevance was achieved as the core problem and processes naturallyemerged from the data rather than being preconceived or logically de-duced. Modifiability further enhanced the credibility of this grounded the-ory because subsequent research or analysis can result in modifications orcorrections.

Findings

As with other grounded theories, this theory consists of a number of tenta-tive hypotheses derived from the grounded data and written in the form ofdeclarative sentences. The hypotheses are illustrated through case examples.Examples given here are limited to statements of participants, but the theoryitself emerged from the interviews and also other forms of data, including theextant literature on moral distress.

Early in the study, constant comparison of data revealed that more wastranspiring with participants in this study than is described in the extant liter-ature. The definition of moral distress in the literature does not include a the-oretically complete picture of the process that occurs. Conflicting with thepresent findings, the extant definition also includes a requirement that the


Stage of ResolutionStage of Ease Stage of Reflection

Situational Bind

Critical Juncture

Interrupts Stage of Ease

Moral Distress

Figure 1The Relationship Between Moral Distress and Moral Reckoning

nurse must actually participate in moral wrongdoing, violating his or herown moral values. Mainly restricted to psychological implications, theextant definition of moral distress also implies an “us against them” mental-ity in which apparently innocent nurses are opposed by powerful wrong-doers. The stories told by informants in the present study did not entirely fitinto the definition of moral distress, so ideas about moral distress constitutedmerely a jumping-off point for further investigation. As analysis proceeded,the newly identified basic social psychological process of moral reckoningemerged. Figure 1 depicts the theory and its relationship to moral distress.

Moral reckoning, the core category of this grounded theory, captures athree-stage process as nurses critically and emotionally reflect on motiva-tions, choices, actions, and consequences of a particularly troubling patientcare situation. To reckon is defined as follows:

to recount, relate, narrate, tell; to allege; to calculate, work out, decide thenature or value of; to consider, judge, or estimate by, or as the result of calcula-tion; to consider, think, suppose, be of opinion; to speak or discourse of some-thing; and to render or give an account (of one’s conduct, etc.). (Simpson &Weiner, 1989, s.v. “Reckon”)

As seen in Figure 2, moral reckoning is a process with three distinct stagesincluding the stage of ease, the stage of resolution, and the stage of reflection.Figure 2 depicts the theory with its stages and their properties.

Stage of Ease

After the initial new nurse jitters, nurses experience a stage of ease inwhich they feel rewarded and fulfilled. Certain properties are foundational tothe stage of ease. Integral are the properties of (a) becoming, which signifiescore beliefs and values of the individual; (b) professionalizing, which relatesto inculcation of the professional norms; (c) institutionalizing, which signi-fies the process of internalizing institutional social norms; and (d) working,the unique experience of the work of nursing. These conditions are critical tounderstanding the process. Conflict between and among the conditions worktogether during a critical incident to produce a situational bind.

Becoming. Through the process of becoming, every person develops a setof core beliefs and values. These evolve over time through experience andformal learning and from the modeling of parents, teachers, ministers, andpeers. Integration and consistency of core values produce moral integrity(Beauchamp & Childress, 2001). Participants in this study revealed theircore beliefs as they told their stories. For example, they talked about a sense


of responsibility to relieve suffering, a commitment to uphold professionaland institutional norms, a duty to advocate for patients, an imperative to keeppromises, and so forth.

Professionalizing. Professionalizing, another property of the stage ofease, includes inculcation of certain cultural norms learned in nursing schooland early practice. Professional norms are conceptual ideals that contributeto the nurse’s idea of what a good nurse should be or do. For the most part,nurses’ professional norms complement core beliefs so that the professionand professional norms are uniquely important to the person. Explicitly,nurses in this study learned that they have unique relationships with patientsand are responsible to keep promises, which are sometimes implicit in therelationship. They also reported perceived professional norms that includethe following nonexclusive, implicit rules: One must follow physicians’orders, complete assigned work with expert skill, and remain altruistic.

