Complexity, complicity and moral distress in nursing

Background Acting professionally is inextricably linked with moral agency. More than three decades ago, the philosopher Andrew Jameton described psychological reactions to compromised moral agency of nurses which he defined as moral distress. This standard definition has led to dense empirical and conceptual research within nursing science and to the proposal of a broad definition. There is evidence of serious effects of moral distress on patient safety and the mental health of healthcare workers. Aims This article discusses the adoption of the concept within nursing science. It examines the recently proposed broad definition of moral distress as a response to situations of perceived moral undesirability and doubts the congruence of the definitions. Arguments The understanding of the prevalence of moral distress in nursing practice is made more difficult by the successive expansion of the definition on which the measuring instruments are based. Despite this lack of clarity, dealing with moral distress remains a serious challenge both for nursing and allied professions. For effective coping, however, it requires a sharpening that takes up the core concerns of both the "old" and the "new" definition: Perceived moral undesirability is proposed as a term encompassing the "whole" of emotional reactions to ethically challenging situations, followed by two kinds of psychological reactions: moral distress for situations of compromised moral agency and moral discomfort for situations in which moral agency is burdensome (but not compromised). In normative terms, moral distress stands for situations of moral complicity, whereas moral discomfort mirrors situations of moral complexity. Conclusion This sharpening makes moral distress sufficiently clear and confirms the core of the standard definition. But also, the concern of the broad definition is taken up and the view is opened for the broad spectrum of morally burdensome experiences that shape the daily work of the health professionals and require specific strategies that secure moral agency.