Institutionalizing. Institutionalizing refers to nurses being socialized toimplicit and explicit norms within the work setting. Sometimes institutionalnorms are congruent with nurses’ core beliefs and professional norms, andsometimes they are not. Explicit institutional norms include completing a jobaccording to institutional standards and respecting lines of authority. Implicit


Grounded Theory of Moral Reckoning in Nursing

Stage of Ease Stage of ReflectionStage of Resolution

Institutionalizing

Professionalizing

Becoming Giving Up

Taking a Stand

Examining Conflicts

Telling the Story

Remembering

Living with theConsequencesWorking

Situational BindInterrupts Stage of Ease

Figure 2Model of the Grounded Theory of Moral Reckoning in Nursing

institutional norms include ensuring that the business makes a profit, fol-lowing orders, handling crises without making waves, and covering. As oneinformant said, “Corporate is bigger than life itself.”

Working. Working is another condition of the stage of ease. Unique inmany ways, the work of nursing is varied, challenging, and rewarding.Nurses attend to the most personal and private needs of patients and learn tre-mendous amounts about their hopes, fears, and desires. They intimatelyknow about suffering patients—from touch, sight, smell, and sound. Nursestell heart-wrenching stories filled with vivid sensual descriptions. Doing thework of nursing includes knowing the patients, witnessing their suffering,accepting the responsibility to care, desiring to do the work well, and know-ing what to do. The conditions of becoming, professionalizing, and institu-tionalizing and the work of nursing are held in fragile balance as nurses enjoythe stage of ease.

During the stage of ease, nurses are motivated by core beliefs and values touphold congruent professional and institutional norms. They are at ease inthe workplace, having technical skills and feeling comfortable practicingwithin the boundaries of self, profession, and institution. They know what isexpected of them and experience a sense of flow and feel at home. For exam-ple, one informant said,

Early in my career I was employed in the hospital setting and very conscien-tious about my work. I was very in tune to the patients and their care, wanting tomake sure that everything was done that was supposed to be done and that Icompleted all my work before the next shift came on. I loved the challenge ofthe medically difficult patient. I always did well in the emergencies—CPR, GIbleeds, chest pains, etc. After those first few months of new nurse jitters, I feltat ease and comfortable at my station.

The stage of ease continues as long as the nurse is fulfilled with the workof nursing and comfortable with the integration of core beliefs and profes-sional and institutional norms. For some, though, a morally troubling eventwill challenge the integration of core beliefs with professional and institu-tional norms. Nurses find themselves in situational binds that herald a criticaljuncture in their professional lives.

Situational Binds

A situational bind interrupts the stage of ease and places the nurse in tur-moil when core beliefs and other claims conflict. Situational binds forcenurses to make difficult decisions and give rise to critical junctures in their


lives. Binds involve serious and complex internal conflicts within individualsand tacit or overt conflicts between nurses and others, all having moral or eth-ical overtones. Inner dialogue leads the nurse to make a critical decision—choosing one value or belief over another. Thus, nurses arrive at a criticaljuncture that compels movement toward resolution and reflection, the re-maining stages of moral reckoning. Types of situational binds include(a) conflicts between core values and professional or institutional norms,(b) moral disagreement among decision makers in the face of power imbal-ance, and (c) workplace deficiencies that cause real or potential harm topatients. These dramatic binds produce significant consequences for nursesand patients.

Professional or institutional norms may conflict with core beliefs. Infor-mants explicitly or implicitly alluded to core beliefs as they talked about thestruggle to come to terms with conflicts involving professional or institu-tional norms. For example, one nurse is still troubled because she believesshe tortured a patient when she followed orders. The patient had a “no code”order and experienced extreme discomfort when the nurses performed naso-tracheal suctioning. He was alert and made his wishes clear. When heattempted to push away the suctioning tube, the nurse followed physicianorders and restrained his arms before suctioning him. In this case, the nursewas in a bind between following procedures sanctioned by the professionand institution (suctioning excess respiratory secretions) and respecting thepatient’s wishes, which seemed to her to be the morally correct action. At onepoint, she said to herself, “This is not what I signed on for.” Another nursewept as she talked about struggling to make sense of the situation when thephysician ordered her to administer a potentially lethal dose of medication.On one hand, she had been socialized to believe that nurses should followphysicians’orders, yet on the other, her core values included a belief that it ismorally wrong to cause the death of another person. The physician wrote theorder and went home while the nurse struggled with these conflicting values.She eventually administered the medication, hastening the patient’s death.Many years later, this nurse still struggles with the conflict between doingwhat she thought was morally right and following the order, thereby doing“what a good nurse would do.”

Power, particularly asymmetrical power relationships and powerlessness,is a theme that frequently emerges from nurses’ stories about morally trou-bling situations. Nurses experience situational binds when they have insightinto patients’ problems yet are powerless in the decision-making process.They feel a strong obligation to respect patients’wishes and a desire to affectthe appropriate outcome yet often fail in their attempts. Nurses feel that theydo not have a voice as they struggle against powerful authorities. For exam-


ple, several informants experienced powerlessness when physicians andfamily members made decisions against autonomous patients’ wishes toperform surgery, insert feeding tubes, perform resuscitation, and so forth.Strongly committed to patient autonomy, the nurses were certain they knewthe patients’ wishes, yet their “hands were tied.” Even though they did notactively participate in moral wrongdoing (in fact they struggled to prevent it),several nurses in the present study felt guilt and great distress as a result.

Power imbalance is also evident when physicians ignore or fail to believenurses’descriptions of deteriorating patient conditions. This is a surprisinglyfrequent theme. Nurses feel a strong sense of responsibility to patients andtake seriously the implicit promise to relieve their suffering. Multiple infor-mants described instances in which on-call physicians refused to come in,refused to order emergency medication, or refused to believe the nurses’evaluations of patients’conditions. For example, one nurse struggled to haveher concerns heard when a middle-aged woman’s condition deteriorated fol-lowing a gunshot wound to the neck. The woman died from a simple woundbecause no one else recognized the urgency of maintaining an open airway,and everyone ignored the nurse’s appeals.

Sometimes nurses perceive themselves to be in binds in the type of asym-metrical power relationships discussed above when there is no frank moralwrongdoing but rather divergent core beliefs. When those with decision-making power hold legitimate beliefs that are different from those of thenurse, the nurse believes that moral wrongdoing is occurring. For example,several participants believed that physicians guided families or patientstoward decisions consistent with the physicians’ values, while the nurses’beliefs were not considered. In these cases, even though there was no moralwrongdoing that an objective bystander could verify, the nurses felt a greatdeal of distress. The two types of cases in which this was most dramaticoccurred when physicians seemed to lead terminally ill patients or their fami-lies toward life sustaining measures or, paradoxically, when physicianssuggested that patients be allowed to die.

Workplace deficiencies conflict with nurses’ moral commitments, lead-ing to distress. This places nurses in situational binds because they are unableto uphold their core values. Deficiencies reported by informants includedchronic staff shortage, unreasonable institutional expectations, and equip-ment failure. For example, nurses experience situational binds when they aretruly committed to providing care that meets professional and institutionalstandards yet must care for more patients than they believe is safe. This leadsto distress when nurses cannot meet all of their own and others’ expectationsand guilt when they perceive real or potential harm to patients. One nurse inthe present study reported that he still feels guilty 20 years after caring for a


patient who died as a direct result of a laryngoscope that failed duringresuscitation attempts.

In the midst of the situational bind or soon after, nurses experience conse-quences such as profound emotions, reactive behaviors, and physical mani-festations. Emotions are directed toward the self or others. Informants saidthey were “very torn,” “bothered horribly,” and “incredibly sad.” They alsodescribed feelings of guilt, anger, powerlessness, conflict, depression, out-rage, betrayal, and devastation. Physical manifestations included near syn-cope, crying, sleeplessness, and vomiting. One nurse said she lost sleep fordays, another cried for the rest of the shift, and another had “crying jags” forseveral days. Behaviors triggered by these emotions included fleeing theunit, “ranting and raving,” drinking alcohol, and sacrificing self to “make itright.”

Having experienced situational binds in patient care, nurses provide carethat may be affected in a number of divergent ways. Subsequent nursing caremay be negatively affected, unchanged, or improved. A few informantsreported that their nursing care was negatively affected or unaffected. Oneinformant was able to perform only routine tasks at the desk and eventuallyrequested a replacement for the remainder of the shift. Another said eventhough she had always loved her work, after a troubling incident she resignedbecause she believed her care would be affected. Most nurses, however,believe that their nursing care improved as a direct result of a situational bind.Some were compelled to make up for what they consider to be wrongdoingby giving more compassionate care, even to the point of sacrificing mealsand personal time. One respondent said that the nurses felt compassion forthe patient and tried to treat him with dignity and give him better care. Othersreported that their care improved in the long term because of lessons theylearned in the process. Painful feelings and realizations about harm to pa-tients propels them toward the stage of resolution.

Stage of Resolution

Situational binds constitute crises of intolerable internal conflict. Thenurse seeks to resolve the problem. The move to set things right signifies thebeginning of the stage of resolution. A critical juncture, this stage often altersprofessional trajectory. There are two foundational choices in the stage ofresolution: making a stand and giving up. These choices are not mutuallyexclusive. In fact, many nurses give up initially, regroup, and make a stand.Others make an unsuccessful stand and later give up.

Making a stand. When confronted with a situational bind, some nursesresolve their distress by claiming their power and making a stand. Making a


stand takes a variety of forms, all of which include professional risk. Nursesmay make a stand by refusing to follow physicians’orders, initiating negotia-tions, breaking the rules, whistle blowing, becoming activists, and so forth.Several informants made a stand when they refused to follow questionableorders. They refused to help with resuscitation if patients had voiced theirobjection, to sign coerced surgical consent, and to administer potentiallyfatal doses of medication. In every instance, another nurse was willing to stepin and follow the order. For example, one nurse refused to give a potentiallyfatal dose of medication to a terminally ill, yet alert, baby who the physicianshad decided to remove from the respirator. Another nurse administered themedication, leaving the informant with significant guilt and distress becauseshe had been unable to prevent what she perceived to be harm to the baby.Making a stand is rarely successful in the short term but may occasionallyimprove the overall situation in the long term when nurses rise above thesesituations and attempt to make system changes.

Nurses also make a stand when they step beyond the customary bound-aries of the profession to do what, to them, seems to be morally correct. Forexample, one nurse had advanced education in pharmacology and was famil-iar with medication protocols in critical care situations. When she could notreach the physician, she gave a medication she believed was needed to save apatient’s life, even though performing the action was against professionaland institutional norms. Making a stand in this way is risky for the nurse. Theactions are sometimes illegal but are commonly successful in the short term.When outcomes are positive, nurses are seldom punished because of congru-ence with the implicit institutional norms of handling crises without makingwaves and covering.

Making a stand through whistle blowing is also risky. Nurses who whistleblow violate many implicit institutional norms. They are ostracized and sub-jected to hearings, firing, legal proceedings, and harassment. One informantsuffered for many years after whistle blowing. Because of the indignities shesuffered, she is under psychiatric care and believes she will never again workas a nurse.

Giving up. Sometimes nurses resolve a situational bind by giving up.In general, nurses give up because they recognize the futility of making anovert 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 placewhere they can live with better integration of core beliefs, professionalnorms, and institutional norms. Giving up includes participating (with re-gret) in an activity they consider to be morally wrong, leaving the unit orresigning, or leaving the profession altogether. Nurses may seem to give up


in the short term but move toward preparing themselves for more autono-mous roles that allow them to make a stand, on principle, in the future.

Stage of Reflection

Having chosen a course of action in the midst of moral conflict, nursesmove from the stage of resolution to the stage of reflection. They rememberand reflect as they reckon their actions. The stage of reflection may last a life-time. The stage of reflection raises questions about prior judgments, particu-lar acts, and the essential self. The properties of the stage of reflection includeremembering, telling the story, examining conflicts, and living with conse-quences. These properties are interrelated and seem to occur in every in-stance of moral reckoning.

Remembering. Remembering is an intriguing property of the stage ofreflection. Nurses retain vivid mental pictures of morally troubling patientcare situations. These memories evoke emotions many years later. As onenurse said, “I don’t let go of it.” Without being asked, nurses invariablydescribe sensual memories of the incident—the sights, sounds, and smells.The images are seared into their minds. Informants said that they can still seethe environment in which the situation took place. They remember specificfacts about patients such as their names, ages, and diagnoses. After 15 or 20years, they remember patients’ faces, exact locations of the patients’ beds,and sometimes a patient’s position in bed. One nurse said she could vividlysee the emergency department as it looked on that day and for a long timecould intermittently smell the odor of burnt flesh that had permeated the unit.

In the midst of remembering, nurses experienced evoked emotion eventhough many years may have passed. Evoked emotions include feelings ofguilt and self-blame and lingering sadness, anger, and anxiety. Nurses feelguilt and self-blame even when they did not actually participate in moralwrongdoing. They have guilt related to the patient’s outcome rather thantheir own participation in a troubling event. Even when they report a series ofevents in which they are blameless—sometimes going beyond what is usu-ally expected, trying to rectify a problem—informants blame themselves forbad patient outcomes saying, for example, “If I had only called a differentdoctor . . . ” or, “If I could have made him believe me . . . . ” Lingering emo-tional effects are profound for many and include anxiety attacks, crying epi-sodes, depression, and prolonged psychiatric care.

Nurses continue to feel anger and to blame those they believe wereresponsible for wrongdoing. Physicians are most often the target of nurses’anger. Other nurses and administrators are also targets of anger and blame.These feelings, harbored for many years, lead to fracturing of professional


relationships. Referring to a physician who refused to come in during anemergency many years ago, one nurse said, “I still have no use for him.”

Telling the story. Emotions called forth during troubling patient situationslinger for many years. The act of telling the story evokes these emotions.Some emotions fade over time, but others linger indefinitely. Rememberingis an iterative process. Nurses continue moral reckoning over time, remem-bering and telling the story as they try to make sense of it. Many informants inthe present study wept as they talked about the incidents, yet they desired totell their stories. All made the initial contact and volunteered to participatedin hour-long interviews. At the close of the interviews, most voiced gratitudefor the chance to tell their stories. Consistent with the present study, Smithand Liehr (1999) propose that as the person tells the story, he or she gains afull-dimensional, reflective awareness of bodily experiences, thoughts, feel-ings, emotions, and values. Patterns are recognized, made explicit, andnamed.

Examining conflicts. Telling their stories, nurses examine conflicts in thesituation. Nurses struggle as they think about conflicts between personal val-ues and professional ideals. They examine their values and ask themselvesquestions about what actually happened, who was to blame, and how theymight avoid similar situations in the future. As they thoughtfully examinethe conflicts, some intellectualize their participation, some set limits, andsome gain strength to make a stand and accept the consequences in futuresituations.

As nurses think about their roles in what they consider past moral wrong-doing, some set limits or make pronouncements about their future actions.They may identify a point beyond which they will not again be willing to go.Others vow to take risks to help patients in the future. For example, one nursetalked about taking care of a young woman who was desperately ill. Eventhough she begged for a cold drink, the nurse withheld fluids because thephysician had written an “NPO” order. After the woman’s death the next day,the nurse vowed never again to refuse the comfort of a cold drink to a dyingpatient.

Living with consequences. Nurses live with the consequences of a situa-tional bind for a prolonged period of time. No longer comfortable in the orig-inal workplace and having fractured professional relationships, nurses maymove from one institution to another or from one specialty area to another.They are likely to seek further education, preparing for more autonomousroles or intending to correct the type of moral wrongs they experienced in the


past. Few informants in this study remain at the bedside, even though mosttalked about enjoying the work of nursing during the stage of ease. Becauseall participants in the present study continued to experience evoked emotionswhen they talked about their experiences, it is possible that the process ofmoral reckoning may continue indefinitely for some nurses who fail to re-solve their feelings.

Discussion

The grounded theory of moral reckoning in nursing is a new and originaltheory that establishes unique connections, making familiar ideas relevantwhile giving integrative scope and a new perspective. It is an evocative theorythat has the power to inform practitioners and leaders about the realities ofthe struggle between personal moral convictions and collective decisionmaking. The theory encompasses moral distress but reaches further, identi-fying a critical juncture in nurses’ lives and better explaining a process thatincludes motivation and conflict, resolution, and subsequent reflection.Based on the life experiences of nurses, the grounded theory of moral reck-oning in nursing is a powerful new theory that transcends, organizes, andsynthesizes the extant literature on moral distress and explains stages of anewly identified basic social process. It also offers important implications fornursing practice, education, and administration and, in the face of a nursingshortage of crisis proportions, presents urgent and unique opportunities forfurther investigation.

The design of this grounded theory research focused on identifying andexamining the experiences of nurses who recognized the personal effects ofmorally troubling patient care situations. Those who volunteered were olderand highly educated. The sample did not include nurses who experienced nodistress. Perhaps this group had successfully dealt with these types of situa-tions through activism or other strategies. Those who did not recognize orexperience inherent conflicts between moral and other claims were alsounrepresented in the sample. The grounded theory of moral reckoning innursing describes only the experiences of those nurses who were motivatedto come forward and tell their stories. Further research is needed to describethe experiences of other groups of nurses and compare them to those in thepresent study.

The grounded theory of moral reckoning in nursing points to a chasmbetween the ethical practice of nurses and formal nursing ethics. This mayindicate what MacIntyre (1988) terms an “epistemological crisis” in nursing,a crisis that occurs when events bring into question ideals and convictions ofa tradition and when previous methods of inquiry, conceptualization, and


principles fall into question. Moral reckoning suggests a need to systemati-cally develop both formal and normative nursing ethics that will serve asaccessible tools to nurses in practice, taking into account the situation ofnurses in practice and sensitive to both the intricacies of the work of nursingand the primacy of human relationships. Such ethics should allow for consid-eration of the uniqueness and particularity of each patient and each situationwhile acknowledging diverse moral perspectives. Nurses should come tounderstand rival traditions’ perspectives as different yet complementaryunderstandings of reality. A new ethics of nursing should bind participants inshared symbolism, meaning, and purpose; recognize gender differenceswhile discarding gender and social bias; encompass values of both caringand curing; and refrain from alienating men from women and doctors fromnurses.

Moral reckoning in nursing suggests a need for enrichment of nursingeducation. Educators should strengthen nursing ethics education, teach strat-egies to improve nurses’ empowerment, model appropriate behaviors, andhelp students learn effective ways to establish intra- and interprofessionalrelationships. Educators should closely examine implicit messages transmit-ted to students, particularly traditions of the discipline that inhibit meaning-ful dialogue and sustain conflict and power imbalance. They should help stu-dents learn strategies and language that prepares them to enter into ethicaldialogue with other professionals and prepare them for the realities of day-to-day practice. They should teach students to be ethically self-aware andfacilitate dialogue that uncovers sources of conflict among core beliefs, pro-fessional traditions, and institutional expectations. They should acknowl-edge the unique relationship between nurses and patients, recognizing spe-cial elements of the relationship such as knowing intimately and witnessingsuffering.

Moral reckoning in nursing also suggests implications for nurses in prac-tice. Avoiding situational binds and searching for integrity-saving compro-mise in morally troubling situations may help some nurses to prevent distressand moral reckoning. In an effort to prepare themselves to make cogent andconsistent moral judgments, nurses should become familiar with the sociol-ogy and history of health care decision making and the basics of moral phi-losophy. Nurses might purposely examine core values and their relationshipto professional and institutional norms. To join the decision-making circle,nurses should learn to appreciate diverse moral perspectives and become flu-ent in the language of nursing and bioethics. Nurses should also join togetherto support each other and find ways for experienced nurses to mentor neo-phytes, exploring conditions that lead to distress and identifying methods tomove beyond it.


The grounded theory of moral reckoning in nursing implicates institu-tional health care as one of the major triggers of moral conflict among nurses.Studies that look at nurses’ satisfaction and nursing turnover identify manyof the same institutional factors as the present research. Synthesizing theexisting research on nurse satisfaction, Larrabee et al. (2003) report thatnurses are more likely to stay in their work setting when they perceive thatthey have control of their practice, adequate autonomy, collaboration withphysicians, adequate staffing, and organizational empowerment. Negativeconsequences of high nursing turnover include threats to patient welfare thatare posed when institutions operate short of staff or with temporary staffing.

Attention should be paid to the relationship between nurses and physi-cians. Communication and collaboration between nurses and physiciansseems to reduce the incidence of nurses’ moral distress. In turn, the relation-ships between nurses and physicians are strongly related to patient outcomes(Baggs & Mick, 2000). Baggs and Mick (2000) reported that their findingsare consistent with a number of studies done in the past three decades thatshowed that nurse-physician collaboration has positive correlation withlower than expected mortality, less decline in functional status, fewer acutecare days, and fewer readmissions. This suggests that strategies to improvenurse-physician collaboration in the institutional setting have the potential toboth prevent nurses’ moral distress and improve patient outcomes.

Nursing administrators need to clearly identify morally worthy goals,examine unit cultures, identify causes of moral distress among nurses,provide support for collaborative decision making, create mechanisms toaddress abuses, and support nurses and other providers who experience dis-tress. Nurse administrators need to advocate for an ethical corporate culture,which Friedman (1992) proposed should include honorable leadership,protection of and responsiveness to nurses who identify moral problems,encouragement toward ethical achievement, and avoidance of hypocrisy.Administrators should also implement strategies to support nurses who areexperiencing distress. As suggested in the recent literature, effective strate-gies include facilitating dialogue, encouraging nurses to be active partici-pants in clinical and ethical decision making, developing support systems,providing opportunities for professional development, strengthening collab-orative teamwork, and identifying and eliminating systematic patterns ofdominance and subordination based on gender, race, and ethnicity (Donchin,2001; Erlen, 2001; Hamric, 2000).

Spiraling technology, longer life spans, and higher health care costs in therecent past have contributed to an atmosphere in which nurses are faced withproblems of ever-increasing moral complexity—situations in which the mostbasic moral beliefs about life and death, right and wrong are challenged.


Moral distress occurs as a result of a dynamic interplay of the nurse’s moraloutlook, commitment to moral principles that may be either intrinsicallyincompatible or incompatible in specific situations, relationships with pa-tients, role identification, and perception of imbalance of power or otherinstitutional constraints. The newly identified grounded theory of moralreckoning in nursing reaches further than moral distress, identifying a criti-cal juncture in nurses’ lives and better explaining a process that includesmotivation and conflict, resolution, and reflection. In the face of a nursingshortage of crisis proportions, the theory of moral reckoning in nursing pres-ents urgent and unique opportunities for reforms in nursing ethics develop-ment, education, practice, and administration and sets the stage for furtherresearch.

References

Anderson, S. L. (1990). Patient advocacy and whistle-blowing in nursing: Help for the helpers.Nursing Forum, 25(3), 5-13.

Baggs, J. G., & Mick, D. J. (2000). Collaboration: A tool addressing ethical issues for el-derly patients near the end of life in intensive care units. Journal of Geriatric Nursing, 26(9),41-47.

Beauchamp, T. L., & Childress, J. F. (2001). Principles of biomedical ethics (5th ed.). New York:Oxford University Press.

Corley, M. C. (1995). Moral distress of critical care nurses. American Journal of Critical Care, 4,280-285.

Davies, B., Clarke, D., Connaughty, S., Cook, K., MacKenzie, B., McCormick, J., et al. (1996).Caring for dying children: Nurses’ experiences. Pediatric Nursing, 22, 500-507.

Donchin, A. (2001). Understanding autonomy relationally: Toward a reconfiguration of bio-ethical principles. Journal of Medicine and Philosophy, 26, 365-386.

Erlen, J. A. (2001). Moral distress: A pervasive problem. Orthopedic Nursing, 20(2), 76-79.Fenton, M. (1988). Moral distress in clinical practice: Implications for the nurse administrator.

Canadian Journal of Nursing Administration, 1(3), 8-11.Friedman, E. (1992). Ethics and corporate culture: Finding a fit. In E. Friedman (Ed.), Choices

and conflict (pp. 101-109). Chicago: American Hospital Association.Glaser, B. G. (1978). Advances in the methodology of grounded theory: Theoretical sensitivity.

Mill Valley, CA: Sociology Press.Glaser, B. G. (Ed.). (1996). Gerund grounded theory: The basic social process dissertation. Mill

Valley, CA: Sociology Press.Glaser, B. G. (1998). Doing grounded theory: Issues and discussion. Mill Valley, CA: Sociology

Press.Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualita-

tive research. New York: Aldine De Gruyter.Hamric, A. B. (2000). Moral distress in everyday ethics. Nursing Outlook, 48, 199-201.Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice Hall.Kelly, B. (1998). Preserving moral integrity: A follow-up study with new graduate nurses. Jour-

nal of Advanced Nursing, 28, 1134-1145.


Krishnasamy, M. (1999). Nursing, morality, and emotions: Phase I and phase II clinical trials andpatients with cancer. Cancer Nursing, 22, 251-259.

Larrabee, J. H., Janney, M. A., Ostrow, C. L., Withrow, M. L., Hobbs, G. R., & Burant, C. (2003).Predicting registered nurse job satisfaction and intent to leave. Journal of Nursing Adminis-tration, 33, 271-283.

Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Beverly Hills, CA: Sage.MacIntyre, A. (1988). Whose justice? Which rationality? Notre Dame, IN: University of Notre

Dame Press.Millette, B. E. (1994). Using Gilligan’s framework to analyze nurses’ stories of moral choices.

Western Journal of Nursing Research, 16, 660-674.Nathaniel, A. K. (2004). A grounded theory of moral reckoning in nursing. The Grounded The-

ory Review, 4(1), 43-58.Redman, B., & Fry, S. T. (2000). Nurses’ ethical conflicts: What is really known about them?

Nursing Ethics, 7, 360-366.Rushton, C. H., & Scanlon, C. (1995). When values conflict with obligations: Safeguards for

nurses. Pediatric Nursing, 21, 260-268.Sandelowski, M. (1986). The problem of rigor in qualitative research. Advances in Nursing Sci-

ence, 8(3), 27-37.Simpson, J. A., & Weiner, E. S. (Eds.). (1989). The Oxford English dictionary (2nd ed., Vol. 13),

s.v. “Reckon.” New York: Oxford University Press.Smith, M. J., & Liehr, P. (1999). Attentively embracing story: A middle-range theory with prac-

tice and research implications. Scholarly Inquiry for Nursing Practice: An InternationalJournal, 13, 187-204.

Viney, C. (1996). A phenomenological study of ethical decision-making experiences amongsenior intensive care nurses and doctors concerning withdrawal of treatment. Nursing inCritical Care, 1, 182-187.

Wilkinson, J. M. (1987-88). Moral distress in nursing practice: Experience and effect. NursingForum, 23(1), 16-29.

Alvita K. Nathaniel, DSN, APRN, BC, is an assistant professor and coordinator of FamilyNurse Practitioner Track at the West Virginia University School of Nursing.


moral reckoning in nursing. a grounded theory study

Documents

oxford university press

morally troubling situations

substantive grounded theory

nurses core beliefs

implicit institutional norms

follow physicians orders

formal nursing ethics

patient care situation